Antibiotics In Paediatrics

1. My preferred antibiotic for acute otitis media (if I decided to treat) would be (tick 1 only):

Penicillin V

Amoxicillin

Co-amoxiclav

Erythromycin

Other

Clarithromycin or Azithromycin if penicillin sensitive

Explanation

Clarithromycin or Azithromycin if penicillin sensitive

2. Gram positive cocci include (tick all that are true):

Streptococcus

Staphylococcus

Meningococcus

Pneumococcus

Enterococcus

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3. In acute otitis media (tick all that are true):

At least 50% of children will be better within 24 hours whatever you do

Antibiotics are indicated in bilateral disease under 2 years

Antibiotics are indicated if there is otorrhoea

Mastoiditis is a recognized complication

The Lancet metanalysis in 2006 suggested benefit for treating bilateral disease under 2 years or in the presence of otorrhoea.
Mastoiditis is a rare but serious complication, with potential of intracranial spread.

Explanation

The Lancet metanalysis in 2006 suggested benefit for treating bilateral disease under 2 years or in the presence of otorrhoea.
Mastoiditis is a rare but serious complication, with potential of intracranial spread.

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4. Streptococcal pharyngitis/tonsillitis is likely if a child with a sore throat has (tick all that are true):

Both anterior cervical lymphadenopathy and a rash

Both anterior cervical lymphadenopathy, fever and absence of a cough

Both anterior cervical lymphadenopathy and a tonsillar exudate

Strep A on a throat swab

A high ASO titre

Lots of different clinical criteria attempting to differentiate strep vs non-strep throat; none reaches a positive predictive value of over 50%.
A throat swab is probably the best way but no good gold standard. May just reflect carriage. ASO titres may take 2 weeks to rise.

Explanation

Lots of different clinical criteria attempting to differentiate strep vs non-strep throat; none reaches a positive predictive value of over 50%.
A throat swab is probably the best way but no good gold standard. May just reflect carriage. ASO titres may take 2 weeks to rise.

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5. Co-amoxiclav is (tick all that are true):

Three times as expensive as amoxicillin

Is associated with cholestatic jaundice

Is active against staph aureus

Is good for bites

A bottle of Augmentin suspension costs nearly £5.
Co-amoxiclav is 6 times more likely to cause cholestatic jaundice than amoxicillin.
Good for dental abscesses and dog bites.

Explanation

A bottle of Augmentin suspension costs nearly £5.
Co-amoxiclav is 6 times more likely to cause cholestatic jaundice than amoxicillin.
Good for dental abscesses and dog bites.

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6. Gram staining is (tick all that are true):

Useful for getting an instant diagnosis

Not useful for mycobacteria

Where positives are purple and negatives are pink

Negative for Haemophilus influenza meningitis

Positive for Gonococcal conjunctivitis

Even PCR takes a good couple of hours, so your best way of getting an instant diagnosis is to gram stain tissue/fluid esp urine, CSF, conjunctival.
Mycobacteria, mycoplasma and other organisms that lack a cell wall will not gram stain reliably.

Explanation

Even PCR takes a good couple of hours, so your best way of getting an instant diagnosis is to gram stain tissue/fluid esp urine, CSF, conjunctival.
Mycobacteria, mycoplasma and other organisms that lack a cell wall will not gram stain reliably.

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7. I would give an antibiotic to a child with sore throat if:

The parents really, really wanted them

Symptoms didn't settle within 48 hours

They were really unwell despite paracetamol, Difflam

I was worried about them getting rheumatic heart disease

Psychosocial factors are important in the presentation of a child with a sore throat to primary care. Parental expectation about getting antibiotics closely matches prescribing rates in international studies. The sicker the child, the better the chance of antibiotics being useful, and the sooner they should be started.
Complications of sore throat are so rare that you would have to treat hundreds of cases to prevent a complication.
Symptomatic relief with analgesia and topical anaesthetic is probably more important. But avoid falling out with parents if possible - if your best attempts at reassurance are unsuccessful, then usually better to issue a prescription than create animosity and distrust.

Explanation

Psychosocial factors are important in the presentation of a child with a sore throat to primary care. Parental expectation about getting antibiotics closely matches prescribing rates in international studies. The sicker the child, the better the chance of antibiotics being useful, and the sooner they should be started.
Complications of sore throat are so rare that you would have to treat hundreds of cases to prevent a complication.
Symptomatic relief with analgesia and topical anaesthetic is probably more important. But avoid falling out with parents if possible - if your best attempts at reassurance are unsuccessful, then usually better to issue a prescription than create animosity and distrust.

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8. In suspected urinary tract infection (tick all that are true):

A 7 day course is superior to a 3 day course in lower tract infection

IV antibiotics are superior to oral antibiotics in upper tract infection

Risk factors should be considered

Under the age of 3yrs, microscopy is preferred to dipstick testing

Dipstick positive for white cells confirm the diagnosis

Upper tract signs include fever, loin pan, vomiting, lethargy. As long as oral antibiotics are tolerated, there is no particular advantage to using IV. A 10 day course should be completed.
Risk factors include constipation, hygiene, vulvovaginitis, posterior urethral valves, vesicoureteric reflux, recurrent infection, evidence of spinal lesion, dysfunctional voiding.

Explanation

Upper tract signs include fever, loin pan, vomiting, lethargy. As long as oral antibiotics are tolerated, there is no particular advantage to using IV. A 10 day course should be completed.
Risk factors include constipation, hygiene, vulvovaginitis, posterior urethral valves, vesicoureteric reflux, recurrent infection, evidence of spinal lesion, dysfunctional voiding.

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9. Beta - lactams (tick all that are true):

Include Meropenem

Are inactivated by defective PBPs

Penetrate the meninges well

Can cause seizures

Meropenem is a carbapenem. These are beta-lactams that are broad spectrum and resistant to beta-lactamases. Cross-sensitivity in penicillin allergy is unusual.
Resistance to penicillin can be mediated either by beta-lactamase or defective Penicillin Binding Proteins.
Beta-lactams do not penetrate the uninflamed meninges well - at high dose they are suitable for treating meningitis, but they should not be used for treating cerebral abscess.

Explanation

Meropenem is a carbapenem. These are beta-lactams that are broad spectrum and resistant to beta-lactamases. Cross-sensitivity in penicillin allergy is unusual.
Resistance to penicillin can be mediated either by beta-lactamase or defective Penicillin Binding Proteins.
Beta-lactams do not penetrate the uninflamed meninges well - at high dose they are suitable for treating meningitis, but they should not be used for treating cerebral abscess.

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10. In a child with lower respiratory tract infection (tick all that are true):

An X-ray is necessary to prove pneumonia

Creps indicate bacterial infection

Mycoplasma is an important pathogen in young children

Chlamydia is an important pathogen in older children

Oseltamivir should be given if child with chronic lung condition presents within 48 hours with Influenza A/B

X-rays do not change management in mild cases so are not necessary.
Wheeze in preschool children is predictive of a viral infection. Creps do not reliably differentiate. Age is another important discriminator.
Mycoplasma and Chlamydia are important pathogens in older children, although microbiological testing is difficult.
Oseltamivir or Zanamavir is recommended when a risk factor is present (eg chronic cardiac/respiratory/renal condition), circulating Influenza A/B and presentation within 48 hours.

Explanation

X-rays do not change management in mild cases so are not necessary.
Wheeze in preschool children is predictive of a viral infection. Creps do not reliably differentiate. Age is another important discriminator.
Mycoplasma and Chlamydia are important pathogens in older children, although microbiological testing is difficult.
Oseltamivir or Zanamavir is recommended when a risk factor is present (eg chronic cardiac/respiratory/renal condition), circulating Influenza A/B and presentation within 48 hours.

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11. Macrolides (tick all that are true):

Include Clarithromycin and Clindamycin

Are bacteriocidal

Are active against mycoplasma

Have mainly GI side effects

Are useful for Staphylococcal infections incl MRSA

Clindamycin is related to macrolides, in that resistance to erythromycin can be a marker of inducible resistance to clindamycin.
Bacteriostatic, not bacteriocidal.
Vomiting and diarrhoea less common with newer agents.

Explanation

Clindamycin is related to macrolides, in that resistance to erythromycin can be a marker of inducible resistance to clindamycin.
Bacteriostatic, not bacteriocidal.
Vomiting and diarrhoea less common with newer agents.

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12. Resistance to penicillin is an important issue in (tick all that are true):

Staphylococcus

Pneumococcus

Group A Streptococcus

Haemophilus influenzae

Most staph, MRSA or not, are resistant to penicillin and amoxicillin.
About 20% of Haemophilus are resistant to amoxicillin.
Penicillin resistance in pneumococcus is an increasing problem in Europe and the US.
Penicillin resistance has never been described in Group A Streptococcus.

Explanation

Most staph, MRSA or not, are resistant to penicillin and amoxicillin.
About 20% of Haemophilus are resistant to amoxicillin.
Penicillin resistance in pneumococcus is an increasing problem in Europe and the US.
Penicillin resistance has never been described in Group A Streptococcus.

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