JOURNAL OF DENTAL SCIENCES
Volume V olume 2 Issue 1
PRESCRIBING ANTIBIOTICS AND ANALGESICS IN CHILDREN Dr. Jyoti Mathur Dr. Amish Diwanji Abstract For the purpose of having a standardized prescription practice, it is very necessary for the operators involved in dispensing treatment in a large set up, to have a quick reference system which would minimize chances of errors due to variation. We at the Department of Pedodontics, Faculty Facult y of Dental Science, Dharmsinh Desai University, Universi ty, have developed a quick reference chart for the ease of prescription. It contains both adult and pediatric doses of frequently prescribed antibiotics and analgesics. A separate section for contraindications and special precautions to the drugs has also been added to avoid complications. Key words- prescription, antibiotics, analgesics, orodental infections, children
Introduction Sir William Osler once said, ``the desire to take medicine is desire to perhaps the greatest feature which distinguishes man from 1 animals.” There exist clear clear cut indications for prophylactic prophylactic antibiotic usage given by renowned medical bodies such as American Heart Association for endocarditis prophylaxis. Still, antibiotics are the most widely abused prescribed drugs on the basis of inappropriate indications, dosages and duration of use. Approximately half of all antibiotics used in 2 hospitals are given to patients without signs or symptoms. The problem is compounded while prescribing for children. Most of the time 'random' age related prescriptions are given based on dosages for adults. The use of inappropriate antimicrobial drugs may result in ineffective therapy or contribute to the development of undesirable antibiotic resistance in the causative pathogens in the community.
Without specific knowledge about correct pediatric dosage based on body weight / surface area and other factors suc h as gestational and postnatal age in neonates, a clinician is liable to prescribe the drugs in inappropriate suboptimal or 3 excess dose with undesirable undesirable consequences. consequences. Therefore, we at the department of Pedodontics, Faculty of Dental Sciences, Dharmsinh Desai University, Nadiad have developed a quick reference chart for antibiotics and analgesics displayed display ed on the notice board for the purpose of standardization standardizati on in prescription practice by students, interns and teaching staff. The following chart is based on body weight of the child, special notes about various drugs interactions and considerations regarding preexisting hepatic and liver disorders are given subsequently subsequent ly in this paper.
Commonly Prescribed Drugs and Dosages (for orodental infections)1,3,4,5,7 Note: - Total - Total pediatric dose should never exceed adult dose. Neonatal doses not included Sr. No.
Drugs
Adult Dose
Pediatric Dose
1
Amoxicillin
250-500mg 3Times/day
20-40mg/Kg/day in 3 doses
2
Amoxicillin + Clavulanic acid (coamoxi clav)
250-500mg amoxicillin +125-250mg clavulanic acid 3 times a day
20-40mg/Kg/day of amoxicillin in 20-40mg/Kg/day 3 doses
3
Ciprofloxacin
250-500mg every 12 hrs
25mg/Kg/day divided in 2 doses (12 hrs each). To be avoided in children below 18 yrs
4
Cefixime
200mg 2 times a day for 7 -10 days
8mg/Kg/day in 2 divided doses
5
Cefadroxil
0.5-1g OD or Bid
30mg/Kg/ day in 2 doses
6
Erythromycin
250-500mg (stearate or estolate salts) or 250-500mg 400mg ethylsuccinate ethylsuccinate salt every 6 hrs
30 to 50 mg /Kg/ day in divided doses every 6hrs
7
Azithromycin
500mg OD
10mg/Kg/day in a single dose
Professor & Head Lecturer Department of Pedodontics and Preventive Dentistry, Faculty of Dental Science, Dharmsinh Desai University, NADIAD-387001. GUJARAT
Address for Correspondence : Dr. Jyoti Mathur Department of Pedodontics and Preventive Dentistry, Faculty of Dental Science, Dharmsinh Desai University, NADIAD-387001. GUJARAT E-mail :
[email protected] drjyotimathur74@gmail. com Ph. : 079 - 2658 9498 36
JOURNAL OF DENTAL SCIENCES
Volume 2 Issue 1
8
Clarithromycin
250-500mg every 12 hrs
7.5mg/Kg twice daily (upto 500mg twice daily)
9
Doxycycline
200mg on day 1 (100mg every 12 hrs) then 100mg daily
(age 8 yrs or older) : 4.4 mg/Kg in 2 divided doses on day 1 than 2.2 mg/Kg/day
10
Tetracycline
250-500 mg every 6 hrs
(age 8yrs or older)25-50 mg/kg/day divided into 6hrly doses
11
Ofloxacin
200-400 BID
10-15 mg/kg/day divided in 2 doses (every 12 hrs), max. dose 800 mg per day
12
Metronidazole
250-750mg every 8 hrs, not to exceed 4g in 24 hrs
30-50 mg/Kg/day in 3 divided doses for 5-10 day
13
Ornidazole
500mg twice daily for 5 days
10mg/ Kg every 12 hrs
14
Paracetamol
0.5-1 gm every 4-6 hrs Maximum dose 4g/day
10-15mg/Kg/ doses every 4-6 hrs maximum 5 doses in 1 day
15
Nimesulide
100mg/dose every 12 hrs
5mg/Kg/day divided every 8-12 hrs
16
Diclofenac sodium
75-150 mg/day in 2-4 divided doses, max. dose - 150mg/day
2-3mg/Kg/day in 2-4 divided doses
17
Ibuprofen
400-600mg/dose every 6-8 hrs maximum dose 2400mg/day
5-10mg/Kg/dose every 6-8hrs max. dose 40 mg/kg daily
18
Mefenamic acid
500 mg TID
Analgesic dose10-25/mg/Kg/day (divided into 6 hrly doses) Antipyretic dose3mg/Kg/dose every 6hrs Precaution – avoid in children with seizures
Antifungals 1. Nystatin Use – Oral candidiasis Neonate: 100,000 units to each side of mouth X QID Infant : 200,000 units to each side of the mouth X QID Children and Adults: 400,000-600,000 units to each side of the mouth X QID 1 Nystatin tablet (500,000) units dissolved in 5 ml glycerin provides 100,000 units/ml
Antibiotic dosing – Virtually all resistance occurs by transposable element gene transfer promoted by the use of 8,9,10 antibiotics, particularly at low doses and for long duration. Antibiotics should be used aggressively and for as short a time as is compatible with patient's remission of the 10,11 disease. Many clinicians follow the pattern of continuing antibiotics for a minimum of 48 hours after disappearance of symptoms. That would mean reevaluating the patient 1-2 11 days after initiation of antibiotics.
Day 1: 6mg/kg (max200mg) PO/IV (OD)
The dosage and duration of the therapy depend upon the nature of the infection and the severity of the infection. A simple urinary tract infection in an adult female may only require 3 days of oral therapy, but deep seated infections like osteomyelitis or endocarditis will require prolonged 13 parenteral therapy for six weeks or more.
Then 3mg /kg/day (max100mg) PO/IV (OD) X 14-21 days
Contraindications and special precautions:
Other Topical Antifungal
In patients with blood disorders, active CNS diseases, hypersensitivity, sever hepatic failure, pregnancy, lactation, neonates, active peptic ulcers, asthma etc, it is advisable to seek opinion from the concerned physician before prescribing these drugs.
2. Fluconazole Neonate >14 days, infants and children a. Oropharangeal or oesophageal candidiasis
Hamycin: Better water solubility than nystatin For Oral thrush: 2 lac units /ml suspension to be applied to the affected area with sterile cotton 2-3 times daily for 7-10 days. Available as 10 ml suspension which gives 200,000 units /ml. Contraindications for all antifungals- hypersensitivity, pregnancy, lactations
Interesting fact – Fluorides, Ibuprofen, Iron Salts, Iodine drugs, tetracycline ingestion may discolor stools black Greenish grey or white/speckling is seen with many oral antibiotics.
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JOURNAL OF DENTAL SCIENCES Important Interactions between Antibiotics and other drugs Ciprofloxacin (and most other quinolones)
Volume 2 Issue 1 5,6,11,
Interacting drug
Effect
Antacids, iron, sucralfate theophyline, cyclosporin, warfarin
Decrease absoption of quinolones (ciprofloxacin) Increase effect of theophyline, cyclosporine, warfarin
NSAID
Increase risk of CNS stimulation seizures
Clindamycin
erythromycin
Mutual antagonism
Erythromycin
carbamazepine
Inceases serum levels of carbamazepine causes nystagmus, ataxia, vomitting, (avoid this combination)
Metronidazole
Anticoagulants increases anticoagulant effect Phenobarbitones, hydantoins Decreases effect of metronidazol
Tetracyclines
antacids, iron, sucralfate,digoxin
For Patients with Liver Disorders
6
Decreases tetracycline effect Increases toxicity of digoxin (may persist for several months in 10% patients)
Phenobarbitone(&OtherSedatives) Sedation
In the presence of hepatic diseases, dosage adjust ment may be indicated for several drugs which are metabolised in the liver
Tetracycline: Teeth pigmentation, enamel hypoplasia, cataract, skeletal growth retardation
(1)
Antimicrobials – doxycycline etc.
Alcohol Congenital cardiac, CNS, limb anomalies, Developmental delay, attention
(2)
Other drugs – Lidocaine
Deficit, autism
-Prednisone is less effective in hepatic disease as it needs hepatic metabolism for activation
Vitamin D analogues (alfacalcidol, calcitriol): Aortic stenosis (supraclavicular), hypercalcemia (avoid high doses)
Drugs in Renal Failure
clindamycin,
metronidazole,
6
In broad terms potentially nephrotoxic drugs need careful modification in dosing pattern in patients with renal insufficiency so as to prevent toxicity while maintaining their adequate therapeutic levels. This is done based on the patients GFR (glomerular filtration rate) in ml/min. The correct dosage is achieved by either (i)
Extension of interval between dosages or
(ii)
Reduction of dosage keeping the interval between doses normal,
(iii) In some case both reduced dosage along with extension in interval is required.
Streptomycin: deafness
Conclusion: For the conclusion, it would be prudent to refresh the topic of . 'selection of appropriate antibiotic therapy' The selection of antibiotic therapy for an infection requires a knowledge of 1) the infecting organism including the pathogen most likely to be present in given clinical or geographical circumstances, 2) the local patterns of antimicrobial resistance in common pathogens, 3) an understanding of pharmacokinetics of the antimicrobials selected. 4) The physiology of the patients, metabolic upsets, renal or hepatic dysfunction, age and 13 available routes of administration. References:
For further details, reference of the topic from the concerned text book is must as most of the commonly prescribed antimicrobials like Cephalosporins,
1.
Yagiella, Dowd and Neidle. Pharmacology & th Therapeutics for Dentistry, 5 edition, Delhi, Elsevier, 2004, pg xvi, introduction.
Penicillins, Metronidazole along with NSAIDs like acetaminophen require specific dose and interval adjustment for renal failure patients.
2.
Yagiella, Dowd and Neidle. Pharmacology & th Therapeutics for Dentistry, 5 edition, Delhi, Elsevier, 2004, pg 596.
Maternal drugs to be avoided or used with great caution 6 during breastfeeding
3.
R.K Suneja. Handbook of Pediatric Drug Therapy and Immunization, 2nd edition, Delhi, Elsevier 2004, pg: Preface to the first edition.
4.
Advanced Drug Review, issue-4,Aug-Nov 2006, Lucknow, The Arora Medical Book publishers Pvt. Ltd.
5.
Lange, Basic& Clinical Pharmacology, Editor -Bertram th G Katzung, 9 edition (international edition) Singapore, McGraw Hill, 2004, pg 1121.
Possible effect on infant Aspirin: Avoid high dose as there is risk of bleeding, Reye's syndrome Estrogens: Gynaecomastia in male infants Metronidazole : Suspend breast feeding for 12hrs after single dose as it is secreted in large amounts in breast milk.
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JOURNAL OF DENTAL SCIENCES
Volume 2
Issue 1
6.
R.K Suneja. Handbook of Pediatric Drug Therapy and Immunization, 2nd edition, Delhi, Elsevier 2004, pg: Preface to the first edition. Pg 247-299.
11. Yagiella, Dowd and Neidle. Pharmacology & th Therapeutics for Dentistry, 5 edition, Delhi, Elsevier, 2004, pg 609.
7.
IDR(Indian drug review) triple i ,vol XIII' no.6, Nov 07Jan 08, Bangalore,CMP Medica India Pvt Ltd
8.
Levy SB: The antibiotics paradox, New York 1992, Plenum press.
12. Yagiella, Dowd and Neidle. Pharmacology & th Therapeutics for Dentistry, 5 edition, Delhi, Elsevier, 2004, pg 620-657, pg 663..
9.
Pallasch TJ: Global antibiotics resistance and its impact on the dental community, J calif Dent. Assoc 28:215233, 2000
13. Davidson's principles &practice of medicine, th international editor-John A.A. Hunter, 20 edition, Philadelphia USA,Elsevier,2006,pg 145
10. Pallasch TJ: How to use antibiotics effectively,J calif Dent. Assoc 21:46-50, 1993.
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