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Use and misuse of antibiotics in
respiratory infections
Dr Jeyaseelan P. Nachiappan
Consultant Infectious Disease Paediatrician
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Aims
To discuss
common respiratory tract infections
data on misuse of antibiotics
reasons for misuse of antibiotics
recommendations for appropriate use of
antibiotics
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National Medical Care Survey 2010
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What is URTI?
Rhinitis, sinusitis,pharyngitis, tonsilitis,laryngobronchitis(ALTB/ croup),laryngitis, otitis media
Usually involves more
than one anatomicalareas eg rhinosinusitis,ALTB
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Common cold syndrome
Gwaltney JM, Hendley JO, Simon G, Jordan WS. Rhinovirus infections in an industrial population. JAMA 1967;202:158-164
139 rhinovirus+ patients
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Natural history
a systematic review - aged between 0 - 4 years
8 RCTs and 2 cohort
at one week 50% may be still coughing + nasaldischarge
at two weeks up to 24% of children may be nobetter
illness duration may be longer than many parentsand clinicians expect
Hay AD, Wilson AD. The natural history of acute cough in children aged 0 to 4 years in primary care:
a systematic review.. Br J Gen Pract. 2002 May;52(478):401-9
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Common cold
prevalence varies by age
highest in age less than 5 yrs
school/daycare are a large reservoir
3-8 viral URTI per yearMeneghetti eMedicine Aug 2006
healthy 3yr old child 6 to10 colds/yr Wald ER Pediatrics. 1991
Exclusively caused by viruses
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Pharyngitis / Tonsilitis
streptococcal pharyngitis 5% to 15%
difficult to distinguish viral and strep
clinical prediction rules
Centor fever can be high grade viral tonsilitis
CPG Sore throat KKM 2003
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Rhinitis versus Sinusitis
sinusitis if symptoms of rhinorrhea or
persistent cough lasting >10-14 days withoutimprovement or worsening
Or
Severe symptoms of acute sinus infection:
Fever (39oC) with purulent nasal discharge
Facial pain or tenderness
Periorbital swelling
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Acute bronchitis
Acute coughing illness last for 3 weeks
> 90% of cases due viruses Purulent sputum not predictive of bacterial
infection.
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Summary
Common cold
common and recurrent
some symptoms persist till 2 weeks
5-15% of tonsillitis may be bacterial
Sinusitis = prolonged rhinitis / cough
Acute bronchitis 90% viral
Prolonged cough
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ANTIBIOTIC USE BY INFECTION
(URTI, n=795)
With antibiotic (%) (n) Total consultations (n)
Nasopharyngitis
(Common cold)7.0% (16) 227
Pharyngitis/ Sorethroat/ Tonsilitis
65.0% (173) 266
Rhinosinusitis 31.2% (5) 16
Otitis media 50.0% (3) 6
URTI 32.5% (91) 280
Ng Li Meng Pharmacy HRPBI 2013 ( unpublished)
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Outpatient Antibiotic Use and
Prevalence of Antibiotic- Resistant
Pneumococci in France and Germany:A Sociocultural Perspective
prevalence of penicillin resistant pneumococci is sharplydivided between France (43%) and Germany (7%).
These differences may be explained on different levels:antibiotic-prescribing practices for respiratory tractinfections; patient-demand factors and health-beliefdifferences; social determinants, including differing child-care practices; and differences in regulatory practices.
Harbarth S. Emerging Infectious Dis Vol.8, No. 12 Dec 2002
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Outpatient antibiotic utilization
daily defined doses.
Resistance 43%
Resistance 7%
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Why are antibiotics misused
prescribed?
Appropriate use of antibiotics
demands (real or imaginary)
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Why are antibiotics misused
prescribed? Patients nowadays are smart. They know when they need an antibiotic..
If they expect antibiotics and dont get it, they will not be satisfied..
Its all my patients fault. They keep on expecting antibiotics to be prescribed.
I am sure I only prescribe antibiotics when it is really indicated
If I do not prescribe an antibiotic, he/she will keep on coming back to me for the
same problem.
How else do I reduce my patients anxiety apart from prescribing antibiotics?
What do you mean communicate with my patient?
I have problems convincing my patient that it is a viral infection
I am a busy doctor. Ive got no time to argue with my patient
Does interventions really work? Will our patients really be satisfied?
But are you sure my patient will not get complications if I do not give him
antibiotics?
But my patient still insists on antibiotics!
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Patients nowadays are smart. They know when
they need an antibiotic..
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Face-to-face survey in Britain in 2003. Of
10,981 randomly selected adults fromEngland, Scotland and Wales, 7120 (65%)
completed the questionnaire.
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Its all my patients fault. They keep on expecting
antibiotics to be prescribed.
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22 non randomly selected GP; 336 patients;Newcastle, Australia
the doctors' opinions about patients'expectations that were the strongest
determinants of prescribing
likely to be prescribed
medicines
patients who expected medications X 3
general practitioner thought that the patient
expected medication X 10
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But I am sure I only prescribe antibiotics when it
is really indicated
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Appropriateness of antibiotic prescribing forrespiratory tract infections (n = 1469)Akkerman A E et al. J. Antimicrob. Chemother. 2005;56:930-936
146 GPs; Netherlands; patients with sinusitis, tonsillitisand bronchitis; 4 weeks winter of 2002/2003
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But are you sure my patient will not get
complications if I do not give him antibiotics?
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But what if my patient adamantly insists on
antibiotics?
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Appropriate use of antibiotics
Communication
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REMEMBER:
Effective communication is moreimportant than an antibiotic for
patient satisfaction.
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Disadvantages of inappropriate
antibiotic prescribing
Resistance in the patient
Resistance in the community
Unnecessary side effects
Promotes magic bullet ; instant cure
mentality
Costs - patients, doctors standing, health caresystems
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TIPS for not overusing antibiotics in
primary care
Tell patients about resistance
Identify patient concerns
Spend time answering questions
Recommend specific symptomatic therapy
Contingency plan if symptoms worsen.
Provide patient education materials
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Recommendations
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Adult recommendations
Acute Tonsillitis
Acute Pharyngitis
Phenoxymethylpenicillin EES
Acute Bacterial Rhinosinusitis Amoxycillin EES
Mild CAP (out-patient)
no morbidity
EES Amoxycillin
Acute tracheobronchitis
- usually viral
None unless symptoms persist
> 7 days
EES
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Paediatric Recommendations
Otitis media Amoxycillin Amoxycillin Clavulanate
Pneumonia (Outpatient) Amoxycillin
Bronchiolitis No antibiotics
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Summary
common infections respiratory tract
infections
data on misuse of antibiotics
reasons for misuse of antibiotics
recommendations for appropriate use of
antibiotics
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Acknowledgements
Dr Benedict Sim Infectious disease Physician
Dr Sheamini Sivasampu CRC
Dr Leong Kar Nim Infectious disease Physician
Ms Ng Li Meng Pharmacist HRPBI
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Thank You