STUDY OF USE OF ANTIBIOTICS IN THE TREATMENT OF ACUTE SUPPURATIVE OTITIS MEDIA IN A TERTIARY CARE SETUP - PowerPoint PPT Presentation

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STUDY OF USE OF ANTIBIOTICS IN THE TREATMENT OF ACUTE SUPPURATIVE OTITIS MEDIA IN A TERTIARY CARE SETUP

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Title: STUDY OF USE OF ANTIBIOTICS IN THE TREATMENT OF ACUTE SUPPURATIVE OTITIS MEDIA IN A TERTIARY CARE SETUP


1
STUDY OF USE OF ANTIBIOTICS IN THE TREATMENT OF
ACUTE SUPPURATIVE OTITIS MEDIA IN A TERTIARY CARE
SETUP
Hiremath Shobha Rani. R1, Mathai. S1, Pradeep.
G1, Nagaraj. E.R2 Sathish. H.S2 1. Dept. of
Pharmacy Practice, Al Ameen College of
Pharmacy, Hosur Road, Bangalore 560 027. 2.
Bangalore Medical College, Bangalore 560 001.
2
Abstract Problem Statement Inappropriate
antimicrobial use can lead to emergence of
bacterial resistance. In India, the problem of
antimicrobial resistance is very high due to
factors such as improper prescribing/dosing and
easy access to antibiotics over the counter.
Management of resistance requires frequent and
systematic review of antimicrobial susceptibility
testing and rational drug use by way of
appropriate guidelines. Objectives To assess the
extent of antibiotic usage in Acute Suppurative
Otitis Media (ASOM) at a Government Tertiary Care
hospital to evaluate the antibacterial
sensitivity pattern to the antibiotics used in
the same and to prepare guidelines for the use
of antibiotics. Design Prospective, randomized
open study. Setting and Population 1100 bed
tertiary care government hospital in urban
Bangalore. Study Population 100 consecutive
outpatients of the ENT Department with a
diagnosis of ASOM formed the study sample.
Intervention Patient prescription analysis was
carried out to assess the type and extent of
antibiotics used. Middle ear pus specimens of the
patients were taken and processed in the
Microbiology department for identification of the
organism, followed by sensitivity testing to
antibiotics. Outcome Measures Type of
antibiotics used identification of the
organisms and sensitivity pattern. Results From
the prescription analysis of 100 patients, it was
found that Amoxicillin was the drug most widely
prescribed, followed by Roxithromycin,
Ciprofloxacin, Co-trimoxazole, Doxycycline,
Cefuroxime, Azithromycin, Sparfloxacin and
Ofloxacin (in descending order). Maximum
antibiotic usage was found in the age group of
1-13 yrs. Identification of bacterial isolates
was obtained from 86 cultures while the remaining
14 were sterile. The most predominant organism
isolated were S. aureus (45 cases) followed by
K.pneumoniae (14 cases) and P. aeruginosa (21
cases). In 6 cases mixture of organisms were also
seen. The descending order of sensitivity of
organism to antibiotics is AmikacingtCiprofloxaci
ngtGentamicingtNorfloxacingtCefotaximegtChloramphenico
lgtCo-trimoxazolegtCephalexingt ErythromycingtPenicill
ingtAmpicillin/Amoxicillin. Guidelines were
prepared based on the findings and submitted to
the ENT department. Conclusions There is very
poor correlation between the antibiotics
prescribed and their sensitivity patterns as is
clearly seen in the case of Amoxicillin, which
continues to be most prescribed though most of
the organisms found in the middle ear specimen
are resistant to it. Sensitivity testing is thus
necessary to prevent treatment failures. The
guidelines have a major role to play in ensuring
rational use of antibiotics during treatment of
ASOM.
3
Introduction
Suppurative Otitis Media(ASOM) refers to a
clinically identifiable bacterial infection of
the middle ear and is usually treated with
antibiotics.  Otitis media has been identified as
one of the most frequent reasons for outpatient
antibiotic therapy and the widespread use of
antibiotics to treat Otitis Media has resulted in
an alarming increase in antibiotic-resistance of
the bacterial strains that cause the same. In
most cases, the causative organism is not
isolated before treatment is initiated and the
choice of antibiotics is based on the efficacy
against the most common pathogens reported in
published studies. The function of sensitivity
testing is to guide the choice of treatment in
individual patient and to provide surveillance
data to monitor resistance trend. Along with the
study of national or international trends of
resistance for any disease, it is important to
gather local information on resistance to form
policies /guidelines in individual localities.
4
AIM To evaluate the rationale of antibiotic usage
in the treatment of Acute Suppurative Otitis
Media , at Victoria Hospital
  • OBJECTIVES
  • To assess the antibiotics prescribed for ASOM in
    the ENT Department of Victoria Hospital.
  • To evaluate the anti bacterial sensitivity
    pattern to the antibiotics used.
  • To prepare guidelines for the use of Antibiotics
    in ASOM in the ENT Department of Victoria
    Hospital.

5
Methods
Study Site ENT Department of Victoria Hospital
(1100 bedded tertiary care hospital in
Bangalore) Study Sample Consecutive 100
outpatients of the ENT Dept with a diagnosis of
Acute Suppurative Otitis Media. Inclusion
Criteria Outpatients - both pediatric and adult
population with Acute Suppurative Otitis Media.
Exclusion Criteria Outpatients - with only ear
pain no ear discharge and patients who were on
antibiotics (oral/parenteral/local application)
at least two weeks before his/her visit to the
hospital.
6
Methodology A detailed patient history was taken
and recorded. Pus specimens were taken with the
help of sterile cotton wool ear swabs by ENT
doctor from the infected ear of the patients. The
samples were processed in the department of
microbiology, Victoria Hospital. One swab was
used for Gram stain and the other swabs were
inoculated into different media namely Chocolate
agar, Blood agar Mac Conkeys Agar. After
inoculation the media were incubated at 370 C for
12-48 hrs. Once the colony appears identification
of the colony is done by standard biochemical
tests. Antibiotic Sensitivity Testing After
isolation of the individual organism, it was
tested for antibiotic sensitivity by disk
diffusion method. Based on the extent of the
zone of inhibition, the sensitivity pattern of
the particular organism to the antibiotic was
determined.
7
Results
The patients age ranged from 3 months to 85 yrs.
62 of the patients were in the age group of 1-13
yrs, 7 in the age group of 13-18 yrs and 31 in
the adult group. 54 of the patients belonged to
lower economic group whereas 46 belonged to the
middle economic group. Symptoms of Acute Otitis
Media in 100 patients
Symptoms Percentage of patients
Discharge Pain Fever Cold Cough Vomiting Tinnitus Itching 100 82 48 69 35 7.9 26 38
8
The antibiotics prescribed in the hospital were
listed from the prescription analysis of 100
patients before the culture sensitivity test and
are shown in Figure 01.
Figure 01 Usage of antibiotics
9
From the analysis of pus specimens of the
patients, bacterial isolates were obtained from
cultures in 86 cases whereas the cultures were
sterile in the remaining 14 cases. Results of the
bacterial cultures are shown in Figure 02.
Figure 02 Bacterial cultures of patients
The most predominant organisms isolated were
S.aureus (45) followed by K. pneumoniae(14) and
P.aeruginosa (8). Mixture of organisms were also
seen (6). Most of the isolates were seen in
children (1-13yrs) followed by adults (18-60yrs).
Mixture of organisms were more seen in age group
of 1-13yrs.
10
The sensitivity pattern of all the isolated
organisms are shown in Figure 03.
Figure 03 Sensitivity pattern of isolated
organism
No. of isolates sensitive to antibiotics
Sensitivity testing was based on the antibiotic
discs available in the microbiology department.
Hence, all the antibiotics prescribed were not
tested.
11
Summary
  • In the hospital, Amoxicillin remains the drug of
    choice, which is in accordance with STGs. It is
    also the most commonly prescribed drug in the
    hospital.
  • However, from the culture sensitivity test it has
    been found that most of the organisms are
    resistant to Amoxicillin which may be attributed
    to the rampant misuse of the drug leading to
    treatment failures.
  • Amoxicillin/Clavulanate may be used as the next
    choice for treating ASOM, in case of resistance
    to amoxicillin.
  • In case of patients allergic to beta lactam
    antibiotics, Cotrimoxazole or Erythromycin or
    Azithromycin can be used.
  • Although the organisms are most sensitive to
    Amikacin, it is not recommended, as ototoxicity
    is one of the primary adverse effects associated
    with Amikacin therapy.
  • Although Gentamicin ear drops are being
    prescribed for ASOM, it is not appropriate due to
    its ototoxicity.

12
  • As the organisms were found to be sensitive to
    fluoroquinolones, prescribing ciprofloxacin may
    be considered in adult patients only as safety
    and efficacy of fluoroquinolones, in children and
    adolescents under age 18 have not been
    established.
  • The organisms are found to be highly sensitive to
    Cefuroxime, a second generation Cephalosporin and
    moderately sensitive to Cephalexin (first
    generation) which may be used in pediatric cases
    as well.
  • Conclusions
  • The study indicates that antibiotics are
    prescribed on an empiric basis without any
    rationale.
  • Routine culture sensitivity testing is not being
    carried out in the hospital.
  • Culture Sensitivity testing is therefore a
    necessity for the rational use of antibiotics in
    the treatment of ASOM.
  • Based on the findings, Guidelines have been
    prepared and submitted to the ENT Department of
    Victoria Hospital in order to promote rational
    use of antibiotics.

13
Guidelines
  • First Line of Treatment
  • Symptomatic treatment with Amoxicillin till the
    results of the culture sensitivity tests are
    obtained. Recommended Dose and Duration For
    pediatrics 125 mg t.i.d to 750 mg b.i.d for 3
    10 days. For adults 250 500 mg every 8 hours
    for 10 days.
  • In case of beta lactam allergy
  • Co-trimoxazole Recommended Dose and Duration
    For pediatrics -TMP 8 mg , 40mg of SMZ/Kg body
    weight/day, in 2 divided doses for 10 days. For
    adults - One DS tablet (160 mg TMP and 800 mg
    SMZ) b.i.d for 10 days.
  • Or
  • Roxithromycin Recommended Dose and Duration For
    pediatrics 2.5 5 mg b.i.d for 5-6 days. For
    adults - 150 mg b.i.d for 5-10 days. All dosage
    to be taken before meals.
  • Second Line of Treatment
  • In case of treatment failure with Amoxicillin,
    Amoxicillin/clavulanate can be used. Recommended
    Dose and Duration For pediatrics - 40 mg/kg/day
    PO in divided doses every 8 hours or 45 mg/kg/day
    in divided doses every 12 hours for 10 days. For
    adults 250 mg t.i.d for 10 days or 500 mg b.i.d
    for 10 days.
  • OR
  • Cefuroxime Recommended Dose and Duration For
    pediatrics 40 mg/kg/day PO in divided doses
    b.i.d for 10 days. For adults 250 mg 500 mg
    b.i.d for 10 days.
  • In case of beta lactam allergy
  • Azithromycin Recommended Dose and Duration For
    pediatrics - 10mg/kg PO on day 1 followed by
    5mg/kg daily from 2nd to 5th day. For adults
    500 mg OD for 5 days.
  • OR
  • Otic Ofloxacin or Ciprofloxacin 10 drops b.i.d
    for 14 days.

14
  • Third Line of Treatment
  • Cefotaxime Recommended Dose and Duration For
    pediatrics - Less than 50 kg, 50-180 mg/kg IM or
    IV in 4-6 divided doses. For adults - 1-2 gms
    t.i.d IM or IV.
  • Ceftriaxone Recommended Dose and Duration For
    pediatrics - 50-75 mg/kg/day IM OD for 3 days.
    For Adults - 1-2 gms IM or IV b.i.d for 4 -14
    days. s

The authors wish to acknowledge WHO, South
East Asia Regional Office (SEARO), World
Health House, New-Delhi, INDIA and Al-Ameen
College of Pharmacy, Bangalore.
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