Principles of antibiotic therapy in paediatrics

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Principles of antibiotic therapy in paediatrics

• Dr. György Fekete

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• Antibiotics
• 1. What is the reason? Indication?
• - local infection
• - empiric and targeted teatment
• - fever general symptoms (CRP, WBC count
  and smear, etc.)

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• 2. Previous microbiological investigations?
• - throat
• - urine
• - haemoculture
• - cerebrospinal fluid

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• 3. What is the potential (bacterial) cause of
  infection?
• - age (newborn, infant, toddler)
• - medical procedure, hospitalisation
• - immune deficiency
• - organ damage (spleen, liver, kidney)

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Neonatal sepsis /meningitis

• Focal infection pneumonia, RDS
• Group B streptococci, E. coli, other
  Gram-negative rods, Listeria monocytogenes
• Th Ampicillin gentamicin
• third generation cephalosporin instead of
  aminoglycoside

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Bacterial meningitis in children, 2months to 12
yrs

• S. pneumoniae, N. meningitidis,
• (H. influenzae type b)
• Therapy - cefotaxime / ceftriaxone
  vancomycine
• - 3. generation cephalosporines
• (Cefotaxime, Ceftriaxone)

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• 4. Which antibiotic will be optimal? First
  choice?
• - data of bacterial resistance
• - site of infection penetration?
• - side effects?
• - bactericide effect
• - administration 1x / day
• - not expensive

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• 5. Any combination is appropriate?
• - nosocomial infection
• - sepsis
• - abdominal and pelvic infections
• - endocarditis
• - empiric treatment
• - active tuberculosis

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Active tuberculosis

• Treatment INH, rifampin, pyrazinamide
• Ethambutol, ethionamide

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• 6. Metabolism, excretion?
• - kidney, liver (monitoring)
• - renal aminoglycosides
• - livererythromycin, clindomycin
• 7. Mode of administration
• - iv, oral
• - switch

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• 8. Dosage ?
• 9. Changing of antiobiotic drug? Indications?
• 10. How long should we treat?
• - Preterm and newborn babies need antibiotic
  therapy of longer duration (sepsis, bacterial
  meningitis, etc.)

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Antimicrobial prophylaxis

• Neonatal conjunctivitis
• Chlamydia trachomatis
• 0,5 erythromycin topically
• Neisseria gonorrhoeae
• 1 silver nitrate or
• 0,5 erythromycin topically

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Antimicrobial prophylaxis

• Splenectomy / asplenia
• Str. pneumoniae
• Penicillin

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Resistant clones of microorganisms

• Str. pneumoniae
• Staph. aureus
• Virulent
• Serious infections
• Overuse of antibiotics
• Viral infections
• Broad spectrum antimicrobial agents

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Antibiotic management of Staphylococcus aureus
infections in US Childrens hospitals, 1999-2008

• Trends in antibiotic management for S. aureus
  infections, hospitalized children
• The use of vancomycin, clindamycin, linezolid,
  trimethoprim-sulfamethoxazole, cefazolin, and
  oxacillin/nafcillin were examined for percentage
  use and days of therapy per 1000 patient- day
• 64 813 patients had a discharge diagnosis for S.
  aureus infection
• The incidence of methicillin-resistant S. aureus
  (MRSA) infections increased 10-fold (2 to 21
  cases per 1000 admissions), methicillin-
  susceptible infection rate remained stable
• Clindamycin showed the greatest increase 21 in
  1999 and 63 in 2008
• Importance of continuous monitoring of local S.
  aureus susceptibility patterns
• Herigon J.C et al. Pediatrics 2010, 1251267

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Broad - spectrum antimicrobial agents

• Drastic changes in bowel flora
• Bleeding disorders
• Emergence of resistant organisms
• Superinfections yeasts, enterococci

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Local (hospital) microbiological laboratory

• Knowing the prevalence of antibiotic resistant
  organisms in a particular community (nursery) is
  helpful in choosing the first-line antibiotic
  regimens

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Specific therapeutic values

• Vancomycin methicillin-resistant staphylococci
• Metronidazole anaerobic infections
• Ceftazidine Pseudomonas aeruginosa
• Trimethoprime sulfamethoxazole shigellosis,
  salmonellosis, Pneumocysis carinii ( pentamidine)

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Test of efficacy patients response

• No respond to seemingly appropriate therapy
  reassessment is needed!
• In some infections additional supportive
  treatment ( surgical) is necessary

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Tonsillitis, tonsillopharyngitis

• Streptococcus pyogenes Penicillin for 10 days
• Penicillin allergy macrolid antibiotics
• Non- Streptococcus origin amoxicillin,
  amoxicillin clavulanic acid, macrolids,
  cephalosporin antibiotics

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Anaerobic infections

• Oropharynx, gastrointestinal tract, vagina, skin
• Gram- negative nonsporulating rods Bacteroides,
  Fusobacterium
• Gram-positive nosporulating rods Eubacterium,
  Propionibacterium

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Anaerobic infections

• Neonates prolonged rupture of membranes,
  amnionitis, obstetric difficulties
• Peritonitis, appendicitis
• Aspiration pneumonia with lung abscess
• Orofacial infections
• Brain abscess

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Periodontal infection (trench mouth)Acute
Necrotizing Ulcerative Gingivitis ( ANUG)

• Periapical abscesses
• Anaerobic osteomyelitis of the mandible /maxilla

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Vincent stomatitits

• Ulcers covered by brown/grey, foul-smelling
  exudate

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Ludwig angina

• Acute cellulitis of the sublingual and
  submandibular spaces
• Rapid spread
• Edema of the tongue and airway

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Anaerobic infections/ treatment

• Cefoxitin, amoxicillin/ clavulanate, clindamycin
• Metronidazole
• Cefotetan
• Imipenem, merapenem
• Piperacillin, tazobactam

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• CEPHALOSPORIN ANTIBIOTICS
• 1. generation drugs
• Cefazolin (Kefzol) does not cross the blood-
  brain barrier. No use for initial th. of sepsis
  / meningitis
• Cefalexin (Keflex. Ospexin)
• Cefadoxil (Duracef)

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• 2. generation drugs
• Cefamandol (Mandokef)
• Cefuroxim (Zinnat, Zinacef)
• Cefoxitin (Mefoxin)
• Cefaclor (Ceclor)

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• 3. generation drugs
• Cefotaxim e (Claforan)
• Ceftriaxone (Rocephin)
• Cefoperazon (Cefobid)
• Ceftazidim ((Fortum)
• Cefixim (Suprax)
• Ceftibuten (Cedax)

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• 4. generation drug
• Cefepim (Maxipime)

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Presentation

• 7-year-old boy
• 3 weeks of headache refractory to acetaminophen,
  1 day of altered mental status, diplopia,
  photophobia
• Physical examination he is difficult to arouse
  and is confused. He vomits once in the ED.
• No skin lesions, signs of meningeal irritation,
  or joint swelling. Bilateral papilledema and
  photophobia
• WBC 15.8x109/L, 85 segmented neutrophils. Lumbar
  puncture, CSF sent for Lyme titers, serum
  antibodies positive for IgG and negative for IgM
• Th 28 days IV ceftriaxone (100 mg/kg per day)
• Additional questioning2 months prior he had
  erythema migrans, was diagnosed as having Lyme
  disease, and was treated with 21 days of
  cefuroxime

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• PENICILLIN
• Penicillin G V Streptococcus
• procain-penicillin Str. pneumoniae

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• METHICILLIN
• Oxacillin
• Staphylococcus aureus
• Nafcillin

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• AMINOPENICILLIN
• (ampicillin , amoxicillin) Streptococcus B
• Str. pneumoniae
• Listeria

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• AMINOPENICILLIN
• beta-lactamase respiratory ,
  inhibitor urinary tract
  infections
• (ampicillinsulfactam,
• amoxicillinclavulanic acid)

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• UREIDOPENICILLIN
• mezlocillin, piperacillin
• (beta-lactamase inhibitor as well)
• piperacillin/tazobactam
• Severe systemic infections

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Tetracyclines

• Good effect
• Chlamydia, Mycoplasma, Actinomyces, Lyme disease,
  pelvic infections, urethritis, brucellosis
• Contraindicated before the age of 10 yrs!

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• ANTIBIOTIC DRUGS
• Active ingredient Product
• Amoxicillin Aktil, Augmentin
• clavulanic acid
• Ampicillin Ospamox, Penstabil,
• Pentrexyl

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• Active ingredient Product
• Ampicillin Unasyn
• Sulbactam
• Azithromycin Sumamed
• Azlocillin Securopen

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• Active ingredient Product
• Cefadroxil Duracef
• Ceftazidime Fortum
• Ceftriaxon Rocephin
• Cefixim Suprax

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• Active ingredient Product
• Cefepime Maxipime
• Ceftibuten Cedax
• Cefoperazon Cefobid
• Cefotaxim Claforan

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• Active ingredient Product
• Cefuroxim Zinacef, Zinnat
• Clarithromycin Klacid
• Clindamycin Dalacin C
• Ciprofloxacin Ciprobay, Cifran,
• Supplin

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• Active ingredient Product
• Imipenem Tienam
• cilostatin
• Josamycin Wilprafen
• Meropenem Meronem
• Metronidazol Klion

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• Active ingredient Product
• Mezlocillin Baypen
• Netilmicin Netromycine
• Penicillin Maripen, Ospen,
• Vegacillin

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• Active ingredient Product
• Sulfamethoxazol Sumetrolim,
• trimethoprim Bactrim, Cotrimel
• Teicoplanin Targocid
• Tobramycin Brulamycin
• Vancomycin Vancocyn