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New Quinolone in AOM

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Warunee Punpanich Queen Sirikit National Institute of Child Health Fostering exploration, discovery and growth Chronology of Fluoroquinolone Introductions ... – PowerPoint PPT presentation

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Title: New Quinolone in AOM


1
New Quinolone in AOM Sinusitis To use or not
to use
  • Warunee Punpanich
  • Queen Sirikit National Institute of Child Health

Fostering exploration, discovery and growth
2
Chronology of Fluoroquinolone
  • Introductions in the United StatesSelected
    Quinolones and Year of Introduction

1960s Naiadixic Acid 1996 Levofloxacin 1986 No
rfloxacin 1998 Trovafloxacin 1987 Ciprofloxaci
n 1999 Gatifloxacin 1991 Ofloxacin 2000 Moxif
loxacin 1992 Temafloxacin 2000 Cllnafloxacin
1996 Sparfloxacin 2001 Gemifloxacin? 1996 Grep
afloxacin 2004 Gemifloxacin
no longer on market never released
3
Fluoroquinolone Advantages Disadvantages
  • Pros Cons
  • ? Broad spectrum activity ? Broad spectrum
    activity
  • ? Convenient dosing ? Use substitutes for
    thinking
  • Systemic coverage with Oral treatment
  • (FQ gen 3-4 bioavailability gt 70) ? Overused
  • ? Avoids beta-lactam and sulfa allergies ? Some
    allergy potential
  • ? Low cost (vis-à-vis IV) ? High cost
    (vis-à-vis PO)
  • ? Specific activities ? Specific side
    effects
  • - atyp resp pathogens - neurotoxicity
  • - STDs - QTc prolongation
  • - anthrax - tendonitis
  • - mycobacteria - C, difficile colitis (?)

4
Adverse Effects of Fluoroquinolones
FQ Cipro Gati Levo Moxi GI / CN
S / / Phototoxicity QTc
1 1 Allergic Glucose 1
Homeostasis lt 1, 1-5, 5 -10 1
FDA warning on the product Information sheet
  • Now only available levoflox and moxiflox only

5
  • Temaflox liver, blood tox
  • Sparflox photosensitivity
  • Grepaflox Bad taste and QT prolongation
  • Levoflox good for CAP in adult, has more balance
    gand g-ve
  • Trovaflox liver, blood tox (same side
    chaintemaflox)
  • Gatiflox hypogly, QT prolong (withdrawn)
  • Moxiflox very broad, use for respir gve
    infection
  • Clinaflox sunburn after fluorescence light,
    never release
  • Gemiflox only Iv form, unexplained rash, little
    use

6
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7
Collateral Damage
CID 200438 (Suppl 4) S341
  • Ecological adverse effects of antibiotic therapy
    ? the selection of drug-resistant organisms and
    the unwanted development of colonization or
    infection with MDR organisms.

Collateral Damage from Antibiotic Therapy CID
200438 (Suppl 4) S341
8
What would you do if you lost everything?
9
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10
Current evidence is limited but supports the use
of penicillin or amoxicillin for 7-14 days.
11
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12
Antimicrobial Tx in AMS meta-analysis
  • Difference in outcome between ATB treatment of
    acute sinusitis in otherwise healthy adults and
    adolescents appear to be small. Therefore, the
    cheapest ATB treatment can be selected.

13
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14
ATB for rhinosinusitis
  • 10-day ATB treatment will reduce the
    probability of persistence n the short to medium
    term. (NNT 8, 95 CI 5-29).
  • These conclusions are based on a small numbers of
    small randomized controlled trials.

15
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16
Economic evaluation of ATB for ABS
  • Confirms the place of amoxicillin as a first
    choice agent for sinusitis, with low dose
    clarithromycin and azithromycin as a second
    choice.

17
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18
  • Total direct charge was 68.98 USD for first-line
    ATB and 135.17 USD for second-line.
  • Those treated with first-line ATB did not have
    clinically significant difference in outcomes
    from those treated with second-line ATB.

19
Cost issue
  • LevofloxacinDose lt5 years  10 mg/kg/bid     
     gt5 years  10 mg/kg/dayCravit ??????
    Daiichi100 mg 23 baht/tablet250 mg 32.5
    baht/tablet500 mg 75  baht/tablet??????
    ????100 mg 11.77 baht/tablet500 mg 40.66
    baht/tablet
  • MoxifloxacinDose 10 mg/kg/dayAvelox ??????
    Bayer-Schering400 mg  100 baht/tablet
  • Amoxicillin 80 MKD
  • 500 mg 2.25 baht/cab
  • Cost for 10 day treatment for a 20 Kg child.
  • 460 Bh
  • 235 Bh
  • 500 Bh
  • 72 Bh

20
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21
Evidence for diagnosis and Tx for sinusitis
  • Good, high-quality evidence for acute
    uncomplicated sinusitis in children is limited.
  • The diagnostic modalities showed poor
    concordance, and treatment options were based on
    inadequate data.
  • More evidence is needed for defining the optimal
    treatment and diagnostic methods for this common
    condition.

22
Summary
  • Wide variety of new quinolone options but with
    different type of toxicity
  • High cost
  • Risk for collateral damage
  • No FDA approve for the use in children
  • No evidence support the use of this agent
  • Limited use in small children because of
    precipitation with 2 cation e.g. milk

23
New Quinolone in AOM Sinusitis To use or not
to use
  • .The choice is yours.
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