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

  2. 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

  3. 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??

  4. 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??

  5. 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

  6. 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)

  7. 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

  8. 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

  9. 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).

  10. Antibiotic Resistance in O.M. • penicillin binding proteins Pneumococcus Penicillins Cephalosporins

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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.

  17. 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.

  18. 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??

  19. 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??

  20. 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.

  21. 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.

  22. 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.

  23. Antibiotic Resistance in O.M. • folder: Antibiotic resistance in OM