Rational Use of Antibiotic in Acute

Respiratory Tract Infection (ARTI)

Dr. Ludy Sofardi, SpA

 Rational Use

Overuse
Pada infeksi
ringan
Penggunaan Muncul Mikroba
Antibiotik Resisten
Misuse
Tidak ada
sarana
diagnostik

Underuse
Dukungan
finansial (-)
The component of therapy in
Infectious Diseases
The benefit of antibiotic
Cure for
bacterial
infection Correct
dose &
only! Bacterial duration
elimination &
eradication
Suppress
the number
of
pathogen
Kill
bacterial
pathogen
caused
disease
How antibiotic kill bacteria?
 Inappropriate use of antibiotics
Increase in
antibiotic use Increase in
resistant strains
Limited treatment
alternatives
more antibiotics
Ineffective empiric
increased therapy
mortality
increased morbidity
more antibiotics

Increased
use of Increased
healthcare hospitalization
resources more antibiotics
Saluran Napas
 Infeksi Respiratori Akut (IRA)
IRA ATAS IRA BAWAH URTI LRTI
Rinitis Epiglotitis Common Cold Bronchitis
Faringitis Croup ( Laringo Pharyngitis (Tonsillitis, Bronchiolitis
trakheobronkhitis ) T-pharyngitis, Nasopharyngitis)
Tonsilitis Bronkhitis Sinusitis, Otitis Media Bacterial, Non Bacterial
Mastoiditis, Epiglotitis Pnemonia
Rinosinositis Bronkhiolitis Herphangina Pleural Effusion
Oral Cavity Infections /Empyema
Otitis media Pnemonia Pharyngoconjuctival fever Lung Abscess
Peritonsil, Retro pharyng Absces
etc
Croup (Laryngitis,
Laringotracheitis, Lt-bronchitis)
URTI : Upper Respiratory Tract Infections , LRTI : Lower Respiratory Tract Infections

Buku Ajar Respirolologi Anak IDAI 2010

Feigin,Text book of Pediatric Infectious Diseases 2009
 Respiratory Tract Infection (RTI)
Acute infection ranging nose to the alveoli
(including sinus, middle ear cavity and pleura)
WHO (2002) :
3.9 million deaths per year (20 % are children)
94.6 million disability adjusted life experience years (DALYs)
6 % total DALYs (70 % of cases in Africa and Southeast Asia)

UNICEF/WHO 2006, WPD 2011 :

Every year 2 million of the 9 million children (< 5 years) died of
pneumonia the forgotten killer of children
 Pneumonia leads causes of childhood deaths

Source: WHO estimates of the causes of death in children, 2000-03 Bryce, Lancet, 26 March 2005
S. pneumoniae is The Most Commonly Identified Organism Overall
Causing CAP (8 Asian Countriesa)
Pathogens isolated (N=390) No. of isolates (%)
S. pneumoniae 114 (29.2)
Klebsiella pneumoniae 60 (15.4)
Hemophilus influenzae 59 (15.1)
Pseudomonas aeruginosa 26 (6.7)
Staphylococcus aureus 19 (4.9)
Mycobacterium tuberculosis 13 (3.3)
Moraxella catarrhalis 12 (3.1)
Other pathogens 77 (19.7)
Mycoplasma pneumoniae 61/556 (11.0)
Chlamydia pneumoniae 55/411 (13.4)
Legionella pneumoniae 7/648 (1.1)

aSouth Korea, China, Taiwan, Hong Kong, India, Singapore, Vietnam, and the Philippines.
Study by ANSORP (Asian Network for Surveillance of Resistant Pathogens Study Group).

Adapted from Song J-H et al. Int J Antimicrob Agents. 2008;31(2):107-114.

 CAP Pathogen Accoding to Age
Neonates 1-2 months 3-12 months 1-5 years >5 years
Streptococcus Chlamydia Viruses Viruses S pneumoniae
group B trachomatis
Enteric gram Ureaplasma Streptococcu S pneumoniae M
negative urealyticum s pneumoniae pneumoniae
Viruses H influenzae Mycoplasma C pneumoniae
pneumoniae
Bordetella Staphylococc Chlamydia
pertussis us aureus pneumoniae
Moraxella
catharrhalis

Disorders of resp tract in children, Kendigs, 2012

Atypical Pathogens are Commonly Implicated in Hospitalized
Community - Acquired Pneumonia (CAP)
22% of CAP cases are caused by Atypical Pathogens

22%
Streptococcus Atypical pathogens:
pneumoniae 34% Legionella spp
Chlamydia spp
Mycoplasma spp

6% Staphylococcus
aureus

Other

Haemophilus influenzae and 15%

Moraxella catarrhalis
Aerobic gram-negative rods
15%
8% (Adapted from Eron JJ et al. Hospital Formulary, 1994.)

Due to the difficulty of culturing atypical bacteria, the prevalence of these organisms in CAP is likely to be underestimated
(File TM et al. Infect Dis Clin North Am, 1998)
CAP, community-acquired pneumonia.
*Preferred treatments of choice change in areas of
high S pneumoniae resistance. Refer to the complete
guidelines for specific recommendations.
The guidelines do not fully address the controversy
concerning the use of quinolones in children. The use
of quinolones in infants and children is considered a
risk
vs benefit decision
CAP, community-acquired pneumonia.
*The addition of clindamycin 40 mg/kg/d IV divided
every 6-8 hours or vancomycin 40-60 mg/kg/day IV
divided every 6-8 hours is recommended for suspected
or
confirmed community-acquired methicillin-resistant
Staphylococcus aureus.
The guidelines do not fully address the controversy
concerning the use of quinolones in children. Use of
quinolones in infants and children is considered a risk vs
benefit decision
 Steps to Better Manage Antibiotic
Resistance
According to appropriate use guidelines, it is
important to:
Use antibiotics only for bacterial infections1
To better manager antibiotic resistance, it is critical to
address:
Use of targeted antibiotics with appropriate-spectrum
activity and dosage2
Improve compliance with antibiotic regimens2

1. Centers for Disease Control and Prevention. Get Smart program. Available at:
http://www.cdc.gov/drugresistance/community/default.htm. Accessed May 2, 2005.
2. Tufts Health Care Institute and Alliance for the Prudent Use of Antibiotics. Practitioner information on prudent use of
antibiotics. Winter 2003. Available at: http://www.tufts.edu/med/apau/thci/ tmciPractitionerFacts.pdf. Accessed June 2, 2005
 Azithromycin Achieves High and Sustained up to 10-day
Concentration at Macrophages and White Blood Cells
Serum Neutrophil and Lung Concentrations of Azithromycin Provides Sustained 10-day
Azithromycin vs Time1 Concentration1,2

100
Aveolar macrophages*

Azithromycin Concentration (g/ml)

Peripheral blood monocytes*

10 Serum
MIC90 2.0 Haemophilis influenzae
Concentrations (mg/L)

Neutrophil
sLung
1 MIC90 0.25 Chlamydia pneumoniae
S. pneum. 0.25 mg/L MIC90 0.25 Streptococcus
pneumoniae
Moraxella
catarrhalis
0.1

MIC90 0.00024 Mycoplasma pneumoniae

0.01 0
0 100 200 300 0 1 2 3 4 5 6 7 8 9 10 Time (Days)
Time (hr)

Serum neutrophil concentrations vs time when azithromycin Graph to show the sustained effect of 5 days of azithromycin. 25 healthy
is administered orally 500mg daily for 3 days and lung volunteers each received 500mg of azithromycin, followed by 250mg once
concentrations vs time after a single 500mg oral dose. daily for 4 days.
*Drug concentrations are in micrograms per milliliter of
monocyte/macrophage volume
1. Amsden GW et al. Short-Course Antimicrobial Therapy. A Clinical Guide. Reprinted 2003 Elsvier Health Communications: Page 7-
15; 2. Olsen et al. Antimicrob Agents Chemother 1996; 40(11):2584
Advantages of Azithromycin for Acute Bacterial
Respiratory Tract Infection Out Patient
Short duration Bactericidal
therapy: 3-5 Once daily dose activity: Typical and
days Atypical

AZITHROMYCIN

Pleasant-tasting oral High concentrations

suspension in tissue until 10 days

Well tolerated
Saluran Pernafasan Atas
Tonsilitis bakteri
Group A beta-hemolytic streptococcus (GABHS), the most
common bacterial etiology, accounts for 15 to 30 percent of
cases of acute pharyngitis in children and 5 to 20 percent in
adults.
Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH, for the Infectious Diseases Society
of America. Practice guidelines for the diagnosis and management of group A streptococcal
pharyngitis. Clin Infect Dis. 2002;35(2):113-125

Among school-aged children, the incidences of acute sore throat,

swab-positive GABHS, and serologically confirmed GABHS infection
are 33, 13, and eight per 100 child-years, respectively.
Danchin MH, Rogers S, Kelpie L, et al. Burden of acute sore throat and group A streptococcal pharyngitis
in school-aged children and their families in Australia. Pediatrics. 2007;120(5):950-957.
 Gambaran Klinis Tonsilofaringitis
Gambaran Group A Streptococcus Virus
(GAS)
Insiden 20 % 80 %

Umur 5-11 tahun Semua umur

Gejala Onset mendadak Onset bervariasi

Nyeri telan Nyeri telan (ringan)
Demam Demam
Sakit kepala Arthralgia, mialgia
Mual,muntah, sakit perut Sakit perut (Epstein Bar)
Tanda Faring : eritema, eksudat Eksudat (-)
Pembesaran kelenjar leher anterior Pembesaran kelenjar (-)
Petekie di palatum Khas eksantem, enantem
Tonsil hipertropi Sering dengan batuk, rhinitis,
Jarang batuk, rhinitis,serak & diare serak & konjungtivitis serta diare

Tanz, Sulman S. Principle and practice of pediatric infctious disease .Long S Pickering L Prober. 2002.
 Gambaran Klinis
Tonsilofaringitis
Tonsilofaringitis ok Streptococcus

Tonsilofaringitis ok Virus
 Menetapkan GAS Tonsilofaringitis

Sistem scoring :
Mc Isaac
Centor/ Centor Modified
Strep score Ebell
Kultur
Rapid Antigen Detection Test ( RADT)
RADT, kultur () modifikasi
ASTO tidak dapat menggantikan RADT
ASTO infeksi baru terjadi recent infection
Sistem skor McIsaac
Centor criteria Tonsilitis

Sensitivitas
spesifisitas 75 %
 2 dari 4 ( + )

Kemungkinan infeksi
bakteri

Hanya 1 Rapid Ag Detection Test (RADT)

Strep A test

Kemungkinan
Infeksi virus
Negatif Positif

Tidak lakukan test ( RADT)

Strep A test Antibiotik (-) Antibiotik (+ )
Penisilin
Kriteria modifikasi
 Kriteria modifikasi
Viral signs:
Conjunctivitis ,Coryza , Cough
Diarrhea
Viral-like exanthema
Bacterial signs:
Tender cervical node
Headache
Petechia on the palate
Fever >38.5oC
Abdominal pain
TOTAL SCORE:
Sudden onset (<12 hours)
Values (age + viral signs + bacterial signs)

THERAPEUTIC OPTION
TABLE 2

Spesifisitas >84%
AB 41-55%
Kriteria modifikasi
Pediatrics 2010;126:e608e614

Spesifisitas 88%
AB 35-55%
 Pilihan Antibiotik GAS
Obat Dosis Frekuensi Lama Rute Sediaan Rating

Penicillin V 27 kg: 250 mg 2 3 x/hari 10 hari Oral Tablet IB

>27 kg: 500 mg

Amoxicillin 50 mg/kg 3x/hari 10 hari Oral Tablet 250 mg, 500 mg IB

[maximum 1 g/hari] Sirup 125 mg/5ml
Sirup 250 mg/5 ml

Benzathine 27 kg: 600,000 U >27 kg: 1x 1 hari IM Vial IB

1,200,000 U
penicillin G
Eritromisin 20-40 mg/kbBB/hari 2-4 x/hari 10 hari Oral Tablet 250 mg, 500 mg IIaB
Sirup 200 mg/5 ml

Azithromycin 12 mg/kg/day 1 x/hari 5 hari Oral Tablet 250 mg, 500 mg IIaB
20 mg/kgBB/hari (maximum 3 hari Oral Sirup 100 mg/5ml
dose, 500 mg/hari) Sirup 200 mg/5 ml

Clarithromycin 15 mg/kg/hari (maximum 250 2 x/hari 10 hari Oral Tablet 250 mg, 500 mg IIaB
mg 2x/hari) Sirup 125 mg/5ml
Sirup 250 mg/5 ml

Cefalexin 50 mg/kg/hari 4 x/hari 10 hari Oral Tablet 250 mg, 500 mg IB

Sirup 125 mg/5ml
Sirup 250 mg/5 ml

Cefadroxil 30 mg/kgBB/hari 2 x/hari 10 hari Oral Tablet 250 mg, 500 mg IB

Sirup 125 mg/5ml
Sirup 250 mg/5 ml

Clindamycin 20 mg/kg/day 3 x/hari 10 hari Oral Tablet 250 mg, 500 mg IIaB
[maximum 1.8 g/hari] Sirup 125 mg/5ml
Sirup 250 mg/5 ml
 Summary
Antibiotic use should depend on
indication either clinical or lab
result
Guideline of indication and selecting
antibiotic is mandatory
Antibiotic use in each patient should
be evaluated
Supporting therapy needed to get a
maximal result
Prudent antibiotic use will give better
patient care beside prevented the
antibiotic resistance
 SEKIAN
TERIMA KASIH