Most studies in Meta-analysis favour use of antibiotics in exacerbations - Prof. Oraby


 Management of Airway Infections

Most studies in Meta-analysis favour use of
antibiotics in exacerbations - Prof. Oraby

CAP patients with shock, bacteremia will need
combination therapy with antimicrobial agents

KARACHI: Most studies in Meta-analysis favour the use of antibiotics in exacerbations. Those patients who get antibiotics are less likely to develop pneumonia. CAP patients with shock, bacteremia will need combination therapy with antimicrobial agents. Area Under Cure (AUC) and minimal inhibitory concentrations (MIC) should be considered while selecting antibiotics. This was stated by Prof. Sayed M.Oraby, Professor of Pulmonology and Critical Care Medicine at Ain Shams University Cairo, Egypt. Hew was making a presentation on Clinical Management of Airway Infections at a series of meeting organized by Abbott Academic Alliance in major cities of Pakistan recently. The meetings which were organized at Lahore, Islamabad and Karachi were very well attended by general practitioners and Family Physicians.

Prof. Sayed M. Oraby talking to Prof. Karim Kammeruddin during MOKSI
symposium organised by Abbott Laboratories at Karachi recently.
Dr. Sarmad Maqbool Director Marketing and Strategy and Dr. Yasir Saeed
Product Manager Abbott Laboratories are also seen in the picture.

Prof. Oraby discussed the clinical management of various Upper Respiratory Tract Infections, Lower Respiratory Tract Infections like sinusitis, pharyngitis, tonsillitis, laryngitis, bronchitis besides community acquired pneumonia (CAP) in detail. Speaking about abuse of antibiotics, he pointed out that viral infections do not need antibiotics. However, if cough is more than five days, it becomes acute condition. NICE UK guidelines, he stated, recommend the use of antibiotics in patients with these infections who are over the age of sixty five years, those with Type-1 and Type-2 diabetes mellitus, have history of CHF and hospitalization. He then referred to the triggering factors for COPD and emphasized the importance of proper selection of an antibiotic. The treating physicians should know when to use antibiotics and when not to use antimicrobial agents. Canadian AECB Therapy Guidelines has divided these patients in three categories i.e. simple chronic bronchitis, complicated bronchitis and chronic supportive with target culture. He was of the view that one should not use antibiotics like amoxicillin, ampicillin, erythromycin, trimethoprime-sulphamethexazole, first generation cephalosporin’s as they have limitations in their antimicrobial activities. He also talked about more recent introductions like macrolides, their use in medical wads, therapy for CAP and their use in Intensive Care Units. We all are aware of different guidelines on the use of antibiotics and studies have confirmed that those patients who are put on fluoroquinolones get better more quickly. Clinical presentation can modify choice of antibiotics and it is advisable that one should use more potent therapy from the very beginning. If the patient is already on some antibiotics, change the antibiotic group.
Continuing Prof. Oraby said that physicians must also know the resistance pattern as there are many multidrug resistance pathogens. Some of the antimicrobial agents has decreased penetration to the site of infection and will develop resistance. He also talked about efflux pump mechanism, alteration of target site and inactivation of antibiotics, use of antibiotics in the treatment of gram negative bacterial infections and their impact on clinical practice. Resistance to macrolides, he said, is also increasing and it is irreversible resistance. Dose of macrolides has also increased.
Prof. Oraby then spoke about the mode of action of fluoroquinolones and said that ciprofloxacin use has now decreased but the use of Moxifloxacin is increasing. Talking about antibiogram and MIC he said that one should use that antibiotic which kills more than 90% of bacteria. Potency was described as concentration of an antibiotic at the site of infection to the MIC. All quinolones, he said, are not the same. They have different MIC. He also talked about their pharmacokinetics and pharmocodynamics. The dose of an antibiotic, he said, is dependent on the type of antibiotic being used. Once daily amino glycosides, fluoroquinolones are recommended as they are more safe and effective but one should be careful as increased dose can lead to toxicity. Rapid resolution of symptoms and clinical cure in CAP is higher with Moxifloxacin and less with Levofloxacin. Moxifloxacin is also extremely useful and effective in uncomplicated skin and skin structure infections, complicated intra-abdominal infections besides mild to moderate pelvic inflammatory diseases.
The presentation was followed by lively discussion in which the participants as well as members of the panel of experts in all these places actively participated in the deliberations. The panelists at Karachi meeting included Dr. Ali, Dr. Shagufta Shafi, Prof. Karim Kammeruddin, Prof. Ashraf Sadiq and Dr. Faisal Faiyaz Zuberi while members of the expert’s panel at Lahore included Prof Saulat Ullah Khan, Prof. Atif Mehmood and Prof. Sardar Fakhar Imam. The Islamabad meeting was jointly chaired by Maj.Gen. Badshah Khan Khattak, Dr. Shazli Manzoor and Dr. Aftab Akhtar.
During discussion at Karachi one of the participants pointed out that low socio economic group patients develop resistance much early as it was economic related. Hence, he emphasized the importance of infection control measures. Vaccination in the community and use of preventive measures as per various guidelines could be much more beneficial. It was also pointed out that evaluating socio economic group was not so easy and it was also difficult to educate the general public. We in Pakistan do not have a proper primary healthcare set up nor do we have a proper referral system. GPs and Family Physicians deal with most of these patients first before they consult a specialist. However, if concerted efforts are made just like creating awareness about MDR TB, the awareness can be increased. Now it is well known and accepted that apart from clinical history, Chest X-ray it is also important to look at the sputum and it is being practiced. Use of pneumococcal vaccine just started in children in Pakistan also figured during the discussion. It was also stated that if those antibiotics are continued to be used which have developed resistance, they will not cure the patient but they will be exposed to harmful side effects. Empiric prescribing problems remain with CAP and AECB but most potent drugs should always be given preference. The participants were reminded that in case of a serious infection, do not prescribe economically priced antibiotics but go for a more potent and effective agent from the very beginning.

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