Logical antibiotic use for pediatricians

2. Logical antibiotic usefor pediatricians Mostafavi N Department of pediatric infectious disease Isfahan university of medical sciences

3. Steps in logic antibiotic prescribe • What diagnosis? • Which organisms? • Is any antibiotic needed? • Is any investigation/procedure needed? ( drainage, culture, lab exam)

4. Steps in logic antibiotic prescribe 5. Best antibiotic?( maximum coverage, narrowest spectrum, oldest, cheapest, available, tolerable, diffusible, least interval, best rout) 6. Is any unusual condition?( drug interactions, allergy, low age, low economy, G6PD deficiency; underlying renal, neurological, hepatic disorders)

5. Steps in logical antibiotic prescribe • Which dose? interval? duration? supply? • Parent education.( measuring amounts of drug, refrigeration) • How parents assess response? When return?( intolerance, no adequate response, adverse reactions, lab results, monitoring safety and efficacy) • Prevention in contacts.( isolation, antibiotic) and patient( prophylactic Abs, IVIG, INF, ..)

6. Question 1 • A 2 years old girl brought with history of 3 days fever, coryza and cough, on examination she has purulent post nasal discharge. • What diagnosis? • Which organisms? • Is any antibiotic needed?

7. Diagnosis of viral URTI • Fever/ clear nasal discharge/ nasal obstruction/ cough/ hoarseness/ sore throat/ pharyngitis/ GI symptomes in 1st 1-4 days • Afterward purulent nasal/postnasal discharge and cough for 5-10 days( sometimes from 1st day) • Complete improve in 14th day

8. Case 1

9. Question 2 • A 16 months old girl brought with history of 3 days fever and coryza and cough, on examination she has purulent post nasal discharge. No antibiotic were prescribed. Three days later the patient returned with recurrence of fever( 38⁰С) and earache. On examination she has mild erythema of the right tympanic membrane and no significant purulent rhinitis. • What diagnosis? • Which organisms? • Is any antibiotic needed?

10. Diagnosis of bacterial AOM • Certain AOM: acute purulent otorrhea or all 3 criteria • Recent onset( < 3-7 days) • Inflammation • Marked redness • Significant ear pain • Effusion • Bulging • Bubbles/air-fluid level • ↓mobility • Uncertain AOM: < 3 criteria • Severe AOM( certain/uncertain): severe otalgia, T> 39⁰С

11. What diagnosis? • A 16 months old girl brought with history of 3 days fever and coryza and cough, on examination she has purulent post nasal discharge. No antibiotic were prescribed. Three days later the patient returned with recurrence of fever( 38⁰С) and earache. On examination she has mild erythema of the right tympanic membrane and no significant purulent rhinitis.

12. What diagnosis?

13. Is any antibiotic needed? • A 16 months old girl brought with history of 3 days fever and coryza and cough, on examination she has purulent post nasal discharge. No antibiotic were prescribed. Three days later the patient returned with recurrence of fever( 38⁰С) and earache. On examination she has mild erythema of the right tympanic membrane and no significant purulent rhinitis.

14. Indications for antibiotic in AOM • Age< 6 mo • Certain AOM in 6- 24 mo • Severe uncertain AOM in 6-24 mo • Severe certain AOM in > 24 mo • No response to 2-3 days observation

15. Is any antibiotic needed?

16. Question 3 • A 16 months old girl brought with history of 3 days fever and coryza and cough, on examination she has purulent post nasal discharge. No antibiotic were prescribed. Three days later the patient returned with recurrence of fever( 38⁰С) and earache. On examination she has mild erythema of the right tympanic membrane and no significant purulent rhinitis. No antibiotic were prescribed. The child returned one day later with severe earach. What diagnosis? Is any antibiotic needed? If yes which antibiotic?

17. Is any antibiotic needed?

18. Which organisms? Which sensitivities? Best antibiotic?

19. Bacteriology of AOM

20. Treatment of AOM

21. Best antibiotic? • A 16 months old girl brought with history of 3 days fever and coryza and cough, on examination she has purulent post nasal discharge. No antibiotic were prescribed. Three days later the patient returned with recurrence of fever( 38⁰С) and earache. On examination she has mild erythema of the right tympanic membrane and no significant purulent rhinitis. No antibiotic were prescribed. The child returned one day later with severe earache. BW= 10 Kg.

22. Best antibiotic?

23. Best antibiotic? • The parent report than the infant had previously serum sickness like reaction which need admission following consumption of Amoxicllin-clavulanate suspension.

24. Conditions that alter the choice

25. Best antibiotic? • The parent report than the infant had previously serum sickness like reaction which need admission following consumption of Amoxicllin-clavulanate suspension.

26. Best antibiotic?

27. Any investigation/procedure? • The parent report that the child has humoral immunodeficiency and receive monthly IVIG?

28. Indications of myringotomy/ tympanocentesis • Severe, refractory pain • Hyperpyrexia • Complications(facial paralysis, mastoiditis, labyrinthitis, or central nervous system infection) • Immunologic compromise • Third-line therapy • Very young infants whose illness presumed to not be limited to middle ear.

29. Parent education • Refrigerated • Discarded after 7 days • Consumption away from meals • Mild diarrhea and rash need no attention

30. How parents assess response? When return? • Good response: • Improve of pain and fever within 1- 3 days • When return? • 2 weeks for frequent recurrences: Improve in tympanic membrane exam • 1-3 mo for all cases: Improve in middle ear effusion • Non-copmpliance • Adveres reactions: diarrhea, rash

31. Logic antibiotic use • diagnosis? • organisms? • antibiotic? • investigation/procedure? • Best antibiotic? • unusual condition? • Dose? Interval? Duration? • Supply? • Parent education • Response? • When return? • Prevention in contacts