New Quinolone in AOM

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New Quinolone in AOM Sinusitis To use or not
to use

• Warunee Punpanich
• Queen Sirikit National Institute of Child Health

Fostering exploration, discovery and growth
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Chronology of Fluoroquinolone

• Introductions in the United StatesSelected
  Quinolones and Year of Introduction

1960s Naiadixic Acid 1996 Levofloxacin 1986 No
rfloxacin 1998 Trovafloxacin 1987 Ciprofloxaci
n 1999 Gatifloxacin 1991 Ofloxacin 2000 Moxif
loxacin 1992 Temafloxacin 2000 Cllnafloxacin
1996 Sparfloxacin 2001 Gemifloxacin? 1996 Grep
afloxacin 2004 Gemifloxacin
no longer on market never released
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Fluoroquinolone Advantages Disadvantages

• Pros Cons
• ? Broad spectrum activity ? Broad spectrum
  activity
• ? Convenient dosing ? Use substitutes for
  thinking
• Systemic coverage with Oral treatment
• (FQ gen 3-4 bioavailability gt 70) ? Overused
• ? Avoids beta-lactam and sulfa allergies ? Some
  allergy potential
• ? Low cost (vis-à-vis IV) ? High cost
  (vis-à-vis PO)
• ? Specific activities ? Specific side
  effects
• - atyp resp pathogens - neurotoxicity
• - STDs - QTc prolongation
• - anthrax - tendonitis
• - mycobacteria - C, difficile colitis (?)

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Adverse Effects of Fluoroquinolones
FQ Cipro Gati Levo Moxi GI / CN
S / / Phototoxicity QTc
1 1 Allergic Glucose 1
Homeostasis lt 1, 1-5, 5 -10 1
FDA warning on the product Information sheet

• Now only available levoflox and moxiflox only

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• Temaflox liver, blood tox
• Sparflox photosensitivity
• Grepaflox Bad taste and QT prolongation
• Levoflox good for CAP in adult, has more balance
  gand g-ve
• Trovaflox liver, blood tox (same side
  chaintemaflox)
• Gatiflox hypogly, QT prolong (withdrawn)
• Moxiflox very broad, use for respir gve
  infection
• Clinaflox sunburn after fluorescence light,
  never release
• Gemiflox only Iv form, unexplained rash, little
  use

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Collateral Damage
CID 200438 (Suppl 4) S341

• Ecological adverse effects of antibiotic therapy
  ? the selection of drug-resistant organisms and
  the unwanted development of colonization or
  infection with MDR organisms.

Collateral Damage from Antibiotic Therapy CID
200438 (Suppl 4) S341
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What would you do if you lost everything?
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Current evidence is limited but supports the use
of penicillin or amoxicillin for 7-14 days.
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Antimicrobial Tx in AMS meta-analysis

• Difference in outcome between ATB treatment of
  acute sinusitis in otherwise healthy adults and
  adolescents appear to be small. Therefore, the
  cheapest ATB treatment can be selected.

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ATB for rhinosinusitis

• 10-day ATB treatment will reduce the
  probability of persistence n the short to medium
  term. (NNT 8, 95 CI 5-29).
• These conclusions are based on a small numbers of
  small randomized controlled trials.

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Economic evaluation of ATB for ABS

• Confirms the place of amoxicillin as a first
  choice agent for sinusitis, with low dose
  clarithromycin and azithromycin as a second
  choice.

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• Total direct charge was 68.98 USD for first-line
  ATB and 135.17 USD for second-line.
• Those treated with first-line ATB did not have
  clinically significant difference in outcomes
  from those treated with second-line ATB.

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Cost issue

• LevofloxacinDose lt5 years  10 mg/kg/bid     
   gt5 years  10 mg/kg/dayCravit ??????
  Daiichi100 mg 23 baht/tablet250 mg 32.5
  baht/tablet500 mg 75  baht/tablet??????
  ????100 mg 11.77 baht/tablet500 mg 40.66
  baht/tablet
• MoxifloxacinDose 10 mg/kg/dayAvelox ??????
  Bayer-Schering400 mg  100 baht/tablet
• Amoxicillin 80 MKD
• 500 mg 2.25 baht/cab

• Cost for 10 day treatment for a 20 Kg child.
• 460 Bh
• 235 Bh
• 500 Bh
• 72 Bh

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Evidence for diagnosis and Tx for sinusitis

• Good, high-quality evidence for acute
  uncomplicated sinusitis in children is limited.
• The diagnostic modalities showed poor
  concordance, and treatment options were based on
  inadequate data.
• More evidence is needed for defining the optimal
  treatment and diagnostic methods for this common
  condition.

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Summary

• Wide variety of new quinolone options but with
  different type of toxicity
• High cost
• Risk for collateral damage
• No FDA approve for the use in children
• No evidence support the use of this agent
• Limited use in small children because of
  precipitation with 2 cation e.g. milk

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New Quinolone in AOM Sinusitis To use or not
to use

• .The choice is yours.