The Indian Academy of Pediatrics Thiruvananthapuram Branch Conducted a RTI (respiratory tract infections) workshop for the Pediatricians on February 3rd 2008 at Classic Avenue ThiruvananthapuramWhat’s so special about managing respiratory tract infections?
Acute respiratory infections among children are one of the commonest causes of mortality and morbidity. Of all outpatient antimicrobial prescriptions, most are issued for respiratory and gastrointestinal infections. Five respiratory conditions: nonspecific upper respiratory tract infections, pharyngitis, otitismedia, sinusitis and bronchitis are the commonest reasons for antimicrobial drug use among children. 
And the irony is that most of these antimicrobials areoften unwarranted.An antibiotic prescription should ideally comprise of the following phases:i) Perception of need : Is the antibiotic necessary? ii) Choice of antibiotic : Which is the most appropriate antibiotic? iii) Choice of regimen : What dose, route, frequency and duration are needed? iv) Monitoring efficacy : Is the chosen antibiotic effective?
The first error in antibiotic prescription is the erroneous trust that we pediatricians have in their ability to treat all infections (read fever). We forget the cardinal pharmacology tenets of antibiotics being only curative for bacterial infections. We also forget that many fevers are not due to infections and neither are all infections due to bacteria.
In fact, majority of infections seen in generalpractice are of viral origin. Despite this awareness, antibiotics are prescribed by rote, often in the belief that this will prevent secondary bacterial infections. Evidence based medicine does not lend credence to this hypothesis, except in certain specificsituations where chemoprophylaxis is advocated.
The second error in our antibiotic prescription is based on the belief that choosing a broad spectrum antibiotic is “safer”and “better”, particularly when one is not sure of the causative organisms (as is usually the case). The newer antibiotics are preferred as it is fashionable to be a leader in the field with the latest on the pen.
Often the friendly neighborhood medical representative has conditioned our mind and primed us about the greater efficacy and safety of the latest antibiotic. The studies which will be quoted will be from some high sounding university, but if one really bothers to probe into the source, it will be invariably funded by a drug company.
It is not uncommon for our professional colleagues to use the latest drugs being swayed by the honeymoon period of their newness, blissfully unaware of the side effects.
In our country, where pro-active pharmacists who will police the drug prescriptions are non existent, prescription audits are unheard of; the physician's responsibility for rational prescription is total. What the pharmaceutical industry needs to realize is that focusing merely on achieving short termsales targets can kill a long term viable product for them.
The third error in prescription is often related to improper route of administration. Injectablesare used more often than needed, in the belief that they expedite the cure. The duration of use is often not regulated and the care giver would not uncommonly stop the antibiotic once the symptoms like fever abate. Lack of proper advise by the pediatrician in this regard further worsens the matter.
Lastly, we often upgrade or change the antibiotics for a patientwho continues to have fever despite antibiotic use. The persistence of fever is not always due to a resistant bug but can be due to incorrect diagnosis, incorrect dose and/or route of administration, phlebitis, antibiotic fever, and very importantly non-compliance by the host. So we need to rethink and rule out these causes beforeshifting antibiotic allegiance.
The end result of the above prescription errors is an increased risk of emergence of resistance strains. Unwarranted exposure to drugs not only increases the development of resistant amongst exposed bacteria but also in other bacteria present in the host's environment. The disease causing bacteriaare much more equalitarian and the genetic engineering works at its best amongthem as they permit intra-and inter-special transfer of mechanism of resistance even to bacteria not exposed to the drugs.
An important example is the risk of increase in Vancomycinresistant Enterococciwith unregulated use of oral 3rd generation Cephalosporins.In the light of above, it is imperative that mechanisms are built to prevent misuse of antibiotics and prevent emergence of resistance. The President of Indian Academy of Pediatrics (2006) has, therefore, made efforts to develop ‘Consensus Guidelines for Rational Antibiotic Therapy for Respiratory Tact Infections’and the same is presented here with the hope that it will help us all to use theantibiotics judiciously and effectively. It is in the interest of all concerned to ensure that the battle between the bugs and drugs is won in the favourof our patients.
A moot question is: “Does better awareness / knowledge actually result in changed practice?”The evidence and experience globally is equivocal. The current understanding is that attitudinal change does not necessarily occur as a result of more information being available. Most of the busy doctors perhaps atbest just gloss over any new publication that reaches them to see if it is of use to them or if it interests them.
Many, of those who would consider it worth a second look,may keep it away for a leisured reading later on but perhaps would never be able to come back to it . So, why have we put efforts into this booklet? Because we sincerely believe and hope that the present guidelines will have better fate due to severalfeatures that are part of its packaging. 
The booklet has an American mini skirt appeal i.e. it is short enough to evoke interest yet long enough to cover the subject. Further, the publication is followed by development of a teaching module based on case histories, which shall be used for several small group education meetings (RTI GEMs). 
We are hoping that this booklet will find space next to your working table as a ready reckonerand shall not be there at a place of pride in your study waiting to be opened. Let us end with this thoughtful quote by G B Shaw We are made wise not by the recollection of our past, but by theresponsibility for our future.
And the irony is that most of these antimicrobials areoften unwarranted.An antibiotic prescription should ideally comprise of the following phases:i) Perception of need : Is the antibiotic necessary? ii) Choice of antibiotic : Which is the most appropriate antibiotic? iii) Choice of regimen : What dose, route, frequency and duration are needed? iv) Monitoring efficacy : Is the chosen antibiotic effective?
The first error in antibiotic prescription is the erroneous trust that we pediatricians have in their ability to treat all infections (read fever). We forget the cardinal pharmacology tenets of antibiotics being only curative for bacterial infections. We also forget that many fevers are not due to infections and neither are all infections due to bacteria.
In fact, majority of infections seen in generalpractice are of viral origin. Despite this awareness, antibiotics are prescribed by rote, often in the belief that this will prevent secondary bacterial infections. Evidence based medicine does not lend credence to this hypothesis, except in certain specificsituations where chemoprophylaxis is advocated.
The second error in our antibiotic prescription is based on the belief that choosing a broad spectrum antibiotic is “safer”and “better”, particularly when one is not sure of the causative organisms (as is usually the case). The newer antibiotics are preferred as it is fashionable to be a leader in the field with the latest on the pen.
Often the friendly neighborhood medical representative has conditioned our mind and primed us about the greater efficacy and safety of the latest antibiotic. The studies which will be quoted will be from some high sounding university, but if one really bothers to probe into the source, it will be invariably funded by a drug company.
It is not uncommon for our professional colleagues to use the latest drugs being swayed by the honeymoon period of their newness, blissfully unaware of the side effects.
In our country, where pro-active pharmacists who will police the drug prescriptions are non existent, prescription audits are unheard of; the physician's responsibility for rational prescription is total. What the pharmaceutical industry needs to realize is that focusing merely on achieving short termsales targets can kill a long term viable product for them.
The third error in prescription is often related to improper route of administration. Injectablesare used more often than needed, in the belief that they expedite the cure. The duration of use is often not regulated and the care giver would not uncommonly stop the antibiotic once the symptoms like fever abate. Lack of proper advise by the pediatrician in this regard further worsens the matter.
Lastly, we often upgrade or change the antibiotics for a patientwho continues to have fever despite antibiotic use. The persistence of fever is not always due to a resistant bug but can be due to incorrect diagnosis, incorrect dose and/or route of administration, phlebitis, antibiotic fever, and very importantly non-compliance by the host. So we need to rethink and rule out these causes beforeshifting antibiotic allegiance.
The end result of the above prescription errors is an increased risk of emergence of resistance strains. Unwarranted exposure to drugs not only increases the development of resistant amongst exposed bacteria but also in other bacteria present in the host's environment. The disease causing bacteriaare much more equalitarian and the genetic engineering works at its best amongthem as they permit intra-and inter-special transfer of mechanism of resistance even to bacteria not exposed to the drugs.
An important example is the risk of increase in Vancomycinresistant Enterococciwith unregulated use of oral 3rd generation Cephalosporins.In the light of above, it is imperative that mechanisms are built to prevent misuse of antibiotics and prevent emergence of resistance. The President of Indian Academy of Pediatrics (2006) has, therefore, made efforts to develop ‘Consensus Guidelines for Rational Antibiotic Therapy for Respiratory Tact Infections’and the same is presented here with the hope that it will help us all to use theantibiotics judiciously and effectively. It is in the interest of all concerned to ensure that the battle between the bugs and drugs is won in the favourof our patients.
A moot question is: “Does better awareness / knowledge actually result in changed practice?”The evidence and experience globally is equivocal. The current understanding is that attitudinal change does not necessarily occur as a result of more information being available. Most of the busy doctors perhaps atbest just gloss over any new publication that reaches them to see if it is of use to them or if it interests them.
Many, of those who would consider it worth a second look,may keep it away for a leisured reading later on but perhaps would never be able to come back to it . So, why have we put efforts into this booklet? Because we sincerely believe and hope that the present guidelines will have better fate due to severalfeatures that are part of its packaging. 
The booklet has an American mini skirt appeal i.e. it is short enough to evoke interest yet long enough to cover the subject. Further, the publication is followed by development of a teaching module based on case histories, which shall be used for several small group education meetings (RTI GEMs). 
We are hoping that this booklet will find space next to your working table as a ready reckonerand shall not be there at a place of pride in your study waiting to be opened. Let us end with this thoughtful quote by G B Shaw We are made wise not by the recollection of our past, but by theresponsibility for our future.
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