to avoid indiscriminatory usage of antibiotics

1. RATIONAL ANTIBIOTIC THERAPY
Dr S.KIRAN KUMAR, M.D.(ped)
Assistant Professor
SVIMS,SPMC(W)

2. OBJECTIVES
 To know what is irrational drug use
 Harms of irrational use
 What is rational prescribing
 Interventions needed for rational
prescribing

3.  Antibiotics are one of the most commonly
prescribed drugs today.
 Rational use of antibiotics is extremely
important as injudicious use can
adversely affect the patient, cause
emergence of antibiotic resistance and
increase the cost of health care.

4. ALEXANDER FLEMING

5. YELLAPRAGAD SUBBARAO

6. Antibiotic Era
 Antibiotics were hailed as
“miracle drugs” after their initial
introduction in 1940s.
 Penicillin, the wonder drug, saved millions of lives in
the 2nd world war and many mothers were saved
from puerperal sepsis.
 Their widespread availability and success led to
such dramatic reduction in the morbidity and
mortality caused by infectious diseases that many
thought it was time to “close the book” on infectious
diseases.

7. Introduction
 As if proving Darwin’s theory of
“Survival of the fittest”, the
bacteria underwent a rapid hitherto
unprecedented evolution to
circumvent this menace to their
survival.
 Being single celled and endowed
with the ability to multiply rapidly,
the change was almost natural and
spontaneous.
RESISTANCE !!!

8. Antimicrobial Resistance
(AMR)
 Indiscriminate use of antibiotics - the
single most important factor responsible
for the menace of AMR.
 Antibiotics are frequently prescribed for
indications in which their use is not
warranted, or an incorrect or suboptimal
antibiotic is prescribed.

9. WHY WORRY about antibiotic
misuse?
Bacteria are increasingly becoming
resistant to treatment with
antibiotics.
•There are no new antibiotics to fight
the resistant bacteria.
We are RE ENTERING a pre antibiotic
era.
•With a danger of losing the fight
against infections to bacteria.
We need to conserve antibiotics.
•We need to use them rationally and
Judiciously.

10. ANTIBIOTIC PARADIGM
Excessive / inappropriate
antibiotic use
Failure of antibiotic
treatment
Antibiotic
resistance

12. What is irrational use of
antibiotics (IUA) ?
 IUA means use of wrong antibiotics, in
wrong dose, by wrong route of
administration, for wrong interval and
duration and in wrong dosage form…

13. Determinants of irrational use of
antibiotics
 On the part of pharmacist/dispenser
◦ Economic incentives
◦ Lack of regulations and enforcements
◦ Unclear role as health providers
 On the part of patients
◦ Lack of access to proper health care
◦ Beliefs and traditions
◦ Over the counter usage
◦ lack of public awareness
about antibiotic misuse complications

14. Determinants of irrational use of
antibiotics
 On the part of policymakers, regulators
and pharmaceutical industry
◦ Lack of rational drug policy, regulations
◦ Uncontrolled marketing tactics
◦ Lack of infrastructure
◦ laxity of regulatory bodies in approval of
antibiotics

15. Causes of irrational use of
antibiotics
Physician related
 Fear of secondary infection.
 Fear of missing serious
bacterial infection,its dire
consequences.
 Pressure from pharma
industry.
 Fear of legal actions – many
physicians prefer an error of
commission to error of
omission.
 Lack of investigation
facilities.
 Mind set –prescription should
have antibiotic

16. Consequences of Irrational use of
antibiotics
 Antimicrobial resistance
 Adverse Drug Reactions
 Increased cost burden.
 Suppress but not control infection ,increased
morbidity and risk of mortality.

17. What is Rational Use of
Drugs?
Requires that patients receive medicines
appropriate to their clinical needs,
in doses to meet individual
requirements,
for an adequate period of time,
at the lowest cost to them and their
community.
(WHO 1985)
Correct Drug; Correct Dose; Correct Duration !!!

18. General Principles Of
Antimicrobial Therapy

19. Antibiotics are prescribed for
 Treating bacterial infections
 Prophylaxis of bacterial infections

20. Antibiotic Prescription
Antibiotic prescription should ideally comprise of
the following phases:
◦ Perception of need - is an antibiotic
necessary?
◦ Choice of antibiotic – which is the most
appropriate antibiotic?
◦ Choice of regimen : What dose, route,
frequency and duration are needed?
◦ Monitoring efficacy : is the antibiotic
effective?

21.  Make a precise clinical diagnosis from the
symptoms, signs and investigations e.g.,
in a case of pyogenic meningitis the
diagnosis could be suspected as follows:
◦ Symptoms: Fever, irritability, altered sensorium,
refusal of feeds, vomiting.
◦ Signs: Febrile, irritable child with altered sensorium,
signs of raised intracranial tension, signs of
meningeal irritation, variable neurological signs.
◦ Investigations: CSF examination, WBC count, sugar,
protein, CSF culture.
 Consider possible etiologic agents - H.
Influenzae, S. Pneumoniae, N,
Meningitides rare.
 Target the most likely ones after
consideration of age, h/o trauma, h/o
neurosurgical procedure etc.

22.  Specify the therapeutic objectives.
◦ Eradication of bacteria and sterilization of
CSF at the earliest by use of bactericidal
drugs • Clinical Cure • Prevention of
relapse • Prevention of early and late
complications, sequel and mortality.
 Consider the seriousness of illness.
 Make an inventory of effective group
of drugs. Bactericidal agents
penicillins, Chloramphenicol, 3rd
generation cephalosporins,
vancomycin etc.

23.  Choose the most appropriate and
effective group based on the criteria of
efficacy, safety, suitability and cost.
 Choose an appropriate antibiotic from
the chosen group.
 Decide route of administration, dosage
schedule and standard prescribed
duration.
 Write a legible prescription with name,
age, sex, weight, diagnosis, drug's
generic name, dose, route frequency
and duration of treatment with other
supportive drugs and treatment
measures with signature and date.

24.  Give relevant information, instructions
and warnings. (Before food or after
food, need for greater intake of water,
alerting or danger signals of
progression of infection and when to
report again etc.
 Monitor and review the therapeutic
response and choose an alternative in
case of intolerance, allergy or other
adverse drug reactions or poor in vivo
response (midcourse correction).

25. Case 1
•5y Krishna
•Fever 2 days
•No other complaints
•Clavam 1tsp BID
•Temp 98.6 All infections are not bacterial –
more often viral than bacterial
Antibiotics are not antipyretics, let
us respect them
Fever the most common reason
for prescribing antibiotics
Antibiotics shouldn’t be started in
hurry
Confirm fever by thermometer
Ac infections present with fever
Some bacterial infections resolve
without antibiotics
Keep temp record
Paracetamol
Explain why is the
child having fever
Fever - a defence
What to observe and
when to follow up

26. Diagnosing Acute Bacterial Infection
 If few principles are strictly followed
antibiotic misuse can be minimized to a great
extent.
 Fever is the hallmark of acute bacterial
infection and hence antibiotic therapy is not
justified in any acute symptom that is
unaccompanied with fever.

27. Exceptions :
 Neonate and shock state may be any exception
to this rule.
 Fever may not represent every time an acute
bacterial
infection.
 Causes of fever
Infection - Bacterial,viral,parasitic
Non-infective - malignancy, collagen vascular
disease, central fever, heat fever, drug fever

28. Approach to fever
FEVER
Is there a fever? Is there infection?
Is it bacterial or viral ?
Is there urgency to
start antibiotic ?

29. Clinical differentiation between
Viral infections Acute bacterial infections
Sudden onset high fever Moderate onset
Gets better by day 3 or day
four
Gradually increases and
peaks on day three or 4.
Comfortable not sick during
interfebrile period
Continues to be sick ever
during interfebrile period
Multi systems disseminated Tends to be localized
Contact history+ Contact history +/-

30.  It is important to realize that definitive
diagnosis of acute bacterial infection is
generally not possible for the first 2-3
days with the exception of
 tonsillitis,
 otitis media,
 acute lymphadenitis and
 bacillary dysentery.

31. Do no harm
Harm ?
•Diagnostic dilemma in partially
treated meningitis
Delay in diagnosis of a potentially
fatal illness
Adverse effect on outcome
•Can have life long
morbidity
Fever
• 1 y boy shiva
• Fever 2 – 3days
• Vomiting
• Augmentin
• Vomiting persists
• Convulsion and referred
• Fever ++
• Admitted
• WBC – 18,400
• CSF – 102 cells, N 30

32.  In absence of definitive diagnosis,serious
bacterial infections (meningitis, pneumonia,
diphtheria and sepsis ) MUST BE RULED
OUT- as delay would result in poor outcome.
 In case of suspicion, appropriate tests and
hospitalization are to be done prior to
antibiotics therapy.

33.  Every paediatrician must document
absence of physical signs of these
serious infections and observe further
course of the febrile illness without
antibiotic therapy.

34.  If fever persists beyond three to four days
without any localization one must consider
urinary tract infection or typhoid fever.
 Its important to do relevant laboratory tests
before instituting antibiotic therapy.
 Delay in starting an antibiotic by a day or two
does not harm the patient.

35.  Routine urine analysis may point to UTI and
ideally urine culture must be done before
starting treatment.
 It is important not to miss diagnosis of UTI as it
may cause irreversible renal damage.
 Typhoid fever demands reasonable definite
diagnosis as treatment has to be giver longer
period to cure.

36. Diagnosing chronic bacterial infections
 Like tuberculosis, chronic UTI, sinusitis
are not easily diagnosed clinically. These
need investigations.
 There are not likely to worsen on the next
few days, So there is enough time to
confirm diagnosis then start antibiotics.
 Antibiotic trial is not rational here.

37.  Antibiotics are also used for prophylaxis
of bacterial infections in selective
situations.
 It is important to strictly follow the standard
protocols for prophylaxis for rational use.
 Routine prophylaxis by broad spectrum
antibiotics is irrational and leads to
development of drug resistant organisms.
PROPHYLACTIC ANTIBIOTIC THERAPY

38. When can I use antibiotics empirically ?
• Ac. Suppurative lymphadenopathy
• Acute bacillary dysentery
Clinically obvious bacterial infection
• UTI on routine urinalysis
• Clinical pneumonia
Clinically probable bacterial infection but after
sending the tests
• Flu like illness which was improving, develops fever, creps
• Measles develops fever during recovery
Atypical progression of a viral infection

39. Empirical Antibiotic therapy
Indications :
 Young infants < 3months of age with high
fever.
 undiagnosed fever in an
immunocompromised patient.
 Fever in patient in intensive care unit
 unaccounted fever in a child with heart
defect probability of subacute bacterial
endocarditis) are high risk situations for
bacterial infections and should be treated
with antibiotics but only after relevant
investigations(CBC, Urinalysis, blood
culture and chest X-ray) sent to laboratory.

40.  Empirical use is based on personal
observation and practical experience.
 Empirical use of antibiotics is scientifically
acceptable if few prerequisites are
judicially met with.
 Therefore, it should be an endeavour of
every physician to justify antibiotic
prescription in general and specially in
case of empirical use.

41. Choice of Antibiotic
 Most of the community-acquired infections
would respond to almost any antibiotics.
 It is important to choose an antibiotic,
which has low potential to develop
resistance such as amoxicillin for oral use
or cefotaxime for parenteral use.

42. Route :
 Oral drug is always preferred unless patients
condition demands use of parenteral drug.
 In such a case, antibiotic available with both
formulations may be the best choice, So that
one could shift to oral therapy with same
drug, once patients condition stabilizes.
 Change from one parenteral drug to another
is not ideal.

43.  In stable conditions, there would always be
time available to monitor response to an
antibiotic and hence choice of antibiotic
should be restricted to first line of drugs.
 First line of antibiotics is adequate for most
of the common community acquired
infections and other antibiotics should be
reserved for specific usage such as
nosocomical infections.

44.  Broad-spectrum antibiotics are not best
for the simple community acquired
infections and infact ,narrow-spectrum
antibiotics hits the organism the hardest.

45. What’s the harm ?
(In giving antibiotics)
Fever
• 6 y, boy sagar
• Fever 5 days
• Amox- clav , no response
• Cefixime
• Better for 2 -3 days
• Fever again
• Cefixime and falcigo
• No response in 3 days
• Ciplox
• Finally referred
• Investigations delayed
Partial response misleads
• Delay in diagnosis
Interferes with proper
interpretation of tests
• TB, Leukemia, KD, SOJIA, SLE
Commonly missed or delayed
•Investigations - ALL

46. CHANGE OF ANTIBIOTIC
 In case of failure of anticipated response,
change of antibiotic may be considered
after adequate trial for 3-4days.
 Second antibiotic must be rationally
chosen, as it should widen the bacterial
cover beyond that offered by the first
antibiotic.
 If second antibiotic fails, it is best to review
the diagnosis.
 Invariably wrong diagnosis is the cause of
antibiotic failure and not the drug itself.

47.  Addition of another antibiotic when the
first one fails is not rational in acute
bacterial infection.
 If first one has failed, it should be
replaced.

48. COMBINATION ANTIBIOTIC THERAPY
 It is irrational to use two antibiotics for a single
infection. It may be necessary only in
selective situations.
 Rationality of combination
-constituents act by different mechanisms
-pharmacokinetics-almost same
-targets organisms causing a single disease
-no supra-additive toxicity

50.  When to use combination therapy
- Life-threatening conditions
- Mixed infections
- To prevent drug resistance
development.
- True synergistic combinations

51. Case
Fever
• 10 y girl Padmini
• High Fever 1 day
• Cefixime 1 ½ tsp BD x 3 d
• Chloroquine 1tspBD x 3
days
Practice Pearls
Don’t use poly therapy – antimalarial
and antibiotic
Don’t use antimalarial without definite
diagnosis
irrational use of Chloroquine over the
time has led to resistance to
chloroquine
Let us use new antimalarial
judiciously
Paracetamol and counseling
Try and differentiate viral from
bacterial
Wait for it to evolve if there are no
red flags
Ask to keep temp. record

52. Common complaints
for which antibiotics are prescribed
FEVER
Cough cold fever
Fever loose
motions vomiting
dysentery
Cough fever
difficulty in
breathing
Skin infections
cellulitis boils
ABSCESS,
Impetigo

53. Case
4 year old Anusha
LM and vomiting since
a day
Watery motions and
passing adequate
urine
Febrile, no
dehydration
Which of the following will you
prescribe ?
Normetrogyl
Taxim O
Ciplox TZ
Lomotil
None
Practice Pearls
Most diarrheas in under 5
are viral
Amebic dysentery is
Extremely uncommon
(< 2%)
• ORS to prevent and correct
dehydration
• Oral Zinc for 14 days
• (20mg in >6m, 10mg in <6m)
Rational treatment

54.  ORS remains the mainstay of therapy
during acute diarrhea and zinc as an
adjunct as an additional modest benefit
in reducing the stool volume and
duration of diarrhea.

55.  10 month old Vani, brought with
 Illness 2 days
 Started with vomiting 6-7/day
 Fever
 Frequency of stool 12-15/day, watery,
large quantity
 On BF + Weaning diet
Case - Vani

56.  Ill look
 Depressed AF
 Dry skin and mucous membrane
 Sunken eyeballs
 Rapid, low volume pulse
How will you manage?
Vani on examination....

57. Child with Acute Diarrhea
Watery Diarrhea
without blood in stool
Diarrhea with
macroscopic blood in stool
in stool
Diarrhea with
Systemic infection
Assess
dehydration
Severe
dehydration
Mild to
moderate
dehydration
IV fluids
ORS(10)
Zinc (11)
Continued
frequent
feeding -
including BF
ORS (10)
Zinc (11)
Continued
frequent
feeding -
including BF
Pallor, Purpura,
Oliguria Hosptalise
No antibiotics

58.  Antimicrobial drugs are not required for routine
treatment of acute diarrhea because most episodes
are caused by pathogens for which antimicrobial
drugs are not effective.
Etiology of acute diarrhea
Pathogen incedence
Rotavirus 25-30%
Enterotoxigenic E.coli (ETEC) 20%
Shigella 5-10%
Enteropathogenic E. Coli (EPEC),
Locally adherent E.coli Campylobacter,salmonella
5-7%
G.lambia, E.histolytica <2%
V. Cholerae 5-10%

59. When should Antimicrobials be given for
acute diarrhea ?
The only specific clinical indications for
use of antimicrobial
agents where they have been found
useful include :
• Suspected cholera with severe
dehydration
• Blood diarrhea (probably shigellosis)
• Seriousness associated non
gastrointestinal infections. e.g.
Pneumonia, septicemia, meningitis,
urinary tract infection etc.

60. Anti diarrheal Agents
 Motility suppressants decrease
intestinal peristalsis and delay the
elimination of causative organisms.
 Their use in infants can be particularly
dangerous causing paralytic ileus
respiratory depression abdominal
distension bacterial overgrowth and
sepsis.

61. Combination therapy
 Several combinations of antibacterial agents
and of antibacterials with antidiarrheals are
available.
 They offer no extra benefits.
 Combination therapy can promote over
growth of harmful resistant bacteria and the
anti motility agents that are often a part of
delay excretion of invasive pathogens.

62. Probiotics
 Insufficient evidence to recommend
probiotics in the treatment of acute
diarrhea.

63.  Enteric fever is an important cause of
morbidity .Resistance in salmonella is
very dynamic and changes with
changing patterns of drug use
 Empirical therapy is started in clinically
suspected but cultures not sent, or
results not available or culture negative.
 It is important to send blood cultures so
that diagnosis is
unequivocal,antimicrobial susceptibility
of isolate and local resistance patterns
will be available.

64. SITUATION Local
susceptibility
patterns
FIRST LINE 2ND LINE
SEVERE
ILLNESS/
INPATIENT/
COMPLICATION
S
High
prevalence of
nalidixic acid
resistance and
Low
prevalence
CEFTRIAXONE
(75-100
mg/kg/day-BD-
IV)-
Cefotaxime,
Aztreonam,
Ampicillin,
chloramphenicol
OUTPATIENT
THERAPY
of resistance to
amp/chloram/
cotrimox
CEFIXIME(15-
20 mg/kg/day)
AZITHROMYCI
N(10-
20mg/kg/day)-
5-7 days
chloramphenicol
Amoxicillin
Cotrimoxozole
High dose
quinolones
Duration- 14 DAYS ,course may be completed with oral third generation
cephalosporins once complications resolved and oral intake is satisfactory.

65. Frank Tally, the chief scientific officer of Cubist
Pharmaceuticals who played a major role in bringing
cefixime

66.  Combination therapy not recommended.
 When failure to respond,if blood cultures
positive –check antimicrobial
susceptibility and modify drug acc,.
 Look for –coinfections ,complications
phlebitis, drug fever, hemophagocytic
syndrome
 Relapse-right dose for right duration.

67. Fever and cold,
cough
• 1yr Shiva
• High fever 2 days
• Cold, cough 2 days
• What will you use?
• Cefixime
• Amox-clav
• Clav pod
• None
Remember
Most of the URI seen in OPDs are viral
Symptomatic treatment
•Counseling
•Self limiting nature of the illness
•Signs to observe for fu

68. Case
• 3 ½ yr old girl renuka
• Cough cold and fever 2 days
• Mother says this is the 4th episode in last
5 months and he gets better only with
antibiotics
• Every episode for 2 -3 days, child doing
well otherwise
Up to 6 episodes/yr of URI not uncommon in a healthy child
“Child better with antibiotics” and not because of antibiotics”

69.  Most upper respiratory tract infections are
viral and do not merit antibiotics. Antibiotics
do not prevent bacterial superinfection.
 Antibiotics are indicated for acute bacterial
sinusitis,ASOM and streptococcal sore
throat. Amoxicillin is the drug of choice for all
;
 In severe or non responsive sinusitis and
otitis media coamoxiclav may be used.
 Third generation cephalosporin's should be
used sparingly.

70. RHINOSINUSITIS
Symptoms :
 Nasal/post nasal discharge
 Daytime cough for more than 10days less
than 30 days.
 Temperature of 102 Fahrenheit.
 Purulent nasal discharge for 3 to 4
consecutive days.

71. Acute
sinusitis
Antibiotics first line Treatment failure 48-
72hrs
Non severe Amoxycillin
(45mg/kg/day BD)
Co-amoxiclav
Severe Coamoxiclav
(30-40mg/kg/day TID)
Ceftriaxone
(75mg/kg/day for
3days)
For patients who are allergic to amoxicillin,
Cefdinir
Cefuroxime
Cefopodoxine
In cases of serious allergic reactions,
Clarithromiycin
Azithromycin.

72. Case 1: sagar
sagar 2 yrs old male,
 Brought with history of fever and cough with rhinorrhoea of
two days
 red eyes,
 diarrhea,
 No exanthema,
 cough ++
 H/o Similar case
in family
 O/E Throat congested
How will you manage?
Your thoughts……………

73. Clinically diagnosed : Viral URI - seasonal
(pharyngotonsillitis)
 Management:
◦ General & Symptomatic Therapy
◦ Antibiotics : Not needed

74. 41/2 year old Sai - brought to your clinic with 2 days
history of high spiking fever and mild cough
From history and examination:
 Has no red eyes or rhinorrhea
 No exanthema
 Difficulty in swallowing,
 No history of similar case in the family
 He looks sick even when afebrile
2nd Case: Sai

75. Sai on examination……
 RR 28, HR 110
 perfusion and B.P normal
 Rt tonsil showed a purulent
discharge with inflammation of
both tonsils
 Bilateral tender cervical LN++
 Ear and Nose – Normal
 Other system examination –
normal
How will you manage?......

76. sagar and Sai– what difference?
sagar
 Acute onset, Red eyes,
rhinorrhea, cough++, diarrhea
 No rashes
 Pharyngeal congestion but no
or scanty exudates and no
cervical lymphadenopathy
 Age less than 3 years
Most probably viral
Sai
 Acute onset, throat pain,
rapid progression, very little
cough/cold
 Pharyngeal congestion
more, thick exudates or
follicles, purulent patchy
lesions on tonsils with tender
enlarged LN
 Toxicity ++
 Age more than 3 years
Most probably bacterial

77. PHARYNGITIS
causes
Viral Bacterial
Rhinovirus Strep pyogenes(15-20%)
Coronavirus gpC/G strep
Adenovirus N gonorrhoea
HSV Corynbackterium
diphheriae
Parainfluenza Arcannobacterium
haemolyticum
Influenza Mycoplasma
coxasackie virus C pneumoniae
EBV Yersinia enterocolitica
Group A B haemoglytic streptococcal pharyngitis is the only commonly occuring form of ba
Pharyngitis for which antibiotic therapy is definitely indicated.

78. GABHS
Conjunctivitis,
Cough,
Coryza,
Viral exanthema
Fever higher than 100f,
Tonsillar swelling or excudates,
Tender cervial lymphadenopathy,
Absence of cough
Viral pharyngitis
Symptomatic
treatment.
Response
No
response
bacterial
Antibiotics

79. Case 3: murali
 murali, a 15 month otherwise healthy
boy had rhinorrhea, cough and fever of
1020F for two days
 On day 3, he became fussy and woke
up crying multiple times at night
WHAT COULD BE WRONG?
HOW DOES ONE EVALUATE THIS CHILD ?

80. MURALI HAS ACUTE OTITIS
MEDIA RIGHT EAR
On examination of Rt ear:
 Erythema
 Fluid
 Impaired mobility
 Acute symptoms
MANAGEMENT ?

81. Management AOM – Under 2
Yrs
 Analgesia
◦ Paracetamol in adequate doses as good as
Ibuprofen
 Antibiotics in divided doses for 10 days
◦ Choice - first line Amoxycillin / Co-
amoxyclav
◦ Second line
 Second generation cephalosporins e.g.
Cefaclor, cefuroxime.
 Co amoxyclav – if not used earlier
 Decongestants no role

82. ACUTE OTITIS MEDIA
 AOM is defined as presence of middle ear
effusion plus the presence of symptoms or sign.
 It can be with perforation or without perforation.
Indications for Antibiotics.
•Children less than 2yrs with bilateral AOM.
•Children >2y with severe infection.
•Children who have AOM with perforation.
•Children at high risk of complication.
•Children who didn't improve after 48 hrs of watchful
waiting.

83. AcuteOtitisMedia Antibiotics first line Treatment failure 48-
72hrs
Non severe Amoxycillin(45mg/kg/
day BD)
coamoxiclav
Severe Coamoxiclav(30-
40mg/kg/day TID)
Ceftriaxone(75mg/kg/
day for 3days)

84. Case
• 7 month Madhu
• Fever, cough and rapid breathing x 2 days
• Febrile, RR 66/m
• Nasal flaring, grunt, Crepts+
• What is it ?
Severe pneumonia
What is recommended ?
Refer to Pediatrician

85.  Pneumonia is the leading cause of mortality and
common cause of morbidity in children below
five years of age.
 In developing countries bacterial infections are
the most common cause of pneumonia
,streptococcus pneumoniae and hemophilus
influenzae being common bacterial pathogens
identified.
 Administration of appropriate antibiotics in the
early course of pneumonia alters the outcome of
illness

86.  In view of better outcome of pneumonia by
early administration of antibiotics and inability
to clinically differentiate between bacterial
and viral pneumonia, antibiotics are
administered to all children with pneumonia.

87. Treatment for pneumonia
Treat a
severe
pneumonia
Below 3
months
Above
3months
severe
3m to 5y
Co amoxiclav
if no response
amoxicillin
Amoxicillin
+/- Azithro
Refer for
hospitalization
Non severe
Above 5yrs

88. Treatment of pneumonia
 Children less than 3 months:
 Hospitalized- intravenous antibiotics
 3rd gen cephalosporins and
aminoglycoside.

89. DISEASE PNEUMONIA
Setting DOMICILLARY- ORAL
Age First line Second line Suspected
staphylococcal disease
3mo to 5y of age Amoxycillin
Cotrimoxazole
Co-amoxy
Clavulanic acid
Cefuroxime
Cefpodoxime
Cefdinir
Amoxycillin +
Cefuroxime
Co-amoxy
Clavulanic acid
5y plus Amoxycillin Macrolide
Co-amoxy
Amoxycillin +
Cefuroxime
Co-amoxy
Clavulanic acid
cloxacillin

90. DISEASE SEVERE PNEUMONIA
Setting IN PATIENT -INTRAVENOUS
Age First line Second line Suspected
staphylococcal disease
3mo to 5y of
age
Inj ampicillin
Inj co-amoxy
Clavulanic acid
Inj ceforoxime
Inj co-amoxy
Clavulanic acid
Inj 3rd gen
cephalosporins
Cefotaxime/ceftriaxone
Inj 3rd gen
cephalosporins
Cefotaxime/ceftriaxone
+
Cloxacillin
inj cefuroxime
Inj co-amoxy
Clavulanic acid
Secondline :
vancomycin/teicoplanin
+inj 3rd gen
cephalosporins
5y plus Inj ampicillin
Inj co-amoxy
Clavulanic acid
Macrolides
Inj co-amoxy
Clavulanic acid
Inj 3rd gen
cephalosporins
Cefotaxime/ceftriaxone
Macrolides
Inj 3rd gen
cephalosporins
Cefotaxime/ceftriaxone
+
Cloxacillin
inj cefuroxime

91. Fever in infants
Need for urgent investigations for acute
bacterial infection.
Consider UTI,pneumonia,meningitis before
specific therapy
Treatment without diagnosis leads to
complications with permanent sequelae

92. RED FLAGS Age <3 months
Not able to to drink or feed
Lethargic or unconcious
Respiratory distress
Convulsions
Sick looking when afebrile
present
absent
Observe and record
temperature
Use only paracetamol
Rule out serious illness
Look for localization
Reasses and investigagate
HOSPITALISATIO
N

93. Don’t miss UTI
UTI is a common cause of fever in
children
Antibiotic without ruling out UTI
may lead to partial or incomplete
treatment and renal scarring
Urinalysis and Culture essential
before Abx
case
• ganesh 4y, is a
k/c/asthma on inhaled
salbutamol and
budesonide
• Fever with chills x 2d
• No cough cold
• Given Amoxicillin
• Urine R – 18-20 pc/hpf
Urinary symptoms may not be there
in young children
Think of UTI in all cases of
FWF

94.  For suspected severe acute UTI-
antimicrobial therapy should be started
immediately after urine culture is sent.

95. Treatment
 Therapy should be prompt to reduce the
morbidity of infection, minimize renal damage
subsequent complications.
 Indications for hospitalization-
 For IV rehydration and IV Antibiotic therapy in
 Children who are dehydrated, are vomiting, are
unable to drink fluids,
 Less than 3 months of age,
 With complicated UTI

96.  The choice of antibiotic should be guided by
local sensitivity patterns.
 A third generation cephalosporin is
preferred.
 Therapy with a single daily dose of an
aminoglycoside may be used in children with
normal renal function.
 Intravenous therapy is given for the first 2-3
days followed by oral antibiotics once the
clinical condition improves.

97. Antimicrobial treatment
Medication Dose , mg/kg/day
PARENTERAL
Ceftriaxone 75-100,in 1-2 divided
doses iv
Cefotaxime 100-150,in 2-3 divided
doses
Amikacin 10-15,single dose iv or
im
Gentamicin 5-6,single dose iv or im
coamoxiclav 30-35 of amoxicillin,in 2
divided doses iv

98.  Children with simple UTI and those above 3
months of age are treated with oral
antibiotics.
 With adequate therapy, there is resolution
of fever and reduction of symptoms by 48-
72 hours.
 Failure to respond may be due to presence
of resistant pathogens, complicating factors
or noncompliance; these patients require
reevaluation.

99. ORAL
Medication Dose , mg/kg/day
oral
Cefixime 8-10,in 2 divided doses
Coamoxiclav 30-35 of amoxicillin,in 2
divided doses
Ciprofloxacin 10-20,in 2 divided doses
Ofloxacin 15-20,in 2 divided doses
Cephalexin 50-70,in 2-3 divided
doses

100. The duration of therapy
 -14 days for infants and children with
complicated UTI
- 7-10 days for uncomplicated UTI.
• Following the treatment of the UTI,
prophylactic antibiotic therapy is initiated
in children below 1 year of age, until
appropriate imaging of the urinary tract is
completed.

101. Newborn with fever
Practice Pearls
• Well looking neonate with fever can
have serious bacterial infections
Document fever
• Environmental or dehydration fever is a
diagnosis by exclusion
Never give antibiotics without
proper work up
Seek pediatrician’s opinion
Case
• 15 d baby of aruna
• Fever x 2 days
• Baby looks well
• What antibiotic ?
• Amxo clav
• Inj Gentamycin
• Cefixime
• Referred to
pediatrician
• Critical and in ICU

102. WHAT WE CAN DO
?????
DONT LISTEN,
I wanna grow

103.  Problem of drug resistance is a result
of our own wrong doing and before the
situation gets out of control, we need
to act seriously.
 Following Protocols and guidelines
formulated by an official scientific
organization will help in rational use of
antibiotics ,would serve the community
best and also protect physicians from
legal hassles.

104.  Every physician should document
probable diagnosis and basis for such
a diagnosis before writing a
prescription.
 Fostering awareness about
antimicrobial resistance and rational
antibiotic practice is to be done which
is a part of the IAP ICMR call to action
declared this year-2014.And it is
ACTION time now!

106.  As a commitment to reduce antibiotic misuse,
September 28 will be observed as Rational
Antibiotic Day and the week (Sep 28 – Oct 4) as
Antibiotic Awareness Week.
 September 28 has been selected in
commemoration with Sir Alexander Fleming's
discovery of penicillin.
 Awareness campaigns, rallies, talks in media,
webinars, and sensitizing the family practioners
on rational antibiotic practices through lecture,
CMEs to be done.

108. EMERGING AND RE EMERGING INFECTIOUS
DISEASES
 The theme of the world health day –
april 7 ,1997 “EMERGING
INFECTIOUS DISEASES-GLOBAL
ALERT:GLOBAL RESPONSE”

109. “The Chennai Declaration”
 “A Roadmap to Tackle the Challenge of Antimicrobial
Resistance - A Joint meeting of Medical Societies in
India” was at Chennai on 24th August. This was the first
ever meeting of medical societies in India on issue of
tackling antimicrobial resistance.
 We had representatives from most medical societies in
India, eminent policy makers from both central and state
governments,
 representatives of WHO, National Accreditation Board
of Hospitals, MCI Drug Controller General of India, and
ICMR along with well-known dignitaries in the Indian
medical field.
 The meeting consisted of interactive discussion
sessions designed to seek experience and views from a
large range of health care professionals and included
six international experts who shared action plans in their
respective regions.
 The intention was to gain a broad consensus and range

110. WHO ADVOCATES 12 KEY INTERVENTIONS TO
PROMOTE MORE RATIONAL USE
 Establishment of a multidisciplinary
national body to coordinate policies on
medicine use
 Use of clinical guidelines
 Development and use of national
essentional medicines list
 Establishment of drug and therapeutics
committees in districts and hospitals
 Inclusion of problem based
pharmacotherapy training training in
undergraduate curricula

111.  Continuing in service medical
education as a licensure requirement
 Supervision , audit and feedback
 Use of independent information on
medicines
 Public education about medicines
 Avoidance of perverse financial
incentives
 Use of appropriate enforced regulation
 Suffficient govt expenditure to ensure
availability of medicines and staff

112. Antibiotic Stewardship
 Restricting the usage of antibiotics
 Restricting use of broad spectrum
antibiotics
 Surveillance and auditing of cultures
 Protocol of antibiotic prescription
 Infection control committee
 Improving infection control practices

113. Surveillance and Audit
 Surveillance culture from the unit
 Audit of processes
- Hand hygiene, IV cannulation, procedures
- Usage of disinfectants
- Availability of disinfectants
 Audit of cultures
- Type of organisms (EOS and LOS)
- Sensitivity pattern
- 1st line, 2nd line empiric antibiotics

114. •Seminars
•Panel discussion
•Updates
Educating Practitioners

115. Educating Consumers
No own antibiotic kit Emphasis on dose
and duration
No self medication

116. TAKE HOME MESSAGE

117. Golden rules for Judicious
use of antimicrobials
Golden rule 1
Acute infection always presents with fever;
in acute illness, absence of fever does not justify
antibiotic
Golden rule 2
Infection is the most common cause of fever in office
practice, though not always bacterial infection
- Viral infection in majority RTI
- Viral infection should not be treated with antibiotic

118. Golden rule 3
Clinical differentiation is possible between
bacterial and viral infection most of the times
• Viral infection is disseminated throughout the system
(URTI / LRTI)
- May affect multiple systems
- Fever is usually high at onset, settles by D3-4
- Child is comfortable and not sick during inter febrile
state
• Bacterial infection is localized to one part of the
system
(acute tonsillitis does not present with running nose or
chest signs)
- Fever is generally moderate at the onset and peaks
by D3-4
• CBC does not differentiate between acute bacterial and
viral infection

119. Golden rule 4
Chronic infection may not be associated with
fever and diagnosis can be difficult
- Relevant laboratory tests are necessary
- Antibiotic is considered only after observing
progress
- There is no need to hurry through antibiotic
prescription

120. Golden rule 5
Choose single oral antibiotic, either covering
suspected gram positive or negative organism,
as per site of infection and age of patient
• Combination of two antibiotics is justified
only in serious bacterial infection without
proof
of specific organism and can be
administered intravenously

121. Golden rule 6
At first visit (within 48 hrs of fever) antibiotic is
justified only
if bacterial infection is clinically certain
and that does not call for any tests prior to starting
the drug
(Acute tonsillitis / acute otitis media / bacillary
dysentery
/ acute suppurative lymphadenitis)
• If bacterial infection is clinically strongly suspected but
should have confirmative tests prior to starting drug,
then order relevant tests and start appropriate antibiotic
(Acute UTI)
• In absence of clinical clue but not suspected to be
serious
disease, observe without antibiotic and follow the

122. R-Reasoning behind prescription
> > - Right dose, route, duration
> > A-Academically updated decisions
> > T-Training of mind (3 ‘O’s-Organ,
Organism, Option)
> > -Training of subordinates (Resident
doctors etc.)
> > -Training parents (not to pressurize
the doctor)
> > -Training chemists (to refrain from
selling without valid prescription)
> > I-Instructions to parents
> > (reconstitution, administration,
completing the course, not to self
medicate)

123. O-Organism
> > ( finding out the causative organism by
culture etc.)
N-Noting down the diagnosis
> > (if you clinically diagnose & write provisional
diagnosis as viral, your hands should shake while
writing an antibiotic)
A-Avoiding double standards
> > ( writing one in private OPD , using a
different one in a general hospital and speaking
totally different in conferences)
> > -Avoiding irrational combinations
> > -Antibiotic Policy
L- Local sensitivity pattern
> > (includes our active efforts & research in
office practice)
E-Ethical considerations
> > -Economic condition of the patient

124. REFERENCES
 IAP- ANTIMICROBIAL THERAPY 2013
GUIDELINES
 Mission:avoid antibiotic abuse-vijay n
yewale
 IAP- vol 51-june15 2014 GUIDELINES
 Optimize use of antibiotics in nicu-
srinivas mukri
 Prescribing antibiotics in pediatrics-raju
shah
 Antimicrobial resistance-ghafur

125.  Iap-vol 16 jul-sep 2014
 recent advancs in pediatrics –anupam
sachdev
 Rational antibiotic therapy – dr.vijay
yewale
 Rational drug therapy-vikas dua,anupam
sachdev

126. Thank You !!!