Moustapha Mounib Senior Consultant of Chest Diseases Military Medical Academy

Since the discovery of penicillin, the first antibiotic known, in 1929 the antibiotics became the magic drug for infectious diseases. Their remarkable healing power observed at that period led to the wide spread uses and often the inappropriate prescriptions and consequently the emergence of the antibiotic abuse and resistance.

The majority of hospitalized patients receive antibiotics for therapy or prophylaxis during their inpatient stay and after discharge. It has been estimated that about fifty percent of patients receive antibiotics needlessly and that the antibiotic prescriptions in hospital are often irrational.

In an analysis of prescribing practices in teaching hospitals worldwide, more than 40 percent of all antimicrobials prescribed were considered inappropriate

Reasons include inappropriate prescribing an antibiotic for prophylaxis, continuation of empiric therapy despite negative culture in a stable patient, and lack of awareness of susceptibility patterns of common pathogens.

Antibiotic misuse- contributing factors

Habits and expectations hard to change “ cultural factors “. Lack of knowledge re risks. Self medication and non completion. Lack of control over aggressive marketing.

Rationale use of antibiotics in respiratory tract infections

But the snot is green. But he is coughing really bad for a whole week But the school wont let him back until he gets an antibiotic for his running nose. But I need to return to work as early as possible. But if I didn’t prescribe an antibiotic I may loose my patients.

“ Who needs a doctor !!! “

Some real situations

Case 1: 2 years old male, brought with history of fever and cough with rhinorrhea of two days. Red eyes, Diarrhea, cough ++. History of similar case in family. O/E : Throat congested.

Clinically diagnosed : Viral Upper Respiratory Tract Infection – seasonal ( Pharyngotonsillitis ). Management : - General and symptomatic therapy. - ANTIBIOTICS : Not Needed.

Case 2 : 40 years old otherwise healthy, non smoker male. Present C/O : -dry cough for 2 weeks. -clear sputum production & fatigue Denies : pharyngitis, fever, chills. Vital signs : normal temperature, respiratory rate & pulse.

Diagnosis : Acute Bronchitis. * Over 90% are viral. * Approximately 60% of patients seeking medical care are given antibiotics !!! * One of the most common causes of antibiotic abuse.

Most common viruses causing acute bronchitis # Coronavirus. # Rhinovirus. # Influenza A and B. # Parainfluenza. # respiratory syncitial virus. # Human metapneumovirus.

Influenza

* Cough, purulent sputum, fever and constitutional complaints during the influenza season. * Amantadine, rimantadine, or neuraminidase inhibitors, must be given within 48 hours of symptoms onset for demonstrable benefit.

Pneumonitis vs Acute bronchitis. Abnormal vital signs : Temp. > 38 degree centigrade. Pulse > 100/min. Respiratory rate > 24/min. Crackles on examination.

Think……. * Post nasal drip syndrome * Asthma * Gastroesophageal reflux

Case 3 : 28 years old otherwise healthy female who complains of : nasal congestion, purulent nasal discharge, maxillary tooth discomfort, hyposmia, and facial pain or pressure that is worse when bending forward, headache, fever ( non acute ), halitosis, fatigue, cough, ear pain, and ear fullness.

@ Almost all cases viral in etiology. - Rhinovirus, Parainfluenza, and Influenza virus. - Usually resolves in % complicated by acute bacterial sinusitis ( Streptococcus pneumoniae and Haemophilus influenzae Self-limited, 75% resolve without ttt. In 1 month.

Average adult has from 2-3 colds and influenza- like illnesses per year. Average child six to ten. Represents approximately one billion acute respiratory illnesses annually. Approximately 0.5 to 2 percent of colds and influenza-like illnesses are complicated by acute bacterial sinusitis.

Take home messages

Viruses cause most common respiratory illnesses Viral illness needs time to heal, antibiotic can not help

Taking antibiotics for viral illnesses will not : *cure the infection. *keep others from getting the illness. *makes the patient feel better. But it will make it more likely to bacterial resistance.

Clinical differentiation is possible between bacterial and viral infection most of the times. * Viral infection is disseminated throughout the system (URT/LRT). Fever is usually high at onset, settles by day 3-4. * Bacterial infection is localized to one part of the system ( acute tonsillitis does not present with running nose or chest signs ). Fever is generally moderate at the onset and peaks by day 3-4.

So there is no need to hurry through antibiotic prescription.

References 1-Angela Heithaus. Internal Medicine Seatle Arts Center.Diagnosis and Treatment of Common Infectious Diseases.2009 (ppt. presentation ) 2-Nagwa Khamis, Than Lecompte. Antibiotic Usage in Hospitals. First edition, Pawla Renouf. Primary/Family Health Care, Aukland, New Zealand. Judicious Use and Misuse of Antibiotics, Cases from the frontline.2007 ( ppt. presentation ) 4-Raju C. Shah. Ankur Institute of Child Health. Prescribing antibiotics in pediatrics office practice (ppt. presentation )

Thank you