RATIONAL USE OF ANTIBIOTICS

CONTENTS
• Reasons for misuse of antibiotics
• What has this led to
• Clinical case scenarios
• Indications of antibiotic usage
• Therapeutic use of antibiotics
• Antibiotic therapy in fever
• Difference between viral & bacterial infection
• When to use an antibiotic
REASON FOR MISUSE OF ANTIBIOTICS
• Availability of antibiotics ‘over the counter’
• Lax FDA allowing Inappropriate formulations
and irrational drug combinations
• Availability of sub standard & expired date
drugs
• Incorrect promotion by pharma companies
• Misuse of antibiotics by clinicians in individual
practice
 WHAT HAS THIS LED TO
• Extended spectrum beta lactamase (ESBL)
producing gram negative bacterial UTI/sepsis
• Vancomycin resistant gram positive Cocci
(VRSA and VRE)
• MDR TB & now XDRTB
• New delhi metallobetalactamase (NDM)
• MDR enteric fever
CASE SCENARIOS
 Case Vignette 1
• IVF baby, LSCS at 36 weeks, AGA, 2.0kg
• No risk factors, BCIAB
• Kept in nursery for observation for 48 hours
• Given IV cefotaxime & IV Amikacin as it is
‘precious baby’
• Comes back a week later with SEPSIS
• Cause ??
• ESBL producing E. coli
 INDICATIONS
• Prolonged rupture of membranes >24 hours
(18 hours in preterm)
• Foul smelling infected amniotic fluid
• Ongoing maternal fever, UTI or sepsis
• Positive High vaginal swab for GBS.
The antibiotic recommended here is IV
Ampicillin
 Case vignette 2
• 2 year old asymptomatic child on INH prophylaxis
• Develops fever, cough, weight loss, goes to 2nd
pediatrician who adds Rifampicin
• Child not better after 6 weeks, CT chest shows
massive lymphadenopathy, gastric lavage grows M.
tuberculosis resistant to all 1st line drugs
• Error ??
• Inadequate number of antibiotics
 Case vignette 3
• 18 months old child with fever, irritability, red bulging
eardrum
• Diagnosis?
• Acute otitis media
• Put on Amoxiclav
• Parents reduced dose to half as child develops
diarrhea
• 4 days later, still running fever and throws a seizure,
CSF grows beta lactamase producing H. influenze
• Error?
• Giving antibiotic in inadequate dose
 Case vignette 4
• Preterm baby with Lethargy and seizure
suggestive of meningitis
• Started on IV cefotaxime and IV amikacin
• Improves, looks fine in 9 days, shifted to oral
antibiotics as parents do not wish to remain in
hospital
• Comes back a month later with chronic
meningitis & brain abscess due to ESBL
producing E. coli
• Giving antibiotics for too short a time
 Case vignette 5 & 6
• 11 month old male child • 3 year old child
• Sudden onset of fever • Cough, cold & vomiting
101.5°F of 1 day duration
• Vomiting previous day • Fever 102°F
• Now has watery loose • Mother has similar
stools symptoms
• Started on ofloxacin- • Oral cephalosporin
ornidazole combination started

Antibiotic started too hastily for possibly a viral infection

Ornidazole is antiamoebic & ofloxacin is for bacillary dysentry.
Giving them together is irrational
DRYING UP
WHEN TO USE AN ANTIBIOTIC
 INDICATIONS OF ANTIBIOTIC USAGE
• Therapeutic
Used to treat existing infection

• Prophylactic
Used to prevent infection
 THERAPEUTIC USE OF ANTIBIOTICS
• Pre-emptive : Infection probable on clinical
grounds but not proven
• Empirical: Infection most likely but exact
organism & senstivity not known
• Definitive: Proven pathogen with or without
antibiotic susceptibility available
 Case vignette 7
• 15 month old child brought to us with
complaints of fever 102°F

Should you start an antibiotic ?

 ANTIBIOTIC THERAPY IN FEVER
• Is there really fever?
• Is it a bacterial infection or is it Viral ?
• If bacterial, some of them maybe self limiting
• Non infectious causes of fever
 DIFFERENTIATION BETWEEN VIRAL &
BACTERIAL INFECTION
VIRAL INFECTION BACTERIAL INFECTION
• High fever at onset, • Moderate at onset, &
better by day 3 or 4, peaks on day 3 or 4
biphasic pattern
possible
• Non toxic • Toxic
• Interfebrile period • Inter febrile period not
normal
normal
• Disseminated (URI+LRI)
• >1 system involved • Localized to one system
• >1 member or Part of system
• No sick contact
 Is an antibiotic necessary?
• Acute infections usually present with fever
• But all infections are not bacterial
• Clinical Differentiation is possible most of
times
• Most immunocompetent patients with acute
infection can wait for evaluation for a day or
two to decide need for antibiotic
 Case vignette 8 & 9
CASE A CASE B
• A neonate is brought • 2 year old boy under
with refusal to feed treatment for ALL
• O/E hypothermic, limp • Hb 8, TLC 1080
• Would you start an (20%neutrophils)ANC 204
antibiotic? • C/o anorexia & fever for
1 day
• Will you start
antibiotic?
YES…antibiotics will be started in both cases
 PRE EMPTIVE ANTIBIOTICS
ONLY IF
High probability of bacterial infection where
waiting is dangerous
• Life threatening infection suspected
• Immunocompromised host
 PRE EMPTIVE ANTIBIOTICS
• Only when infection suspected on clinical
grounds but not proven
• May start with broad spectrum/ multiple
antibiotics
• Simultaneously attempt to prove the presence of
infection and identify the organism as soon as
possible
• Do not hesitate to ‘step down’ to a more
appropriate antibiotic if infection is diagnosed or
discontinue antibiotics if infection is not proved
 Case vignette 10 & 11
• 4 year girl • 2 year boy
• Right submandibular • High fever X 2 days
swelling • Blood & mucus in stools
• Diagnosis ? X 1 day
• Acute suppurative LN • Diagnosis?
• Bacillary dysentry

Antibiotic?
Bacterial infection is
obvious clinically
 Case vignette 12 & 13
• 2.5 year old boy • 5 year girl
• Fever, cough X 3 days • Fever since 5 days
• Breathlessness X 1 day • Poor appetite
• Febrile, sick, Crepts+ • O/E sick look, toxic,
• Clinical Pneumonia coated tongue,
hepatosplenomegaly+

Would you start an antibiotic??

Yes….High probability of bacterial infection
Send investigations before starting antibiotics
 Case vignette 14
• 5 year girl
• Fever X 2 days
• Dysuria X 1day
• Urine r/m- 15 pus cells/HPF
• Start antibiotic ?
• YES
• Clinical diagnosis corroborated by lab investigations
• But attempt microbiological diagnosis- send urine
culture
 Case vignette 15
• 16 month girl, high fever, coryza & cough
• Maculopapular measles like rash, starting on day 3
behind the ears and spreading centrifugally over 2
days
• Afebrile on day 7
• Develops fever again on day 8 with cough &
breathlessness
• Start antibiotic?
• Yes…..Viral infection with atypical progression with
suspected superadded bacterial infection
 EMPIRIC ANTIBIOTICS
WHEN TO USE
• Bacterial infection is obvious clinically
• High probability of bacterial infection on
clinical grounds
• High probability of bacterial infection on
clinical grounds + suggestive lab investigations
• Viral Infection with atypical progress
HOW TO CHOOSE YOUR ANTIBIOTIC?
• Which pathogen?
• Suspected drug resistance?
• Site of infection
• Severity of illness
• Host comorbidities
• Choose a single agent as far as possible
 HOW CHOICE IS MADE
• FOR NON SEVERE INFECTIONS
Adequate to use antibiotic that is likely to
succeed in 75-85% cases so there is
opportunity to change to 2nd line
FOR SEVERE INFECTIONS
One should aim at 95% success rate
 EMPIRICAL THERAPY IS ACCEPTABLE
Because definitive therapy, though ideal, is not always
possible
Reasons:
• Tests for detection of organisms have been sent but
results awaited
• Organisms cannot be accessed for culture
(pneumonia, otitis media)
• Organisms cannot be cultured in laboratory
(fastidious and slow growers)
• Facilities for culture are not available or affordable
• Cultures are hindered by prior antibiotic therapy
 DEFINITIVE THERAPY
• Requires microbial diagnosis
• Usually based on culture with AST
 So we should inculcate the culture of sending
cultures
 Need to take precautions while cultures
 And culture report need to be analyzed carefully
before presribing the antibiotic
 TAKE HOME MESSAGE
PROMOTE RATIONAL ANTIBIOTIC THERAPY
• Decide if antibiotics are needed
• Get cultures before starting antibiotics or use non
culture methods of diagnosis/point of care testing
• Know your local flora & their antibiotic sensitivity
• Ensure all orders have formulation, dose, duration &
precautions during administrations
• Take an “antibiotic timeout” reassessing need for
antibiotics after 48-72 hours
• Ensure adherence
 INK WHAT YOU THINK!
Before writing any prescription
Step 1: Think what is the diagnosis
Step 2: Write your clinical impression
Step 3: Prescribe antibiotic
THANK YOU!