CAREFUL ANTIBIOTIC USE

Transcription

1 Make promoting appropriate antibiotic use part of your routine clinical practice When parents ask for antibiotics to treat viral infections: PRACTICE TIPS Create an office environment to promote the reduction in antibiotic use. Explain that unnecessary antibiotics can be harmful. Talk about antibiotic use at 4 and 12 month well child visits. Tell parents that based on the latest evidence, unnecessary antibiotics CAN be harmful, by promoting resistant organisms in their child and the community. Share the facts. Explain that bacterial infections can be cured by antibiotics, but viral infections never are. Explain that treating viral infections with antibiotics to prevent bacterial infections does not work. Build cooperation and trust. Convey a sense of partnership and don t dismiss the illness as only a viral infection. Encourage active management of the illness. Explicitly plan treatment of symptoms with parents. Describe the expected normal time course of the illness and tell parents to come back if the symptoms persist or worsen. Be confident with the recommendation to use alternative treatments. Prescribe analgesics and decongestants, if appropriate. Emphasize the importance of adequate nutrition and hydration. Consider providing care packages with nonantibiotic therapies. The AAP Guidelines for Health Supervision III (1997) now include counseling on antibiotic use as an integral part of well-child care. Start the educational process in the waiting room. Videotapes, posters, and other materials are available. ( Involve office personnel in the educational process. Reenforcement of provider messages by office staff can be a powerful adjunct to change patient attitudes. Use the CDC/AAP pamphlets and principles to support your treatment decisions. Provide information to help parents understand when the risks of using antibiotics outweigh the benefits.

2 When parents request antibiotics for rhinitis or the common cold... Give them an explanation, not a prescription. Remember: RHINITIS VERSUS SINUSITIS IN CHILDREN 1 Treating sinusitis: Children have 2-9 viral respiratory illnesses per year. 2 In uncomplicated colds, cough and nasal discharge may persist for 14 days or more long after other symptoms have resolved Duration of symptoms in 139 rhinovirus colds 3 Target likely organisms with first-line drugs: Amoxicillin, Amoxicillin/Clavulanate 6 Use shortest effective course: Should see improvement in 2-3 days. Continue treatment for 7 days after symptoms improve or resolve (usually a day course). 7 fever myalgia sneezing sore throat % of patients with symptom 70% 60% 50% 40% 30% 20% 10% 0% day of illness cough nasal discharge % of patients with symptom 70% 60% 50% 40% 30% 20% 10% 0% day of illness Consider imaging studies in recurrent or unclear cases: But remember that some sinus involvement is frequent early in the course of uncomplicated viral URI - so interpret studies with caution. Share the CDC/AAP principles and pamphlets with parents to help them understand when antibiotic treatment risks outweigh the benefits. Controlled studies do not support antibiotic treatment of mucopurulent rhinitis. 4 Antibiotics do not effectively treat URI, or prevent subsequent bacterial infections. 5 Don t overdiagnose sinusitis Though most viral URIs involve the paranasal sinuses, only a small minority are complicated by bacterial sinusitis. Avoid unneccesary treatment by using strict criteria for diagnosis: 5 Symptoms of rhinorrhea or persistent daytime cough lasting more than days without improvement. or Severe symptoms of acute sinus infection: - fever (> 39 C) with purulent nasal dis charge - facial pain or tenderness - periorbital swelling rhinorrhea, fever, and cough are symptoms of viral URI changes in mucous to yellow, thick, or green are the natural course of viral URI, NOT an indication for antibiotics. 8 treating viral URI will not shorten the course of illness or prevent bacterial infection Rosenstein N, Phillips WR, Gerber MA, Marcy SM, Schwartz B, Dowell SF. The common cold-principles of judicious use. Pediatrics 1998;101: Monto AS, Ullman BM. Acute respiratory illness in an American community. JAMA 1974;227: Gwaltney JM, Hendley JO, Simon G, Jordan WS. Rhinovirus infections in an industrial population. JAMA 1967;202: Todd JK, Todd N, Damato J, Todd WA. Bacteriology and treatment of purulent nasopharyngitis: a double blind, placebo-controlled evaluation. Pediatric Inf Dis J 1984;3: Gadomski AM. Potential interventions for preventing pneumonia among young children: lack of effect of antibiotic treatment for upper respiratory infections. Pediatric Infect Dis J 1993;12: Avorn J, Solomon D. Cultural and economic factors that (mis)shape antibiotic use: the nonpharmacologic basis of therapeutics. Ann of Intern Med 2000:133: O Brien KL, Dowell SF, Schwartz B, et al. Acute sinusitis prin-ciples of judicious use of antimicrobial agents. Pediatrics 1998;101: Wald ER. Purulent nasal discharge. Pediatric Infect Dis J 1991;10:

3 Otitis media with effusion does not require antibiotic treatment Acute otitis media does not always require antibiotic treatment OTITIS MEDIA Differentiating Acute Otitis Media (AOM) from Otitis Media with Effusion (OME): A tool for promoting appropriate antibiotic use. 1, 2 Always use pneumatic otoscopy or tympanometry to confirm middle ear effusion No effusion Not OME or AOM Yes effusion present Signs or symptoms of AOM-including ear pain, fever, and bulging yellow or red TM Yes AOM History of acute onset of signs and symptoms WITH The presence of middle ear effusion (indicated by bulging of the TM or limited/absent TM mobility or otorrhea or air-fluid level) WITH Signs or symptoms of middle-ear inflammation (indicated by distinct erythema of the TM or distinct otalgia) No OME Presence of effusion (including immobility of the tympanic membrane) WITHOUT Signs or symptoms of acute infection. Nonspecific signs and symptoms (rhinitis, cough, diarrhea) are often present. TREATMENT Management should include assessment of pain if pain is present, clinician should recommend treatment to reduce pain. Age Certain Diagnosis Uncertain Diagnosis < 6 mo Antibacterial therapy Antibacterial therapy 6 mo to 2 y Antibacterial therapy > 2 y Antibacterial therapy if severe illness; observation option* if nonsevere illness Antibacterial therapy if severe illness; observation option* if nonsevere illness Observation option* *Observation is an appropriate option only when follow-up can be ensured and antibacterial agents started if symptoms persist or worsen. Nonsevere illness is mild otalgia and fever <39 C in the past 24 hours. Severe illness is moderate to severe otalgia or fever > 39 C. A certain diagnosis of AOM meets all 3 criteria: 1) rapid onset, 2) signs of middle ear effusion, and 3) signs and symptoms of middle-ear inflammation. TREATMENT Antibiotic treatment has not been demonstrated to be effective in long-term resolution of OME. A single course of treatment for days may be used when a parent or caregiver expresses a strong aversion to impending surgery. 4 Share this algorithm with parents. Explain when the risks of using antibiotics outweigh the benefits. Avoiding unnecessary treatment of OME would save up to 6-8 million courses of antibiotics each year. 3 If the patient fails to respond to the initial management option within hours, clinician must reassess to confirm AOM and exclude other causes of illness. If AOM is confirmed in: - Patient initially managed with observation, begin antibacterial therapy. - Patient initially managed with antibacterial agent, change the agent. : 1. American Academy of Pediatrics and American Academy of Family Physicians, Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113(5): Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Otitis media-principles of judicious use of antimicrobial agents. Pediatrics 1998;101(1 Suppl Pt 2): Stool SE, Berg AO, Berman S, et al. Otitis media with effusion in young children. Clinical practice guideline. AHCPR Publication no American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. Otitis media with effusion. Pediatrics 2004;113(5):

4 To avoid antibiotic resistance: treat only proven group A strep PHARYNGITIS IN CHILDREN 1 If you are entirely comfortable selecting which pharyngitis patients to treat 10 days with penicillin, perhaps you don t understand the situation. - Stillerman and Bernstein, 1961 Most sore throats are caused by viral agents. 2 Experts discourage treatment pending culture results 5-6, but if you do... Make sure to stop antibiotics when culture is negative. Discourage parents from saving antibiotics. If an antibiotic is prescribed: Use a penicillin as treatment for group A strep. 7 NO group A strep are resistant to penicillin. Treatment is 90% effective at elimination of strep, and may be higher in the prevention of acute rheumatic fever (ARF). Carriers are at very low risk for both ARF and spreading infection. 7 Clinical findings alone do not adequately distinguish Strep vs. Non-Strep pharyngitis. 3 BUT, prominent rhinorrhea, cough, hoarseness, conjuntivitis, or diarrhea suggest a VIRAL etiology. 4 Antigen tests (rapid Strep kits) or culture should be positive before beginning antibiotic treatment. Experts suggest confirming negative results on antigen tests with culture. 5 Remember that most cases with clinical signs of strep, like exudate and adenopathy, are viral. Use erythromycin if penicillin allergic. 1. Schwartz B, Marcy SM, Phillips WR, Gerber MA, Dowell SF, Pharyngitis-principles of judicious use of antimicrobial agents. Pediatrics 1998;101: Tanz RR, Shulman ST. Diagnosis and treatment of group A streptococcal pharyngitis. Semin Pediatr Infect Dis 1995;6: Poses RM, Cebul RD, Collins M, et al. The accuracy of experienced physicians probability estimates for patients with sore throat: implications for decision making. JAMA 1985;254: Denson MR. Viral pharyngitis. Semin Pediatr Infect Dis 1995;6: American Academy of Pediatrics. Group A streptococcal infections. In: Pickering LK, ed Red Book: Report of the Committee on infectious Diseases. 25th ed. Elk Grove, IL: American Academy of Pediatrics; 2000: Middleton DB, D Amico FD, Merenstein JH. Standardized symptomatic treatment versus penicillin as initial therapy for streptococcal pharyngitis. J Pediatr 1988;113: Shulman ST, Gerber MA, Tanz RR, Markowitz M. Streptococcal pharyngitis: the case for penicillin therapy. Pediatr Infect Dis J 1994;13:1-7.

5 Cough illness in the well-appearing child: Antibiotics are NOT the answer. COUGH ILLNESS/BRONCHITIS 1 Cough illness/bronchitis is principally caused by viral pathogens. 2 Airway inflammation and sputum production are non-specific responses and do not imply a bacterial etiology. Authors of a meta-analysis of six randomized trials (in adults) concluded that antibiotics were ineffective in treating cough illness/bronchitis. 3 Antibiotic treatment of upper respiratory infections do not prevent bacterial complications such as pneumonia. 4 Do not use antibiotics for: Cough <10-14 days in well-appearing child without physical signs of pneumonia. Consider antibiotics only for: Suspected pneumonia, based on fever with focal exam, infiltrate on chest x-ray, tachypnea, or toxic appearance. Prolonged cough (>10-14 days without improvement) may suggest specific illnesses (e.g. sinusitis) that warrant antibiotic treatment. 5 Treatment with a macrolide (erythromycin) may be warranted in the child older than 5 years when mycoplasma or pertussis is suspected. 6 When parents demand antibiotics... Acknowledge the child s symptoms and discomfort. Promote active management with non-pharmacologic treatments. Give realistic time course for resolution. Share the CDC/AAP principles and pamphlets with parents to help them understand when the risks of antibiotic treatment outweigh the benefits. 1.OBrien KL, Dowell SF, Schwartz B, Marcy SM, Phillips WR, Gerber MA. Cough illness/bronchitisprinciples of judicious use of antimicrobial agents. Pediatrics 1998;101: Chapman RS, Henderson FW, Clyde WA, Collier AM, Denny FW. The epidemiology of tracheobronchitis in pediatric practice. Am J Epidemiol 1981;114: Orr PH, Scherer K, Macdonald A, Moffatt MEK. Randomized placebo-controlled trials of antibiotics for acute bronchitis: a critical review of the literature. J Fam Pract 1993;36: Gadomski AM. Potential interventions for preventing pneumonia among young children: lack of effect of antibiotic treatment for upper respiratory infections. Pediatr Infect Dis J 1993;12: Wald E. Management of Sinusitis in infants and Children. Pediatr Infect Dis J 1988;7: Denny FW, Clyde WA, Glezen WP. Mycoplasma pneumoniae disease clinical spectrum, pathophysiology, epidemiology and control. J Infect Dis 1971;123:74-92.