Management & Prophylaxis of Cardio-respiratory illnesses

1. Management & Prophylaxis of Cardio-respiratory illnesses DR SWATI BHAVE Senior consultant Pediatric & Adolescent medicine Indraprastha Apollo Hospital New Delhi Member Standing committee ASPID ( Asian Society of Pediatric infectious disease ( 2000-03) ) Standing committee IPA ( International Pediatric Association 2001-07) President 2000 Indian Academy of Pediatrics

2. Prophylactic antibiotics for cystic fibrosis • Three studies, totaling 177patients aged 0-7 years on enrollment, were suitable for inclusion in the review. • A reduced prevalence of Staphylococcus aureus in the respiratory secretions was seen in children receiving anti-staphylococcal antibiotic prophylaxis, although no effect was seen on other common pathogens. • One eligible study showed a shorter duration of hospital admissions in the second year ofl ife, in patients receiving prophylaxis. No effect on infant lung function has been shown after one year of prophylactic treatment. • Data are not available on adverse effects of the interventions. There was a trend towards a lower cumulative isolation • Update of: Cochrane Database Syst Rev. 2000;(2):CD001912. . Smyth A, Walters S.

3. Prophylactic antibiotics for cystic fibrosis • There was a trend towards a lower cumulative isolation rate of P aeruginosa in the prophylaxis group,after three years. • However, as the duration of the studies reviewed has been oft hree years or less, conclusions cannot be drawn about the long term effects of prophylaxis on acquisition of P. aeruginosa and survival. • REVIEWER'SCONCLUSIONS: Anti-staphylococcal antibiotic prophylaxis may be of benefit when commenced early in infancy and continued up to three years of age. There is insufficient evidence from this review to say whether use in older children, or adults, or for periods of over three years is beneficial.  • Update of: Cochrane Database Syst Rev. 2000;(2):CD001912. . Smyth A, Walters S.

4. Prophylactic antibiotics for cystic fibrosis: objectives . • (1) improves clinical status, lung function and survival • (2) causes adverse effects (e.g. diarrhea,skin rash, candidiasis) • (3) leads to fewer isolates of common pathogens from respiratory secretions • (4) leads to the emergence of antibiotic resistance and the colonization of the respiratory tract with organisms, e.g. Pseudomonas aeruginosa. • Smith A, Walters S . Cochrane Database Syst Rev. 2003;(3):CD001912.

5. Anti-staphylococcal antibiotic prophylaxis • leads to fewer children having isolates of Staph. aureus, when commenced early in infancy and continued up to six years of age. The clinical importance of this finding is uncertain. • Further research may establish whether the trend towards more children with CF with Pseudomonas aeruginosa, after four to six years of prophylaxis, is a chance finding. • Future work should explore whether choice of prophylactic antibiotic or duration of treatment might influence infection with P aeruginosa.

6.  Vaccine development for capsulate bacteria causing pneumonia.  Hib vaccine can prevent pneumonia in developing countries. SP conjugate vaccine prevents X-ray confirmed pneumonia in low incident populations, but protection appears more marginal in high incident populations. Non-vaccine SP stenotypes have demonstrated increased carriage and mucosal disease, but not invasive disease following vaccination. GBS vaccines are in the early stages of clinical development as prenatal or antenatal vaccines. Russell FM, Buttery J. Curr Opin Pulm Med. 2003 May;9(3):227-32.

7. Selective decontamination of the digestive tract. • Ventilator-associated pneumonia usually originates : patient's oropharyngeal microflora. • In selective digestive decontamination, topical antibiotics : applied to the oropharynx and stomach for prevention of pneumonia and other infections, • Also used for the prevention of gut-derived infections in acute necrotizing pancreatitis and liver transplantation • Krueger WA, Unertl KE.  Curr Opin Crit Care. 2002 Apr;8(2):139-44.

8. Remains controversial Selective decontamination of the digestive tract. • Reduction of the incidence of pneumonias accepted, but the extent of reduction is debated. • Mortality was not reduced in most individual trials.increased resistance & shift to Gram-positive • selection of appropriate groups of patients for underlying diseases and severity of illness, & and selection of ICUs, based on the endemic resistance patterns • Krueger WA, Unertl KE.  Curr Opin Crit Care. 2002 Apr;8(2):139-44.

9. Prospects for the prevention and control of pseudomonal infection in children with cystic fibrosis. • by eliminating cross-infection and by early aggressive antibiotic treatment of the first positive sputum culture and of subsequent intermittent colonisation. By using chronic suppressive antibiotic maintenance therapy and anti-inflammatory drugs it is however, possible to maintain the lung function of these patients for a number of years. Hoiby N Paediatr Drugs. 2000 Nov-Dec;2(6):451-63.

10. Antibiotics for preventing pneumonia in children with measles. • The quality of the trials reviewed was poor, and they provide very weak evidence for giving antibiotics to all children with measles. Available evidence suggests that antibiotics should be given only if a child has clinical signs of pneumonia or other evidence of sepsis. Shann F, D'Souza RM, D'Souza R.,Cochrane Database Syst Rev. 2000;(2):CD001477.

11.  Vaccine development for capsulate bacteria causing pneumonia.  Hib vaccine can prevent pneumonia in developing countries. SP conjugate vaccine prevents X-ray confirmed pneumonia in low incident populations, but protection appears more marginal in high incident populations. Non-vaccine SP stenotypes have demonstrated increased carriage and mucosal disease, but not invasive disease following vaccination. GBS vaccines are in the early stages of clinical development as prenatal or antenatal vaccines. Russell FM, Buttery J. Curr Opin Pulm Med. 2003 May;9(3):227-32.

12. Pulmonary fungal infections in immuno-compromised children. Treatment is usually successful if initiate dearly, although pulmonary aspergillosis and zygomycosis are portentous ailments unless surgical resection or prompt immunologic recovery ensue.  • Shenep JL, Flynn PM. Curr Opin Pediatr. 1997 Jun;9(3):213-8.

13. Use of prophylactic antibiotics in cancer patients . • Severe neutropenia < 100/mm3) for> 2 weeks should receive oral antibiotic prophylaxis. • At present, trimethoprim sulfamethoxazole in combination with either nystatin or amphotericin B is the best regimen for reducing the incidence of serious infections. • Wolff LJ. Am J Pediatr Hematol Oncol. 1984 Fall;6(3):267-76.

14. THERAPY HAS IMPORTANT ROLE Management of valvular heart dis-ease: • stabilization of patients until the time of surgery, treatment of the underlying • cause,and prevention of bacterial endocarditis and rheumatic fever • it is still not proven to alter the course of valvular heart disease or the time of surgery when a serious structural abnormality is Cleveland clinic journal of medicine volume 68 • number 10 october 2001881rug

15. ANTIBIOTICPROPHYLAXIS in Rheumatic disease Prophylaxis is indicated if • echocardiography shows evidence of a rheumatic etiology of valve disease

16. Summary • Prophylactic antibiotics should be judiciously used • There are recommendations based on good research studies • A protocol should be standardized for each setup that should be strictly followed by all the concerned personalle