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Evidence-based Pediatric Practice - Rationality vs. Reality

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Dr Uday Bodhankar, Nagpur    16 January 2018

  1. Clinicians need information - We need it up to 60 times per week and it could affect eight decisions per day. But we get on an average, the clinically important knowledge of physicians deteriorates rapidly after we complete our training.
  2. The practice of evidence-based medicine (EBM) requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research.
  3. Important elements of EBM – Convert patient healthcare needs into answerable questions; track down the best evidence; critically appraise evidence; apply results into clinical practice; evaluate your performance.
  4. Answerable questions are the backbone of practising EBM. In practice, good questions usually include patient’s clinical needs; interventions; comparison; clinical outcomes (PICO).
  5. Commit to a national statement of purpose – NHM – for improving the healthcare system. To practice EBM, formulate clinical questions before you start; use existing reviews; use checklists as a prompt in your critical appraisal; use help and examples from books, checklists, EBM internet sites.
  6. Commonest reasons for antimicrobial drug use among children in office practice are nonspecific URTI, otitis media, diarrhea, fever without focus. Most of the time, these antimicrobials are unwarranted.
  7. For rational prescription, follow these guidelines – Make a specific diagnosis and select a drug of choice; consider the pathophysiology of diagnosis selected; select a specific therapeutic goal; determine the appropriate dosing regimen; take account of drug interactions and adverse effects; device a plan for monitoring the drugs’ action; plan a program for patient education. Multiple patient variables such as developmental physiology, past medical history, pharmacokinetic and pharmacodynamic properties, desired therapeutic outcomes, and psychosocial issues need to be considered when designing appropriate drug therapy regimen for children.
  8. The choice of antibiotics is determined by: source or focus of infection; patient’s age and immunologic status; identifying if it is community-acquired or nosocomial infection. Characteristics of an ideal antibiotic – Harms the bacteria, not the host; narrow spectrum with minimal adverse effects; good distribution to site of infection; has high threshold for developing resistance; is inexpensive.
  9. Golden rules for judicious use of antimicrobials – 1) Acute infection always presents with fever; in acute illness, presence of fever does not justify antibiotic use; 2) Infection is the most common cause of fever in practice, though not always of bacterial etiology; 3) Clinical differentiation is possible between bacterial and viral infection; viral infection may affect multiple systems, while bacterial infection is localized to one part of the system; 4) Chronic infection may not be associated with fever and diagnosis can be difficult. Relevant laboratory tests are necessary. Antibiotics to be considered only after observing progress; 5) Choose single oral antibiotic, either covering suspected gram +ve or –ve organism, as per site of infection and age of patient. Combination of antibiotics is justified only in serious bacterial infection without proof of specific organism and can be administered intravenously; 6) After first visit (within 48 hours of fever), antibiotic is justified only if bacterial infection is clinically certain.
  10. The child is the biggest beneficiary of rational antibiotic therapy.
  11. Proper collection of specimen for cultures – Collect specimen before starting antibiotics; collect sample with due precautions; send sample from correct site; tissue, fluid, aspirate are better than swabs; expedite transport; send adequate amount of sample.
  12. Escalation is changing over from the current antibiotic to another one which is more potent or has a broader spectrum. How to escalate – Add an enzyme inhibitor; change to a more potent molecule; add another antibiotic of a different class.
  13. De-escalation is a method of narrowing empiric therapy based both on culture reports and clinical improvement.
  14. Benefits of de-escalation – Decrease in antibiotic related adverse events and super-infection; cost savings; multidrug resistant bugs in hospital environment are reduced. In order to prevent antibiotic resistance, encourage rational antibiotic therapy, use combination therapy selectively, practice infection control, promote immunization.

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