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Antibiotic Resistance in O.M. Joseph Lopreiato MD,MPH Associate Professor of Pediatrics Uniformed Services University of the Health Sciences Bethesda, MD Nov 1999 Antibiotic Resistance in O.M.

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antibiotic resistance in o m
Antibiotic Resistance in O.M.

Joseph Lopreiato MD,MPH

Associate Professor of Pediatrics

Uniformed Services University

of the Health Sciences

Bethesda, MD

Nov 1999

antibiotic resistance in o m2
Antibiotic Resistance in O.M.

“Doctors are men who prescribe medicines of which they know little; to cure diseases of which they know less; in human beings of whom they know nothing” - Voltaire

antibiotic resistance in o m3
Antibiotic Resistance in O.M.
  • Case 1: A 9 month old infant has a chief complaint of fever and fussiness since last PM. She has had a URI for the last several days, but has otherwise been well. PMH is significant for OM at age 6 months and day care attendance. After examination, you diagnosis AOM and prescribe Amoxicillin. After 3 days, the patient returns with persistent fever to 101 and fussiness. On exam you note that the TM is still erythematous and bulging. What do you do next??
antibiotic resistance in o m4
Antibiotic Resistance in O.M.
  • Case 2: A 24 month old child comes into your office for a routine health maintenance visit. He has been well and has had no significant PMH. On examination you note a right TM that is dull and has decreased mobility. The child has not had any significant symptoms. What would you do next??
antibiotic resistance in o m5
Antibiotic Resistance in O.M.
  • Organisms in Otitis Media:
    • Pneumococcus : 35% of cases
    • Haemophilus Influenza: 30% of cases
    • Moraxella Catarrhalis: 10% of cases
    • Virus: 33% of cases
    • Staph species
    • Strep species
    • Mycoplasma
antibiotic resistance in o m6
Antibiotic Resistance in O.M.

What’s causing resistant bacteria??

  • many more kids in daycare
  • increased use of antibiotics, especially broad spectrum agents
  • incomplete courses of therapy
  • Inappropriate therapy (for OME)
antibiotic resistance in o m7
Antibiotic Resistance in O.M.

Resistance seems to be correlated with :

  • Use of any antibiotic in the past 3 months
  • White race
  • Higher SES
  • Day care attendance

J Pediatr 128:757. 1996

antibiotic resistance in o m8
Antibiotic Resistance in O.M.

Antibiotic use is on the rise. In 1996, percentage of times that antibiotics were prescribed for children:

  • 34% to patients with a cold
  • 38% for other URI’s
  • 52% for patients with “bronchitis”

JAMA 279:875. 1998

antibiotic resistance in o m9
Antibiotic Resistance in O.M.

Mechanisms of resistance:

  • Microorganism produces an enzyme that destroys antibiotics (e.g. beta lactamase).
  • The bacteria changes its permeability to the antibiotic (e.g. tetracycline & erythromycin).
  • The bacteria develops an altered receptor for the antibiotic (eg penicillin binding protein).
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Antibiotic Resistance in O.M.
  • penicillin binding proteins

Pneumococcus

Penicillins

Cephalosporins

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Antibiotic Resistance in O.M.

Bacteria in otitis media:

  • Haemophilus influenza: 30-40% resistant
  • Moraxella Cat. : 90% resistant
  • Strep Pneumonia: 20-40% resistant to penicillins/cephalosporins
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Antibiotic Resistance in O.M.
  • Recommendations of Working Group:
  • Amoxicillin still the first choice!
      • Pneumcoccus still # 1 organism
      • Most pneumcocci are low to intermediately resistant
      • We have lots of experience with this drug
antibiotic resistance in o m13
Antibiotic Resistance in O.M.
  • Clinical failure after 3 days:
    • Consider resistant pneumococci/ H. influenza
      • Amoxicillin/clavulanate 80-90 mg/kg/day
      • Cefuroxime axetil 30 mg/kg/day
      • IM ceftriaxone 50 mg/kg/day for 3 days
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Antibiotic Resistance in O.M.
  • Recommendations of Working Group:
  • Failure after 10-28 days:
    • Same as 3 days
  • Patients who fail Amoxicillin more likely to have TMP/SMP and Macrolide resistance.
  • Expect some surprises!

Pediatr Infect Dis J. 18:1-9. 1999

antibiotic resistance in o m15
Antibiotic Resistance in O.M.

Why isn’t there a magic bullet?

100 patients with OM 33 viral

66 bacterial

33 spontaneous cure33 persist

20 eventual cure13 remain Sx

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Antibiotic Resistance in O.M.

What to do - Lope’s rules of the Road:

  • AOM has a high spontaneous cure rate. because the immune system and host factors (like ET function) account for the vast majority of clinical cures.
  • Certain individuals have a greater risk than others for recurrent AOM.
  • Antibiotics can relieve symptoms faster, but at a price.
antibiotic resistance in o m17
Antibiotic Resistance in O.M.
  • Treatment must be individualized according to risk factors such as age, daycare attendance, and prior history.
  • Curbing antibiotic use starts with you
    • see your patients often.
    • avoid having“strangers” diagnose your patient.
    • be communicative as to the risks and benefits with your parents.
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Antibiotic Resistance in O.M.
  • Case 1: A 9 month old infant has a chief complaint of fever and fussiness since last PM. She has had a URI for the last several days, but has otherwise been well. PMH is significant for OM at age 6 months and day care attendance. After examination, you diagnosis AOM and prescribe Amoxicillin. After 3 days, the patient returns with persistent fever to 101 and fussiness. On exam you note that the TM is still erythematous and bulging. What do you do next??
antibiotic resistance in o m19
Antibiotic Resistance in O.M.
  • Case 2: A 24 month old child comes into your office for a routine health maintenance visit. He has been well and has had no significant PMH. On examination you note a right TM is dull and has decreased mobility. The child has not had any significant symptoms. What would you do next??
antibiotic resistance in o m20
Antibiotic Resistance in O.M.
  • References:
  • Dowell S. Acute otitis media : management and surveillance in an era of pneumoccal resistance: a report from the drug-resistant Streptococcus pneumonia working group. Pediatric Infectious Disease Journal 1999;18:1-9.
  • Klein JO. The “in vivo sensitivity test” for acute otitis media. Pediatric Infectious Disease Journal 1998;17:774-775.
  • Lipsy BA. Fluoroquinolone toxicity profiles: a review focusing on newer agents. Clinical Infectious Diseases 1999;28:352-364.
antibiotic resistance in o m21
Antibiotic Resistance in O.M.
  • References (con’t):
  • Dowell SF. Otitis media: principles of judicious use of antimicrobial agents. Pediatrics 1998;101:165-171.
  • Leibovitz E. Bacteriological efficacy of a three day intramuscular ceftrixone regimen in nonresponsive acute otitis media. Pediatric Infectious Disease Journal 1998;17:1126-1131.
  • Arnold KE. Risk factors for carriage of drug resistant Streptococcus pneumonia among children in Memphis, Tennessee. J. of Pediatrics 1996;128:757-764.
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Antibiotic Resistance in O.M.
  • References (con’t):
  • Nyquist A-C. Antibiotic prescribing for children with colds, URI, and bronchitis by ambulatory physicians in the United States. JAMA 1998;279:875-877.
  • Heikkinen T. Short term use of amoxicillin-clavulanate during upper respiratory tract infection for prevention of otitis media. Journal of Pediatrics 1995;126:313-316.
  • Mangione-Smith R. The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics 1999;103:711-718.
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Antibiotic Resistance in O.M.
  • folder: Antibiotic resistance in OM
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