ID/01(P) AUDIT OF ANTIMICROBIAL PRESCRIPTIONS FOR HOSPITALISED CHILDREN IN A TERTIARY CARE CHILDREN’S HOSPITAL.
Sripradha S, K.R.Aparna, S. Balasubramanian
Kanchi Kamakoti CHILDS Trust Hospital,12-A, Nageswara Road, Nungambakkam, Chennai – 34.
Introduction: There is paucity of data on antimicrobial prescribing practices in pediatric hospital setting in India especially in private sector. Aim: To describe and investigate the prescribing pattern of antimicrobials for pediatric inpatients in a tertiary care setting. Design: Retrospective descriptive study Setting and Methods: Case records of 1000 children from 1 month to 18 years of age hospitalised and treated between August 1st 2004 to 30th July 2005 in a single paediatric unit were analysed for the following antimicrobial used or not indication & details of the same type of antimicrobial Justification of antimicrobial use Results: A total no. of 420 children received antimicrobial agents (42%). More no. of children in age group of 1-5 years 65% (273) received antimicrobial agents when compared to infants and children above 5 years. The following are the indications in decreasing order for antimicrobial prescriptions. WALRI-15.71%(66) Enteric Fever-14.29%(60) Others-13.57%(57) UTI-12.86%(54) URI-11.67 %(49) Pneumonia-8.81%(37) Meningitis-5.48%(23) Skin / Skeletal infection-9.05%(17) Dysentery-3.57%(15) AGE-2.86%(12) Leptospirosis-2.86%(12) LRI-2.14%(9) Sepsis-2.14%(9) The most frequently used antimicrobials were as follows: Amoxyicillin / Amoxyclav-40.24% (169) Cephalosporins I Generation - 0. 71% (3) II Generation- 8.33% (77) III Generation - 12.86% (54) Others - 27.86% (117) Conclusion: More preschool children tend to receive antimicrobial agents when compared to infants. Inspite of application of guidelines for using antimicrobial therapy appropriately, nearly 1/10 of the children who received antibiotics did not require the same as per established guidelines. Our observations emphasize the need for National guidelines for appropriate antimicrobial prescription practice in the Indian context.
ID/02(P) A NEW FOCUS OF PEDIATRIC SCRUB TYPHUS IN NORTHERN INDIA
Sanjay Mahajan,Naveen Sankhyan,R K Kaushal
Indira Gandhi Medical College,Shimla,HP,171001
Objective: To study, the clinical profile of Scrub Typhus occurring in children of this hilly state. Methods: Clinical profile of five cases of acute febrile illness presenting in rainy season, and showing positive serology to Orientia tsutsugamushi on Microimmunofluorescence assay are detailed. Results: Four males and one female with age range 3-15 were studied. Fever (5), chills and rigors (2), headache (1), vomiting (5), pain abdomen (1), altered sensorium (1), seizures (1), facial puffiness(2),generalized lymphadenopathy (5), hepatomegaly (1) and splenomegaly (1), were main presenting features. Abnormalities of liver function tests (2) & renal function tests (1) were main biochemical abnormalities noted. Two had titers 1:160; one ≥ 160 & two ≥320 to Proteus OXK antigen, 4 had 1: 40-80 titers to Proteus OX2 & 19 antigens. On Microimmunofluorescence assay, all 5 patients showed titers (IgG and IgM) to Orientia tsutsugamushi (O. Kato and O. Kawasaki strains) and serology to Spotted Fever Group Rickettsioses was negative. The exact characterization of strains, prevalent in our area, is on by PCR. Four of the 5 were treated with Azithromycin and one with Doxycycline. Time to defervesence ranged from 18-96 hrs after commencing therapy. Four children improved after treatment and 1 died.Conclusion: In hills of northern India, Scrub typhus should be considered in febrile children, especially during rainy season.
ID/03(P) AN UNUSUAL ASSOCIATION OF THROMBOCYTOPENIA WITH PLASMODIUM VIVAX MALARIA CASES
Sunil Gomber, Manish Kumar. Department of pediatrics, University College of
Medical Sciences and Guru Teg Bahadur Hospital, Delhi-95, India.
Most of the complications associated with malaria are known to occur with Plasmodium falciparum infection. Anemia and thrombocytopenia has been uncommonly reported with Plasmodium vivax infection. We report three such cases of vivax malaria that presented with thrombocytopenia. The first case presented in shock, the condition not reported earlier with vivax malaria. The other two cases presented with anemia, thrombocytopenia and splenomegaly. All the patients were treated with choloroquine and discharged successfully. Thrombocytopenia improved and regression in spleen size was noted at discharge. Cause of thrombocytopenia is not exactly known. However one study has shown increased platelet associated IgG (PAIgG) leading to thrombocytopenia. The message is that thrombocytopenia does occur with vivax malaria and one should consider the possibility of vivax malaria in cases of fever with thrombocytopenia.
ID/04(O) A PROSPECTIVE CLINICOBACTERIOLOGICAL STUDY OF TYPHOID FEVER IN DELHI
Deepti Chaturvedi,Devendra Mishra,Vikas Manchanda, Mukta Mantan, Ds Chauhan, Manoja Das
Department of Pediatrics and Laboratory Medicine, Chacha Nehru Bal Chikitsalaya [Maulana Azad Medical College], Geeta Colony, Delhi-110031
Objective:1.To study the clinical profile and sensitivity pattern of enteric fever in children. 2.To correlate the clinical features with the drug sensitivity pattern in patients with MDRST and non-MDRST. Design and Setting: Prospective study, Government Pediatric hospital attached to a medical college Methods: All culture positive typhoid patients diagnosed between 27th January to 26th September2005 (8 months) were studied .The presenting features, clinical findings, hospital course, complications, bacteriological profile and response to therapy were entered in a pretested structured proforma. Results: There were 52 children treated as typhoid fever of which 23(44 %) were culture positive and 43(83%) were Widal positive. Out of these culture positive cases, 4(17 %) were MDR typhoid. The age varied from 7 months to 12 years. Maximum number of children belonged to age group 5 to 10 yrs with an average age of 6.25 yrs. Out of the 23 culture positive cases 7 (30 %) were males and 16 (70 %) were females. The mean duration of fever at presentation was 16 days with a wide range from 5 to 60 days. The other important presenting complaints were pain in abdomen (77%), decreased oral acceptance (25%), bowel complaints (56%),cough (19%),urinary complaints(13%),hepatomegaly (65%), splenomegaly (48%). The mean period of defervescence of fever was 4 days. The complication rate was (6%). The resistance pattern would be discussed in detail. Conclusions: The duration of fever at presentation (18 days vs. 15 days) and mean time to defervescence (9day vs.4 days) were longer in MDRST. The overall complication rate was low (6 %) and not different between the two groups. There is a resurgence of non-MDRST in the community in our area, and this information needs to be considered when deciding empiric antibiotics for suspected enteric fever in the community.
ID/05(O) ASSESSMENT OF YALE OBSERVATION SCALE (YOS) TO PREDICT BACTEREMIA IN FEBRILE CHILDREN AGED 3 TO 36 MONTHS.
Akash Bang, Pushpa Chaturvedi
Department of Pediatrics, Mahatma Gandhi Institute of Medical Sciences and Kasturba Hospital, Sevagram. 442102. Dst. Wardha.
Fever in children aged 3-36 months, even in absence of localizing signs, may be due to bacteremia. Untreated bacteremia can cause serious complications including death. In absence of culture facilities in rural India, observational scales like YOS gain prime importance in prediction of bacteremia. Design: Prospective hospital based study. Methods: 219 consecutive febrile inpatients aged 3-36 months were the subjects. Before giving antipyretics, rectal temperature was recorded. YOS scores were assessed by 2 independent blinded residents. History, clinical examination and investigations followed. Blood cultures were taken in all children before antibiotics. Point estimates and 95%confidence intervals were calculated for sensitivity, specificity, positive & negative predictive values and likelihood ratios for use of YOS as a diagnostic test in prediction of bacteremia. The best cut off value for a positive YOS test was established by calculating these statistical values separately for a cut off YOS score of 8, 10 and 12 and plotting ROC curve. Reliability of YOS was assessed by the inter-observer agreement through kappa statistics. Results: Study population (n=219) had 59.36% males and a mean age of 15.24 months. 28.16% subjects had bacteremia. Mean YOS scores were significantly higher in bacteremic children (14.9 vs 8.78 in non-bacteremic, p=0.00001) Sensitivity, specificity, PPV, NPV, LR+ and LR- of YOS score >10 to predict bacteremia were 87.93%, 83.78%, 68.00%, 94.66%, 5.42 and 0.14 respectively. Those of YOS score >8 were 96.55%, 65.54%, 52.34%, 97.98%, 2.80 and 0.05 respectively and of a YOS score >12 were 48.28%, 91.22%, 68.29%, 81.82%, 5.5 and 0.5 respectively. ROC curve showed YOS score >10 to be the best cut off for prediction of bacteremia. Area under ROC curve was 0.9001. The chance corrected inter-observer agreement (kappa) was 0.7919. Conclusions: YOS is a simple, easy to administer, cost-effective and useful test to predict bacteremia in a febrile child aged 3-36 months due to its high sensitivity and reproducibility.
ID/06(P) BRUCELLOSIS IN ADOLESCENT FEMALE-A CASE STUDY
Renuka Mohanty, Subhranshu Sekhar Kar, amarendra Mahapatro
Hi-Tech Medical College,Bhubaneswar-10
Introduction- Brucellosis is a zoonosis transmitted to the humans from infected animals. It continues to be a major health problem worldwide. Humans are accidental hosts and acquire this disease from direct contact with an infected animal or consumption of infected products. Case report- A 14 year old female child of middle socio economic family was brought to the hospital with chief complaints of fever (remittent) for 8 days, multiple joint pains for 6days & severe headache with maculopapular rashes for 3 days. The past history, family, immunization developmental history was uneventful. In dietary history, it was found that she was taking milk from household cattles & goats from her village. On examination, the child was toxic looking with maculopapular rashes, hepatosplenomegaly and fundoscopy revealing mild blurring of disc margins (both eyes) indicating early papilledema. There was mild neck stiffness but no focal neurologic deficit. So provisionally she was diagnosed as complicated malaria with septicaemia. Investigations- Complete blood count, urine & stool exam were normal. ICT-P.f.,P.v.-(-ve),ASOtitre > 1:200I.U.(+ve), CXR(PA)-NAD, Blood & Urine C/S-NO growth, C.S.F. analysis & CT Scan-NAD and serum agglutination test (SAT) for Brucella revealed titres of B. abortus > 1:160 and B. melitensis > 1:320 indicating strongly positive result. SAT after 7 days of treatment revealed Brucella titres of 1:160 but shows a declining trend. Treatment- She was treated with Ceftriaxone, Quinine, Falcigo, Linezolid and Treonam. On third day with negative MP report Falcigo & Quinine were omitted. Dexamethasone and Mannitol were added for papilledema. Regimen for Brucella was started after getting SAT report and other antibiotics were omitted. Thus the child was treated with Cap Doxycycline 200 mg/day for 4-6 weeks and inj. Gentamicin 5 mg/kg/day & Tab Rifampicin 600 mg/day for 4-6 months. The child responded dramatically to the treatment protocol. Conclusion- As the clinical features are not disease specific, often diagnostic dilemma occurs and it is confused with malarial or typhoid fever. Hence proper history pertaining to ingestion of infected products from animals gives a clue for diagnosis.
ID/07(O) BACTERIAL SEPSIS IN CHILDREN WITH CEREBRAL MALARIA
Sudhir Mishra, Sarala Sunder, DP Patra, PK Gupta
Department of Pediatrics, Tata Main Hospital, Jamshedpur- 831001
Introduction: Cerebral malaria is a common killer disease of children in this part of the world. Some children were noted to be blood culture positive. Aims and Objective: To study the frequency of sepsis in children with cerebral malaria and compare it with falciparum malaria without cerebral involvement. Material and Methods: Children diagnosed as cases of falciparum malaria either on smear or a card test were included in this study conducted over a period of two years. Uncomplicated cases were excluded from the study. Pre-designed and pre-tested proforma was used to record clinical details, investigations results, treatment given and outcome. All children with cerebral malaria received antibiotic therapy in addition to antimalarial(s) and supportive care. Results: A total of 331 children – 193 with cerebral malaria and 138 with other complications were included in this study. Multisystem involvement was seen in 66.3% children in cerebral malaria group. Gastro-intestinal bleeding (44.4%) and acute renal failure (11.4%) were other common complications seen in children with cerebral malaria. Gastro-intestinal bleeding (81.1%) and acute renal failure (32.6%) were the common complications seen in children without cerebral involvement. Bacteremia was found in 21.7% children in cerebral malaria group and 7.9% in children without cerebral involvement. Mortality was 1.55% in cerebral malaria cases. There was no death in children with other complications during the period of study. Conclusion: Data from this study suggests that sepsis in cerebral malaria is found with a frequency that demands routine evaluation and use of broad spectrum antibiotic(s) for improved survival.
ID/08(O) MALARIA-PRESENT TREATMENT SCENARIO-NATIONAL ANTIMALARIAL PROTOCOL-A PARADOX
Radha Tripathy, Leena Das, Arakhita Swain, Sailajanandan Parida, Arun Agrawalla, Aswini Kumar Mohanty
SVP PG Institute of Pediatrics and SCB Medical College, Cuttack, Orissa
Design: Prospective study. Setting: Tertiary care Teaching Hospital. Period: June 2004 to May 2005. Objective:To evaluate the present antimalarial chemotherapy received by patients before hospitalization and how far the present scenario of antimalarial chemotherapy is helpful in promoting DRUG RESISTANCE ?? Materials and Methods: 268 hospitalized children aged between 2 month to 14 years with diagnosis of Falciparum malaria (Slide and/or ICT +ve) were evaluated for the history of taking antimalarial chemotherapy prior to hospitalization. Evaluation was based on history of drug intake (adequacy, dosage, duration) and whether self-medicated / prescription by health care providers. Later, the cases were treated as per the WHO protocol. Outcome in terms of mortality was compared and analyzed. Results: Out of 268 slide and/or ICT +ve falciparum malaria cases, only 113(42.2%) received antimalarial chemotherapy before hospitalization. Out of these 113 cases, 105 (93%) received monotherapy (Chloroquine, Quinine, α,β arte-ether, Sulfadoxin-Pyrimethamin (SP), Arteether and Artesunate (40%, 24%,20%, 1%, 3.5% and 4% respectively) and 8 (7%) received combination (Artesunate + Quinine, Arteether + Quinine and Chloroquine + SP in 3.5%, 2.7% and 1% respectively) antimalarial chemotherapy. 50 children (44%) received antimalarial chemotherapy in proper dosage whereas 63(56%) received improper dosage. In respect to monotherapy, inadequate dosing was observed in 22% in Chloroquine group, 85% in Quinine group and 70% in Artemesinin derivatives. All combination antimalarial chemotherapy were administered in improper dosage excepting lone case of Chloroquin +SP. 10% cases of Chloroquine was self-medicated whereas other antimalarial drugs were administered by health providers. Mortality was much higher among the children receiving no antimalarial drugs(17.4%) in comparision to those who received antimalarial chemotherapy (6.2%). Mortality was much lower in the group receiving proper dosage of Chloroquine in comparision to newer Artemesinin derivatives which was received in improper doses (75%). Summary and Conclusion: Pre-Hospital Chemotherapy against Malaria should not only be rationalized but also the awareness and availability of the same drugs should be ensured at minimum cost to the users. Use of antimalarial chemotherapy with under-dosing, and/or failure to comply full course of treatment (particularly the newer Artemesinin derivatives) have a significant adverse effect.