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Guidelines for the Use of Antibiotics in Respiratory Tract Infections

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Azad Haleem
Azad Haleem

This document discusses antibiotics, including their definitions, classifications, mechanisms of action, and appropriate uses for various infections. It notes that antibiotics can kill or inhibit microorganisms and come in various classes. It provides details on antibiotic classifications including their spectrum of activity (broad vs narrow), site of action, and type of action (bacteriostatic vs bactericidal). The document also discusses antibiotic resistance and inappropriate prescription of antibiotics. It provides guidance on appropriate antibiotic use for various respiratory tract infections like otitis media, sinusitis, pharyngitis, cough illnesses, and pneumonia.

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Guidelines for the Use of Antibiotics in Respiratory Tract Infections
Guidelines for the Use of Antibiotics in Respiratory Tract Infections
ANTIBIOTICS • Antibiotics can be defined as substances capable of killing & inhibiting the growth of micro organisms. • The term antibiotics literally means “against life”; in this case, against microbes. • There are many types of antibiotics— antibacterials, antivirals, antifungals, and antiparasitics.
• Antibiotics have transformed the practice of medicine, making once lethal infections readily treatable and making other medical advances, like cancer chemotherapy and organ transplants, possible. ANTIBIOTICS
Classifications of Antibiotics Classifications of Antibiotics Spectrum of activity Broad spectrum Narrow spectrum Site of action Type of action Bacteriostatic Bactericidal
1. Mechanism of action Site of action
2. Mode of action • Bacteriostatic vs. bactericidal drugs; • Bacteriostatic – arrest the growth and replication of bacteria at serum levels achievable in the patient. – limit the spread of infection while the body's immune system attacks, immobilizes, and eliminates the pathogens. Type of action
• Bactericidal – kill bacteria at drug serum levels achievable in the patient. • It is possible for ATB to be bacteriostatic for one organism and bactericidal for another. 2. Mode of action
2. Type of action
3. Spectrum of activity o Narrow spectrum • only against a single or a limited group of microorganisms, e.g. INH is active only against mycobacteria. o Broad spectrum • affect a wide variety of microbial species. • Alter the normal bacterial flora ???? • precipitate a superinfection of an organism, e.g., candida.
3. Spectrum of activity
Drug resistance • about 30% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or suboptimal. • Like all medications, antibiotics have serious adverse effects, which occur in roughly 20% of hospitalized patients who receive them.
Inappropriate prescription • CDC estimates more than two million people are infected with antibiotic-resistant organisms, resulting in approximately 23,000 deaths annually. • “Antibiotic resistance comes mainly because of inappropriate or improper use of antibiotics by physicians. Some 150 million prescriptions are written annually in this country. And 60 percent of them — that translates to 90 million prescriptions — are for antibiotics. Of those, 50 million are absolutely unnecessary or inappropriate”. — Dr. Philip Tierno, director of clinical microbiology and diagnostic immunology at New York University Medical Center
Facing the End of the Antibiotic Era • Very few new antibiotics during past 30 years • More toxic antibiotics being used to treat common infections • Future currently not looking very promising
Acute Respiratory Tract Infections
ILLNESS/PATHOGEN Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis INDICATIONS FOR ANTIBIOTIC TREATMENT When to treat with an antibiotic: Recent, usually abrupt onset of signs and symptoms of middle ear inflammation and effusion and Presence of middle ear effusion that is indicated by any of the following: bulging of the tympanic membrane, limited or absent mobility of tympanic membrane, air fluid level behind the tympanic membrane, otorrhea and Signs or symptoms of middle ear inflammation as indicated by distinct erythema of the tympanic membrane or Distinct otalgia (discomfort clearly referable to the ear[s] that interferes with or precludes normal activity or sleep) When not to treat with an antibiotic: Otitis media with effusion Otitis media
ANTIBIOTIC First-line therapy High-dosage amoxicillin (80 to 90 mg per kg per day) If severe illness or additional coverage desired:high-dosage amoxicillin/clavulanate (80 to 90 mg per kg per day of amoxicillin component) Alternative therapy Non anaphylactic penicillin-allergic: cefdinir , cefpodoxime , or cefuroxime. penicillin allergy: azithromycin or clarithromycin Unable to tolerate oral antibiotic: ceftriaxone Otitis media Usual antibiotic duration 10 days
Acute bacterial sinusitis S. pneumoniae, nontypeable H. influenzae, M. catarrhalis When to treat with an antibiotic: Diagnosis may include some or all of the following symptoms or signs: nasal drainage, nasal congestion, facial pressure or pain, postnasal discharge, hyposmia, anosmia, fever, cough, fatigue, maxillary dental pain, ear pressure or fullness. When not to treat with an antibiotic: Antibiotic use should be reserved for moderate symptoms not improving after 10 days or that worsen after five to seven days, and severe symptoms. Usual antibiotic duration: 10 days Failure to respond after 72 hours of antibiotics: reevaluate patient and switch to alternate antibiotic. Fiberoptic endoscopy or sinus aspiration for culture may be necessary. First-line therapy Amoxicillin (80 to 90 mg per kg per day) Alternative therapy Amoxicillin/clavulan ate (80 to 90 mg per kg per day of amoxicillin component), cefpodoxime, cefuroxime, cefdinir, ceftriaxone For beta-lactam allergy: TMP-SMX (Bactrim, Septra), macrolides. Acute bacterial sinusitis
Pharyngitis Streptococcus pyogenes, routine respiratory viruses When to treat with an antibiotic: S. pyogenes (group A streptococcal infection). Symptoms and signs: sore throat, fever, headache, nausea, vomiting, abdominal pain, tonsillopharyngeal erythema, exudates, palatal petechiae, tender enlarged anterior cervical lymph nodes. Confirm diagnosis with throat culture or rapid antigen testing. When not to treat with an antibiotic: Respiratory viral causes, conjunctivitis, cough, rhinorrhea, diarrhea uncommon with group A streptococcal infection First-line therapy Penicillin V , penicillin G benzathine penicillin Alternative therapy Amoxicillin, Oral cephalosporins, macrolides Pharyngitis
Nonspecific cough illness/bronchitis> 90 percent of cases caused by routine respiratory viruses < 10 percent of cases caused by Bordetella pertussis, Chlamydia pneumoniae, or Mycoplasma pneumoniae When to treat with an antibiotic: Presents with prolonged un improving cough (14 days); should clinically differentiate from pneumonia. Pertussis should be reported to public health authorities. C. pneumoniae and M. pneumoniae may occur in older children (unusual in those younger than five years). When not to treat with an antibiotic: Nonspecific cough illness Treatment reserved for B. pertussis, C. pneumoniae, M. pneumoniae Macrolides (tetracyclines for children older than eight years) Nonspecific cough illness/bronchitis
nonspecific URI > 200 viruses, including rhinoviruses, coronaviruses, adenoviruses, respiratory syncytial virus, enteroviruses (coxsackieviruses and echoviruses), influenza viruses, and parainfluenza virus When not to treat with an antibiotic: Sore throat, sneezing, mild cough, fever (generally less than 102ºF [39ºC], for less than three days), rhinorrhea, nasal congestion; self-limited Adequate fluid intake; may advise rest, over-the-counter medications, humidifier Nonspecific URI
Age group Pathogen Neonates (<3 wk) Group B streptococcus, Escherichia coli, other Gram-negative bacilli, Streptococcus pneumoniae, Haemophill (type b,* nontypeable) 3 wk-3 mo Respiratory syncytial virus, other respiratory viruses (rhinoviruses, parainfluenza viruses, influenza viruses, hum metapneumovirus, adenovirus), S. pneumoniae, H. influenzae (type b,* nontypeable); if patient is afebrile, consider Chlamydia trachomatis. 4 mo-4 yr Respiratory syncytial virus, other respiratory viruses (rhinoviruses, parainfluenza viruses, influenza viruses, huma metapneumovirus, adenovirus), S. pneumoniae, H. influenzae (type b,* nontypeable), Mycoplasma pneumonia, group A streptococcus. More than 5 years M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. influenzae (type b,* nontypeable), influenza, adenovirus, other respiratory viruses, Legionella pneumophila. Lower respiratory tract infection (LRTI)
• Admission is advised for severe LRTI. This is indicated by: • Oxygen saturation <92%. • Respiratory rate >70 breaths/minute (≥50 breaths/minute in an older child). • Prolonged central capillary refill time >2 seconds. • Difficulty in breathing as shown by intermittent apnoea, grunting and not feeding. • Presence of comorbidity - eg, congenital heart disease, chronic lung disease of prematurity, chronic respiratory conditions such as cystic fibrosis, bronchiectasis or immune deficiency should also prompt consideration of admission. • Admission should also be considered for: • All children under the age of 6 months. • Children in whom treatment with antibiotics has failed (most children improve after 48 hours of oral, outpatient antibiotics). • Patients with troublesome pleuritic pain.
Treatment • For mildly ill children who do not require hospitalization, amoxicillin is recommended. • With the emergence of penicillin-resistant pneumococci, high doses of amoxicillin (90 mg/kg/day orally divided twice daily) should be prescribed unless local data indicate a low prevalence of resistance. • Therapeutic alternatives include cefuroxime and amoxicillin/clavulanate.
• For school-aged children and adolescents or when infection with M. pneumoniae or C. pneumoniae is suspected, a macrolide antibiotic is an appropriate choice for outpatient management. • Azithromycin is generally preferred, , while clarithromycin or doxycycline (for children 8 yr or older) are alternatives. • For adolescents, a respiratory fluoroquinolone (levofloxacin, moxifloxacin) may also be considered as an alternative if there are contraindications to other agents.
• The empiric treatment of suspected bacterial pneumonia in a hospitalized child requires an approach based on local epidemiology, the immunization status of the child, and the clinical manifestations at the time of presentation. • In areas without substantial high-level penicillin resistance among S. pneumoniae, children who are fully immunized against. H. influenzae type b and S. pneumoniae and are not severely ill should receive ampicillin or penicillin G. • For children who do not meet ceftriaxone or cefotaxime may be used. • If clinical features suggest staphylococcal pneumonia (pneumatoceles, empyema), initial therapy should also include vancomycin • Moreover, if infection with M. pneumonia or C. pneumoniae is suspected, macrolide antibiotic should be included in the in the treatment regimen.
• If viral pneumonia is suspected, it is reasonable to withhold antibiotic therapy, especially for preschool- aged patients who are mildly ill, have clinical evidence suggesting viral infection, and are in no respirator distress. • However, up to 30% of patients with known viral infection. particularly influenza viruses, may have coexisting bacterial pathogens. • Therefore, if the decision is made to withhold antibiotic therapy on the basis of presumptive diagnosis of a viral infection, deterioration in clinical status should signal the possibility of superimposed bacterial infection, and antibiotic therapy should be initiated.
• The optimal duration of antibiotic treatment for pneumonia has not been well-established in controlled studies. • However, antibiotics should generally be continued until the patient has been afebrile for 72 hr, and the total duration should not be less than 10 days (or 5 days if azithromycin is used). • Preliminary studies suggest that a reduction of previously elevated serum procalcitonin levels to an absolute level (0.1-0.25 µg/L) may help determine when to stop treatment.
• In addition to antibiotics, oral zinc (10 mg/day for < 12 mo, 20 mg/day for ≥ 12 mo given for 7 days) may reduce mortality among children in developing countries with clinically defined severe pneumonia.
THANKS FOR LIMITATION IN USING OF ANTIBIOTICS

More Related Content

Guidelines for the Use of Antibiotics in Respiratory Tract Infections

  • 3. ANTIBIOTICS • Antibiotics can be defined as substances capable of killing & inhibiting the growth of micro organisms. • The term antibiotics literally means “against life”; in this case, against microbes. • There are many types of antibiotics— antibacterials, antivirals, antifungals, and antiparasitics.
  • 4. • Antibiotics have transformed the practice of medicine, making once lethal infections readily treatable and making other medical advances, like cancer chemotherapy and organ transplants, possible. ANTIBIOTICS
  • 5. Classifications of Antibiotics Classifications of Antibiotics Spectrum of activity Broad spectrum Narrow spectrum Site of action Type of action Bacteriostatic Bactericidal
  • 6. 1. Mechanism of action Site of action
  • 7. 2. Mode of action • Bacteriostatic vs. bactericidal drugs; • Bacteriostatic – arrest the growth and replication of bacteria at serum levels achievable in the patient. – limit the spread of infection while the body's immune system attacks, immobilizes, and eliminates the pathogens. Type of action
  • 8. • Bactericidal – kill bacteria at drug serum levels achievable in the patient. • It is possible for ATB to be bacteriostatic for one organism and bactericidal for another. 2. Mode of action
  • 9. 2. Type of action
  • 10. 3. Spectrum of activity o Narrow spectrum • only against a single or a limited group of microorganisms, e.g. INH is active only against mycobacteria. o Broad spectrum • affect a wide variety of microbial species. • Alter the normal bacterial flora ???? • precipitate a superinfection of an organism, e.g., candida.
  • 11. 3. Spectrum of activity
  • 12. Drug resistance • about 30% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or suboptimal. • Like all medications, antibiotics have serious adverse effects, which occur in roughly 20% of hospitalized patients who receive them.
  • 13. Inappropriate prescription • CDC estimates more than two million people are infected with antibiotic-resistant organisms, resulting in approximately 23,000 deaths annually. • “Antibiotic resistance comes mainly because of inappropriate or improper use of antibiotics by physicians. Some 150 million prescriptions are written annually in this country. And 60 percent of them — that translates to 90 million prescriptions — are for antibiotics. Of those, 50 million are absolutely unnecessary or inappropriate”. — Dr. Philip Tierno, director of clinical microbiology and diagnostic immunology at New York University Medical Center
  • 14. Facing the End of the Antibiotic Era • Very few new antibiotics during past 30 years • More toxic antibiotics being used to treat common infections • Future currently not looking very promising
  • 16. ILLNESS/PATHOGEN Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis INDICATIONS FOR ANTIBIOTIC TREATMENT When to treat with an antibiotic: Recent, usually abrupt onset of signs and symptoms of middle ear inflammation and effusion and Presence of middle ear effusion that is indicated by any of the following: bulging of the tympanic membrane, limited or absent mobility of tympanic membrane, air fluid level behind the tympanic membrane, otorrhea and Signs or symptoms of middle ear inflammation as indicated by distinct erythema of the tympanic membrane or Distinct otalgia (discomfort clearly referable to the ear[s] that interferes with or precludes normal activity or sleep) When not to treat with an antibiotic: Otitis media with effusion Otitis media
  • 17. ANTIBIOTIC First-line therapy High-dosage amoxicillin (80 to 90 mg per kg per day) If severe illness or additional coverage desired:high-dosage amoxicillin/clavulanate (80 to 90 mg per kg per day of amoxicillin component) Alternative therapy Non anaphylactic penicillin-allergic: cefdinir , cefpodoxime , or cefuroxime. penicillin allergy: azithromycin or clarithromycin Unable to tolerate oral antibiotic: ceftriaxone Otitis media Usual antibiotic duration 10 days
  • 18. Acute bacterial sinusitis S. pneumoniae, nontypeable H. influenzae, M. catarrhalis When to treat with an antibiotic: Diagnosis may include some or all of the following symptoms or signs: nasal drainage, nasal congestion, facial pressure or pain, postnasal discharge, hyposmia, anosmia, fever, cough, fatigue, maxillary dental pain, ear pressure or fullness. When not to treat with an antibiotic: Antibiotic use should be reserved for moderate symptoms not improving after 10 days or that worsen after five to seven days, and severe symptoms. Usual antibiotic duration: 10 days Failure to respond after 72 hours of antibiotics: reevaluate patient and switch to alternate antibiotic. Fiberoptic endoscopy or sinus aspiration for culture may be necessary. First-line therapy Amoxicillin (80 to 90 mg per kg per day) Alternative therapy Amoxicillin/clavulan ate (80 to 90 mg per kg per day of amoxicillin component), cefpodoxime, cefuroxime, cefdinir, ceftriaxone For beta-lactam allergy: TMP-SMX (Bactrim, Septra), macrolides. Acute bacterial sinusitis
  • 19. Pharyngitis Streptococcus pyogenes, routine respiratory viruses When to treat with an antibiotic: S. pyogenes (group A streptococcal infection). Symptoms and signs: sore throat, fever, headache, nausea, vomiting, abdominal pain, tonsillopharyngeal erythema, exudates, palatal petechiae, tender enlarged anterior cervical lymph nodes. Confirm diagnosis with throat culture or rapid antigen testing. When not to treat with an antibiotic: Respiratory viral causes, conjunctivitis, cough, rhinorrhea, diarrhea uncommon with group A streptococcal infection First-line therapy Penicillin V , penicillin G benzathine penicillin Alternative therapy Amoxicillin, Oral cephalosporins, macrolides Pharyngitis
  • 20. Nonspecific cough illness/bronchitis> 90 percent of cases caused by routine respiratory viruses < 10 percent of cases caused by Bordetella pertussis, Chlamydia pneumoniae, or Mycoplasma pneumoniae When to treat with an antibiotic: Presents with prolonged un improving cough (14 days); should clinically differentiate from pneumonia. Pertussis should be reported to public health authorities. C. pneumoniae and M. pneumoniae may occur in older children (unusual in those younger than five years). When not to treat with an antibiotic: Nonspecific cough illness Treatment reserved for B. pertussis, C. pneumoniae, M. pneumoniae Macrolides (tetracyclines for children older than eight years) Nonspecific cough illness/bronchitis
  • 21. nonspecific URI > 200 viruses, including rhinoviruses, coronaviruses, adenoviruses, respiratory syncytial virus, enteroviruses (coxsackieviruses and echoviruses), influenza viruses, and parainfluenza virus When not to treat with an antibiotic: Sore throat, sneezing, mild cough, fever (generally less than 102ºF [39ºC], for less than three days), rhinorrhea, nasal congestion; self-limited Adequate fluid intake; may advise rest, over-the-counter medications, humidifier Nonspecific URI
  • 22. Age group Pathogen Neonates (<3 wk) Group B streptococcus, Escherichia coli, other Gram-negative bacilli, Streptococcus pneumoniae, Haemophill (type b,* nontypeable) 3 wk-3 mo Respiratory syncytial virus, other respiratory viruses (rhinoviruses, parainfluenza viruses, influenza viruses, hum metapneumovirus, adenovirus), S. pneumoniae, H. influenzae (type b,* nontypeable); if patient is afebrile, consider Chlamydia trachomatis. 4 mo-4 yr Respiratory syncytial virus, other respiratory viruses (rhinoviruses, parainfluenza viruses, influenza viruses, huma metapneumovirus, adenovirus), S. pneumoniae, H. influenzae (type b,* nontypeable), Mycoplasma pneumonia, group A streptococcus. More than 5 years M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. influenzae (type b,* nontypeable), influenza, adenovirus, other respiratory viruses, Legionella pneumophila. Lower respiratory tract infection (LRTI)
  • 23. • Admission is advised for severe LRTI. This is indicated by: • Oxygen saturation <92%. • Respiratory rate >70 breaths/minute (≥50 breaths/minute in an older child). • Prolonged central capillary refill time >2 seconds. • Difficulty in breathing as shown by intermittent apnoea, grunting and not feeding. • Presence of comorbidity - eg, congenital heart disease, chronic lung disease of prematurity, chronic respiratory conditions such as cystic fibrosis, bronchiectasis or immune deficiency should also prompt consideration of admission. • Admission should also be considered for: • All children under the age of 6 months. • Children in whom treatment with antibiotics has failed (most children improve after 48 hours of oral, outpatient antibiotics). • Patients with troublesome pleuritic pain.
  • 24. Treatment • For mildly ill children who do not require hospitalization, amoxicillin is recommended. • With the emergence of penicillin-resistant pneumococci, high doses of amoxicillin (90 mg/kg/day orally divided twice daily) should be prescribed unless local data indicate a low prevalence of resistance. • Therapeutic alternatives include cefuroxime and amoxicillin/clavulanate.
  • 25. • For school-aged children and adolescents or when infection with M. pneumoniae or C. pneumoniae is suspected, a macrolide antibiotic is an appropriate choice for outpatient management. • Azithromycin is generally preferred, , while clarithromycin or doxycycline (for children 8 yr or older) are alternatives. • For adolescents, a respiratory fluoroquinolone (levofloxacin, moxifloxacin) may also be considered as an alternative if there are contraindications to other agents.
  • 26. • The empiric treatment of suspected bacterial pneumonia in a hospitalized child requires an approach based on local epidemiology, the immunization status of the child, and the clinical manifestations at the time of presentation. • In areas without substantial high-level penicillin resistance among S. pneumoniae, children who are fully immunized against. H. influenzae type b and S. pneumoniae and are not severely ill should receive ampicillin or penicillin G. • For children who do not meet ceftriaxone or cefotaxime may be used. • If clinical features suggest staphylococcal pneumonia (pneumatoceles, empyema), initial therapy should also include vancomycin • Moreover, if infection with M. pneumonia or C. pneumoniae is suspected, macrolide antibiotic should be included in the in the treatment regimen.
  • 27. • If viral pneumonia is suspected, it is reasonable to withhold antibiotic therapy, especially for preschool- aged patients who are mildly ill, have clinical evidence suggesting viral infection, and are in no respirator distress. • However, up to 30% of patients with known viral infection. particularly influenza viruses, may have coexisting bacterial pathogens. • Therefore, if the decision is made to withhold antibiotic therapy on the basis of presumptive diagnosis of a viral infection, deterioration in clinical status should signal the possibility of superimposed bacterial infection, and antibiotic therapy should be initiated.
  • 28. • The optimal duration of antibiotic treatment for pneumonia has not been well-established in controlled studies. • However, antibiotics should generally be continued until the patient has been afebrile for 72 hr, and the total duration should not be less than 10 days (or 5 days if azithromycin is used). • Preliminary studies suggest that a reduction of previously elevated serum procalcitonin levels to an absolute level (0.1-0.25 µg/L) may help determine when to stop treatment.
  • 29. • In addition to antibiotics, oral zinc (10 mg/day for < 12 mo, 20 mg/day for ≥ 12 mo given for 7 days) may reduce mortality among children in developing countries with clinically defined severe pneumonia.
  • 30. THANKS FOR LIMITATION IN USING OF ANTIBIOTICS