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 CLAVOMED FOR TREATING BACTERIAL COMPLICATIONS OF ACUTE RESPIRATORY DISORDERS IN ALLERGIC CHILDREN – TREATMENT ALGORITHM 
RUSUDAN KARSELADZE, MD, PhD, Professor
The head of Allergology and Clinical Immunology Department at I. Pagava Pediatric Institute
Full professor of Iv. Javakhishvili Tbilisi State University, Medical Faculty,
Head of Department of Pediatrics
Allergic pathologies are one of the most difficult parts of clinical pediatry, contributed by: high prevalence in this age group, wide spectrum of causative allergens, difficulty in their revealing, irrational antibiotic therapy, variable clinical expression and lack of adequate clinical effectiveness of present treatment options.
Everything mentioned above is proved by statistical data.
·    These last 20 years number of patients with allergic disorders has increased by 1.5.
·    More than 100 million people allover the world (4-6% of world population) suffer from bronchial asthma.
·    Prevalence of asthma has nearly doubled in the last 2-3 decades.
·    Atopic dermatitis takes high (50-75%) in the whole allergic disorders.
·    In 20% of children with food allergy, timely and adequate treatment has clinical curative effect.
·    In 41% with food allergy, transformation of the clinical expression is made by changing target organ.
·    In 38% food allergy can be formed with involving some of the crucial organs (skin, gastrointestinal system, respiratory system).
·    In 34% increased sensitivity toward other allergens can be formed.
 
In addition to disturbing epidemiologic data of allergy, acute respiratory disorders in pediatric age group are also alarming.
·    According to WHO data 2,2 million people die today with acute respiratory disorders (3/4 of these by pneumonia).
·    Acute viral respiratory infection (AVRI) peaks on 2-3 years of life, because of increase in social activity of a child.
·    Number of AVRI is nearly 6 in children aging 3-7 years and 3 in children 7-17 years of age.
·    Since birth to graduating from school children experience AVRI about 60 times.
 
Childhood respiratory disorders are infectious origin mostly, so rational and effective antibiotic therapy especially in allergic children is still actual.
 
Respiratory disorders of various origin (viral, bacterial, fungal, intracellular pathogens, mixed flora) have alike clinical picture; Regarding that frequently irrational treatment leads to worsening so main as allergic pathologies complications in allergic predisposed children. Increase in resistance toward traditional antimicrobial drugs is also common problem.
 
Diseases of respiratory tract can be acute and chronic. Acute ones (ARD) are mostly of viral origin (Influenza, Parainfluenza, Adenovirus, Respiratory Syncitial Rhino Virus, etc). Such infections have seasonal character and are common during cold seasons and sometimes have epidemic outbreaks, especially in children collective.
 
In addition primary bacterial respiratory diseases are caused mostly by Pneumococci
(Sе.pneumoniae), group A hemolytic streptococci (St.pyogenes, viridans, etc.), Haemophilus influenzae, Mycoplasma pneumoniae, Moraxella catarrhalis. The agents mentioned above often cause pharyngitis, follicular and lacunar anginas, acute otitis media, sinusitis and epiglottitis.
 
Bacterial origin of acute respiratory disease is indicated by: increased body temperature for >3 days, formation layer of pus, mucosal/pyogenic or pyogenic exudates from nose, marked intoxication and increased duration of the illness.
 
Bacterial respiratory infections can be primary, but mostly (60%) they are complications of viral infections, in 20% - "children infections" (Measles, Whooping cough). In children contributing factors are presence of: adenoid vegetations, chronic tonsillitis, sinusitis, allergy predisposition, especially when allergy is irrationally treated with anti-histamine medications, that changes organism’s reactivity, decreases local and non-specific immunity and recurrent respiratory infections by its way cause organism’s sensibilization.
Irrational treatment of children’s acute bacterial respiratory diseases, presence of chronic processes, negative environmental factors all contribute to worsening of recurring allergic pathologies. Therefore it is crucial to make rational treatment algorithm for probable bacterial infections.
 
Despite presence of vast array of medications, treatment of respiratory infections is not always effective, the reason is inadequate and not up to date treatment regimen. In majority of cases patients with bacterial respiratory infections are treated intuitively, because at the initial stages of the disease clinical picture of bacterial and viral infections are alike, and treatment is subjective and solely depends on physicians private experience. Not infrequently, antibiotic treatment is out of controll, causes emergence of resistant strains and is etiologically inappropriate .This guideline of empiric antibacterial treatment is indicated during the presence of the following clinical signs.
·    marked intoxication
·    fever for >3 days duration
·    presence of mucosal/ purulent or purulent sputum or nasal discharge
·    small age of the patient, especially the first 2 years of life
·    clinical picture of bronchiolitis or pneumonia
·    marked obstructive syndrome
·    increased disease duration.
Table 1
Symptoms of probable bacterial infection
 
Symptoms
Clinical forms
Confirmation
Sore throat, pharyngeal membrane
Group A streptococcal angina
microbiological researche of throat culture
Earache
Acute otitis (middle ear)
Otoscopy
Lymphadenopathy
Lymphadenitis
 
Nasal discharge (>2 weeks)
Sinusitis
X-ray of nasal sinuses
Dispnoe without obstruction;
asimetrical wheezing by auscultation
Pneumonia
Chest X-ray
Leukocytoses (12X109) and/or >5%
Neutrophils and/or >6%
ESR >20 mm/h
Pneumonia or bacterial infection of other localization including urinary tract infections
X-ray, urine analysis, observation
 
Table 2
Principles of choosing initial etiologic treatment,
during various clinical forms of bacterial infections in children
 
Clinical Forms
Main causative agents
Drug of choice
Alternative medications
Pharyngitis
Group A St.pyogenes
Penicillin
Macrolides
Acute tonsilitis
Group А St.pyogenes
Amoxicillin
first generation Cephalosporins
Macrolides
Lincosamides
 
Recurring tonsilo-pharyngitis
Pneumococcus,
Staphilococcus
Amoxicillin/ Clavulanic acid
 
Acute Sinusitis
Pneumococci H.Influenzae
Moraxella catarrhalis
Amoxicillin
Amoxicillin/ Clavulanic acid
Cefuroxime
Cefaclor
Azithromycin
Claritromycin
Chronic sinusitis
Pneumococus H.influenzae
S.aureus
Anaerobes
Amoxicillin/ Clavulanic acid +/–
Aminoglycosides
Third generation Cephalosporins (Ceftriaxone) Fluconazole
 Acute Otitis media
Pneumococcus, H.influenzae
Amoxicillin Amoxicillin / Clavulanic acid
Azithromycin
 
Second or third generation Cephalosporins
Laryngitis
Group A St.pyogenes
Pneumococcus
Staphilococcus
Azithromycin, Cefuroxime xetil
Third generation Cephalosporins (Ceftriaxone)
Epiglotitis
Pneumococcus H.influenzae Meningococcus
Second generation Cephalosporins (Cefuroxime)
Carbapenems
Bronchitis with bacterial super infection
Pneumococus Moraxella catarrhalis Mycoplasma pneumoniae
Chlamydia
pneumoniae
 
 
Amoxicillin / Clavulanic acid
Macrolides
Second generation Cephalosporins Lincosamides Tetracycline in children >10 years
 
One of the main component of adequate ethiopathogenetic antimicrobial treatment, despite severity and localization of the disease process is rational antibiotic therapy.
 
Classic requirement for choosing right medication is sensitivity of causative organisms toward antibacterial medications. Rational antibiotic therapy is determined by following factors:
·    Nosologic forms of infiltrative processes
·    Degree of sensitivity toward antimicrobial agents
·    Degree of activity of antimicrobials toward specific causative agents
·    Possibility to achieve desired effective antimicrobial medication concentration in diseased tissues and organs
·    Pharmacodynamic, pharmacokinetic and side effect profile of chosen medications for pediatric patients
·    Age of the pediatric patient, coexistence of other pathology and its therapy methods.
 
For the most respiratory diseases drugs of choice are Penicillins and Cephalosporins.
Among "protected" forms of oral semi-synthetic Penicillins it is wise to use such
medication combinations that include Amoxicillin. The spectrum of Amoxicillin is like that of Ampicillin but it is 5-7 times more active. Amoxicillin superiority against Ampicillin is given in table 3.
 
 
 
 
Table 3
Relative comparison of Amoxicillin and Ampicillin
 
Relative criteria
Amoxicillin
Ampicillin
Activity against Pneumococus
+++
++
Oral Bioavilability
90%
40%
Food influence on gastrointestinal absorbtion
No
2 times decreases absorbtion
Spectrum of antibacterial activity
Gram positive and gram negative flora
Gram positive and rgam negative flora
Antimicrobial activity
 5–7 times more active relative to Ampicillin
Less effective
Concentration in the sputum
High
Intermediate
 
Use of Amoxicillin in combination with such medications that protect it from action of β-lactamase, gives opportunity to increase its spectrum of activity, because protected forms retain bactericidal activities against Penicillin resistant strains.
 
Considering high rate of β-lactamase producing agents are frequent causes of pediatric respiratory infections, it is obvious that usage of "protected" Penicillins is very important. Clavulanic acid and Sulbactam are β-lactamase inhibitors that are used to protect semi-synthetic Penicillins against bacterial enzymes. Amoxicillin with Clavulanic acid is most common such combination.
 
In Pediatric practice it is very important to consider allergic status of the patient, minimize such complications and maintain efficancy. Of course considering safety and cost-effectiveness. With this regard CLAVOMED is best of choice, despite age of patient.
 
 
 
 
Treatment Algorithm of Acute Respiratory Disease’s
Bacterial Complications
Prescription
Effectiveness*
 
The first episode
(no prior use of antibiotics)
Etiology:
Non-encapsulated H.influenzae,
Pneumococcus
Amoxicillin Amoxicillin/clavulanic acid in case of Penicillin intolerance Macrolides
Long-term treatment for 7-14 days
(depending on the disease type)
Recurred episode
(with prior antibiotic use)
Etiology:
Non-encapsulated H.influenzae, Pneumococcus,
M.catarrhalis,etc
Amoxicillin
Amoxicillin/clavulanic acid Cefuroxime
Ceftriaxone, etc
Treatment according sensitivity of the flora against special antibiotics
 
*Evaluation of effectiveness: lowering body temperature
 
CLAVOMED is recommended for etiologic treatment regardless of patient age, this medication satisfies every requirement to be used in pediatric patients.
·    Wide spectrum antibacterial action
·    High bioavailability after oral intake and high desired tissue concentration
·    Desired safety margins
·    Comfortable to be used in children.
 
CLAVOMED has wide indications: respiratory infections, uro-genital infections , gastrointestinal infections, skin and soft tissue infections, odontogenic, bone and connective tissue infections, post surgical antimicrobial prophylaxis.
Children, their parents and professional physicians need safe and effective medications. CLAVOMED certainly satisfy all these requirements.