Abbott Academic Alliance – A division of Abbott Laboratories Pakistan organized a series of Meeting on “Clinical Management of Airway Infections” recently at Karachi Lahore and Islamabad respectively. Prof. Sayed Muhammad Oraby, Professor of Pulmonology and Critical Care Medicine at Ain Shams University Cairo, Egypt was invited as the Keynote speaker. The Meeting was attended by a large number of general practitioners and family physicians. The Panel discussion was also the part of the Meeting.
The panelists of Karachi Meeting include Dr. Ali, Dr. Shagufta Shafi, Prof. Karim Kammeruddin, Prof. Ashraf Sadiq and Dr. Faisal Faiyaz Zuberi, while Prof. Saulat Ullah Khan, Prof. Atif Mehmood and Prof. Sardar Fakhar Imam were the panel of Lahore Meeting. The Islamabad meeting panelist includes Maj. Gen. Badshah Khan Khattak, Dr. Shazli Manzoor and Dr. Aftab Akhtar.
Prof. Sayed M. Oraby sharing his views on the occasion discussed in detail the clinical management of various Upper Respiratory Tract Infections, Lower Respiratory Tract Infections like sinusitis, pharyngitis, tonsillitis, laryngitis, bronchitis and community acquired pneumonia (CAP). He said that it is a viral infection and does need any antibiotics. However, if cough is more than five days, it becomes acute condition. Referring the NICE UK guidelines, he said that the use of antibiotics with these infections over the age of 65 years, those with Type-1 and Type-2 diabetes mellitus, have history of CHF and hospitalization. He emphasized the importance of proper selection of an antibiotic. Physicians and General Practitioner should know when to use antibiotics and 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 said that one should not use antibiotics like amoxicillin, ampicillin, erythromycin, trimethoprime-sulphamethexazole, first generation cephalosporin’s as they have limitations in their antimicrobial activities. Talking about recent introductions like macrolides, their use in medical wads, therapy for CAP and their use in Intensive Care Units. Different guidelines on the use of antibiotics and studies have confirmed that those patients using 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.
Prof. Oraby informed 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. 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.
Talking about pharmacokinetics and pharmocodynamics, he said that the dose of an antibiotic 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.
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. In Pakistan there is no 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.