Practical Tips for Overcoming Antibiotic Resistance

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Practical Tips for Overcoming Antibiotic
Resistance

• Randel Cardott MD

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Reuters April 30 2003-Antibiotic Resistance Now
Deemed a Public Health Crisis. The medical
community is losing the fight against
antibiotic-resistant superbugs
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Antibiotic Resistance is function of antibiotic
use, and we are using tons of antibiotics Dr.
Martin Blaser, Infectious Diseases Society of
America panelist.
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Every time you prescribe an antibiotic, you are
affecting not just that patient, but all living
and future living organisms
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CDC estimates that 50 million of the 150 million
antibiotic prescriptions written annually are
unnecessary. Sci Am March 1998
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National Ambulatory Medical Care survey 28,787
adult charts Antibiotics Prescribed. 51
Common Colds 52 URIs 66 Acute Bronchitis

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JAMA 1998279875-877 Pediatric
visits Antibiotics Prescribed Common
Cold-44 URIs-46 Bronchitis-75
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NEJM 1997337441-6 Finland study-after
restricting macrolide use in outpatient settings
erythromycin resistance among Group A Strep
dropped from 16.5 to 8.6 in a four
year period.
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U of Iowa Hygienic Lab Polk County 2002 S.
Pneum. PCN Resistance 23 S. Pneum. MDR
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We Over-Prescribe!!!!! Why? Patient
Satisfaction Genuine desire to help
Lack of knowledge Over-estimate value of
antibiotics
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We have focused on the Big Four Pharyngitis-80
viral Bronchitis-90viral Sinusitis-80
resolve spontaneously AOM-80 resolve
spontaneously All four rank in Top
10 Dx in Ambulatory visits
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Acute Pharyngitis Rapid antigen testing /-
Centor clinical criteria Appr
opriately selected and used rapid antigen assays
will reach approx. 90 sens and
spec. Clinical criteria ( maximal sens and
spec 75) Fever, tonsillar exudate, tender
ACNs, absence of cough.
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Our approach Treat empirically if all four
criteria present. Use antigen assay if 2 or
3 criteria present. (Do back-up if under
18) Treat empirically if documented
household exposure
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All patients receive Important Facts about
Sore Throats handout All patients are
offered analgesics and supportive care
Penicillin is used first-line Beta-lactam
stable antibiotic for treatment failures
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Acute Bronchitis No evidence indicates that
S. Pneumoniae, H. Influenza, or M catarrhalis
produce acute bronchitis without underlying lung
disease. Randomized placebo-controlled
trials have failed to support a role for
antibiotics. Principles of Appropriate
Antibiotic Use for Treatment of Acute Bronchitis
in Adults. Annals of Internal Medicine March
2001.
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Only B. pertussis, M. pnuemonia and C. Pnuemonia
have been established as non-viral causes of
uncomplicated bronchitis. This group makes up
about 5-10
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In setting of acute cough (lt2-3 wks) the primary
diagnostic objective should be to exclude
pneumonia. In adults the absence of
abnormalities in vital signs heart rate greater
than or equal to 100bpm, resp rate greater than
or equal to 24 bpm,or oral temp greater than or
equal to 100.5 (38 C) and nl chest exam
sufficiently reduces the likelihood of pneumonia
to the point that further diagnostic testing is
usually not necessary.
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Our approach Offer an explanation not an
antibiotic Consider B-agonist MDI
before antitussives because of the transient
bronchial hyperresponsiveness
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Sinusitis Primary care physicians tend
to think of sinusitis as an acute bacterial
infection and prescribe antibiotics in 85-98
of cases.
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Bacterial and viral rhinosinusitis are difficult
to differentiate on clinical grounds. Primary
care physicians classifying patients as highly
likely are correct 40-50 based on sinus
aspiration.
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Acute Bacterial Sinusitis usually results from
sinus ostia obstruction secondary to a viral
URI. Only 2 of viral URIs in adults are
complicated by bacterial rhinosinusitis.
Bacterial sinusitis is not common in patients
whose symptoms have lasted less than 7 days
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CT scans show mucosal abnormalities in 87 of
young adults with viral URIs. Computed
tomographic study of the common cold. NEJM
1994330
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Antibiotics vs. Placebo in
Sinusitis Meta-analysis of five trials-81
cured or improved on antibiotics at 14 days vs.
66 on placebo. Absolute benefit of 15 with
number needed to treat for benefit approx. seven.
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In most cases only patients with specific
findings of maxillary pain or tenderness in the
face or teeth and persistent purulent nasal
discharge who are not improving after 7 days and
those with severe rhinosinusitis symptoms,
regardless of duration should be treated with
antibiotics. Annals of Internal Medicine March
2001
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Our Approach If we decide to treat we use
Amoxicillin first line for the uncomplicated
cases(some advocate high dose therapy) and
decongestants. Impact of first line vs
second line antibiotics for the treatment of
Acute Uncomplicated Sinusitis. JAMA Oct17 2001.
Total of 29102 patients treated with first or
second line. First line success 90.1 , Second
line success 90.8
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Acute Otitis Media Acute otitis media will
resolve within one week without antibiotics in
more than four fifths of children prescribing an
antibiotic increases this rate by only 13
percent. When antibiotic therapy is used,
amoxicillin is as good as any other antibiotic
despite the fact that a third of the bacteria are
resistant to this drug in vitro. NEJM Oct
10,2002
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AOM with bulging TM-immediate Rx AOM without
bulging TM-delayed RX Recurrent AOM-delayed RX
Resistant bacterial otitis-HD Augmentin, Ceftin,
or IM Rocephin Delayed RX initiate
treatment with acetaminophen provide Rx for high
dose amoxicillin to be used only if otalgia or
fever persists or if there is no clinical
improvement after 48-72hrs
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Zithromax single dose therapy for AOM - (double
blind,controlled,randomized trial) azithromycin
30mg/kg vs 10days of amoxicillin/clavulanate Q
12hrs. Clinical success rate was 75 for both
at 28-32days. (No data on the placebo success
rate!)
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Principles for Judicious use of antibiotics in
children CDC/AAP Dx not made unless fluid
is present OM should be classified as AOM or
OME on basis of the signs and sx of acute
illness OME should not be treated with
antibiotics Effusion is likely to
persist after Rx and does not require repeat
Rx Prophylaxis for AOM should be used only
with strict criteria Pediatrics 1998101
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Acute Otitis media management and surveillance
in an era of pneumococcal resistance. Pediatric
Infect Dis J 199918
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Meets Case Definition of AOM and age 12 years
Acute Otitis Media Flow Sheet
Penicillin Allergy?  
Alternative Antibiotic  
Yes
  Age 2 Years?  
No
Day Care Attendance?  
No
 
Antibiotics In last 30 days?  
No
Yes
Yes
Antibiotics In last 3 Month?  
Antibiotics In last 30 days?  
Yes
No
Ceftin Or HD Amoxicillin Or H D Augmentin  
Yes
No
Yes
No
High Dose (HD) Amoxicillin  
Ceftin Or HD Amoxicillin Or H D Augmentin  
Ceftin Or HD Amox Or H D Augmentin
High Dose (HD) Amoxicillin  
Regular dose Amoxicillin  
Algorithm
 
Documentation
 
 
 
 
 
Appendix D
 
 
 
 
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Current Treatment (Manually Edited)
High dose Amoxicillin or Amoxicillin/clavulanate
coded BSL 10 (17.5) had high dose
checked 6 of 10 had specific
dose recorded, ranged from 32.6 to 55 mg/kg/day
FUP 24 (34.8) had high dose checked
Mean among 24 73.4 mg/kg/day
n 11 were ? 80 mg/kg/day

n 7 were ? 70
mg/kg/day Reminder High dose is
defined as 80-90 mg/kg/day of Amoxicillin
Last Page of Appendix E

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Patient Satisfaction depends on communication not
antibiotic prescriptions
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Just Say No!
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Dr. Stephen Richards 3 Rs to avoid
resistance the right antibiotic at
the right time for the right reason