Use and Misuse of Antibiotics in Resp Infections HBUK

7/29/2019 Use and Misuse of Antibiotics in Resp Infections HBUK

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Use and misuse of antibiotics in

respiratory infections

Dr Jeyaseelan P. Nachiappan

Consultant Infectious Disease Paediatrician


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Aims

To discuss

common respiratory tract infections

data on misuse of antibiotics

reasons for misuse of antibiotics

recommendations for appropriate use of

antibiotics


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National Medical Care Survey 2010


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What is URTI?

Rhinitis, sinusitis,pharyngitis, tonsilitis,laryngobronchitis(ALTB/ croup),laryngitis, otitis media

Usually involves more

than one anatomicalareas eg rhinosinusitis,ALTB


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Common cold syndrome

Gwaltney JM, Hendley JO, Simon G, Jordan WS. Rhinovirus infections in an industrial population. JAMA 1967;202:158-164

139 rhinovirus+ patients


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Natural history

a systematic review - aged between 0 - 4 years

8 RCTs and 2 cohort

at one week 50% may be still coughing + nasaldischarge

at two weeks up to 24% of children may be nobetter

illness duration may be longer than many parentsand clinicians expect

Hay AD, Wilson AD. The natural history of acute cough in children aged 0 to 4 years in primary care:

a systematic review.. Br J Gen Pract. 2002 May;52(478):401-9


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Common cold

prevalence varies by age

highest in age less than 5 yrs

school/daycare are a large reservoir

3-8 viral URTI per yearMeneghetti eMedicine Aug 2006

healthy 3yr old child 6 to10 colds/yr Wald ER Pediatrics. 1991

Exclusively caused by viruses


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Pharyngitis / Tonsilitis

streptococcal pharyngitis 5% to 15%

difficult to distinguish viral and strep

clinical prediction rules

Centor fever can be high grade viral tonsilitis

CPG Sore throat KKM 2003


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Rhinitis versus Sinusitis

sinusitis if symptoms of rhinorrhea or

persistent cough lasting >10-14 days withoutimprovement or worsening

Or

Severe symptoms of acute sinus infection:

Fever (39oC) with purulent nasal discharge

Facial pain or tenderness

Periorbital swelling


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Acute bronchitis

Acute coughing illness last for 3 weeks

> 90% of cases due viruses Purulent sputum not predictive of bacterial

infection.


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Summary

Common cold

common and recurrent

some symptoms persist till 2 weeks

5-15% of tonsillitis may be bacterial

Sinusitis = prolonged rhinitis / cough

Acute bronchitis 90% viral

Prolonged cough


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ANTIBIOTIC USE BY INFECTION

(URTI, n=795)

With antibiotic (%) (n) Total consultations (n)

Nasopharyngitis

(Common cold)7.0% (16) 227

Pharyngitis/ Sorethroat/ Tonsilitis

65.0% (173) 266

Rhinosinusitis 31.2% (5) 16

Otitis media 50.0% (3) 6

URTI 32.5% (91) 280

Ng Li Meng Pharmacy HRPBI 2013 ( unpublished)


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Outpatient Antibiotic Use and

Prevalence of Antibiotic- Resistant

Pneumococci in France and Germany:A Sociocultural Perspective

prevalence of penicillin resistant pneumococci is sharplydivided between France (43%) and Germany (7%).

These differences may be explained on different levels:antibiotic-prescribing practices for respiratory tractinfections; patient-demand factors and health-beliefdifferences; social determinants, including differing child-care practices; and differences in regulatory practices.

Harbarth S. Emerging Infectious Dis Vol.8, No. 12 Dec 2002


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Outpatient antibiotic utilization

daily defined doses.

Resistance 43%

Resistance 7%


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Why are antibiotics misused

prescribed?

Appropriate use of antibiotics

demands (real or imaginary)


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Why are antibiotics misused

prescribed? Patients nowadays are smart. They know when they need an antibiotic..

If they expect antibiotics and dont get it, they will not be satisfied..

Its all my patients fault. They keep on expecting antibiotics to be prescribed.

I am sure I only prescribe antibiotics when it is really indicated

If I do not prescribe an antibiotic, he/she will keep on coming back to me for the

same problem.

How else do I reduce my patients anxiety apart from prescribing antibiotics?

What do you mean communicate with my patient?

I have problems convincing my patient that it is a viral infection

I am a busy doctor. Ive got no time to argue with my patient

Does interventions really work? Will our patients really be satisfied?

But are you sure my patient will not get complications if I do not give him

antibiotics?

But my patient still insists on antibiotics!


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Patients nowadays are smart. They know when

they need an antibiotic..


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Face-to-face survey in Britain in 2003. Of

10,981 randomly selected adults fromEngland, Scotland and Wales, 7120 (65%)

completed the questionnaire.


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Its all my patients fault. They keep on expecting

antibiotics to be prescribed.


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22 non randomly selected GP; 336 patients;Newcastle, Australia

the doctors' opinions about patients'expectations that were the strongest

determinants of prescribing

likely to be prescribed

medicines

patients who expected medications X 3

general practitioner thought that the patient

expected medication X 10


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But I am sure I only prescribe antibiotics when it

is really indicated


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Appropriateness of antibiotic prescribing forrespiratory tract infections (n = 1469)Akkerman A E et al. J. Antimicrob. Chemother. 2005;56:930-936

146 GPs; Netherlands; patients with sinusitis, tonsillitisand bronchitis; 4 weeks winter of 2002/2003


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But are you sure my patient will not get

complications if I do not give him antibiotics?


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But what if my patient adamantly insists on

antibiotics?


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Appropriate use of antibiotics

Communication


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REMEMBER:

Effective communication is moreimportant than an antibiotic for

patient satisfaction.


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Disadvantages of inappropriate

antibiotic prescribing

Resistance in the patient

Resistance in the community

Unnecessary side effects

Promotes magic bullet ; instant cure

mentality

Costs - patients, doctors standing, health caresystems


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TIPS for not overusing antibiotics in

primary care

Tell patients about resistance

Identify patient concerns

Spend time answering questions

Recommend specific symptomatic therapy

Contingency plan if symptoms worsen.

Provide patient education materials


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Recommendations


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Adult recommendations

Acute Tonsillitis

Acute Pharyngitis

Phenoxymethylpenicillin EES

Acute Bacterial Rhinosinusitis Amoxycillin EES

Mild CAP (out-patient)

no morbidity

EES Amoxycillin

Acute tracheobronchitis

- usually viral

None unless symptoms persist

> 7 days

EES


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Paediatric Recommendations

Otitis media Amoxycillin Amoxycillin Clavulanate

Pneumonia (Outpatient) Amoxycillin

Bronchiolitis No antibiotics


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Summary

common infections respiratory tract

infections

data on misuse of antibiotics

reasons for misuse of antibiotics

recommendations for appropriate use of

antibiotics


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Acknowledgements

Dr Benedict Sim Infectious disease Physician

Dr Sheamini Sivasampu CRC

Dr Leong Kar Nim Infectious disease Physician

Ms Ng Li Meng Pharmacist HRPBI


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Thank You

Use and Misuse of Antibiotics in Resp Infections HBUK

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