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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.

Joseph Lopreiato MD,MPH

Associate Professor of Pediatrics

Uniformed Services University

of the Health Sciences

Bethesda, MD

Nov 1999


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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


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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??


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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??


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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


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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)


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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


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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


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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


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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


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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.


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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??


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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??


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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.


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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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