The place of amoxicillin/clavulanate in treatment of community-acquired pneumonia

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Amoxicillin and pneumonia

Community-acquired pneumonia is a widespread infection, occupying an important place in the structure of morbidity and mortality of the population worldwide. Incidence of pneumonia in Europe is 2-15 per 1,000 persons per year . It rises to 25-44/1000 in old age and reaches 68-114/1000 in nursing home residents . In the United States, community-acquired pneumonia affects 4 million people annually. It is the cause of more than 1 mln. hospitalizations . There are also significant economic costs to society. For example, in the U.S. the annual cost of treatment is about $10 billion. per year .

The statistical average incidence of pneumonia is 10-15/1000 . The prevalence of community-acquired pneumonias among the elderly in Moscow is 17.4/1000 .

Pneumonias (including community-acquired pneumonias) are the 6th leading cause of death . Death rate from pneumonia continues to grow everywhere. In the United States, for example, between 1979 and 1994, the number of cases of pneumonia increased by 59%. it increased by 59% . To a considerable degree it is determined by the increase of elderly people’s share in the population structure. However, age-adjusted mortality also increased by 22%, indicating the role of other factors in the changing epidemiology of pneumonia .

A variety of microorganisms can act as etiological factors of community-acquired pneumonia (Table.). The main causative agent is Streptococcus pneumoniae, which accounts for approximately 15-35% of cases of. According to a meta-analysis of 122 publications from 1966 to 1995., pneumococcal pneumonias account for about 2/3 of all deaths in community-acquired pneumonia . Frequent pathogens also include Mycoplasma pneumoniae, Chlamydia pneumoniae, Haemophilus influenzae. Together with S. pneumoniae they cause over 60% of cases . Rarer etiological factors are chlamydiae, staphylococci, Klebsiella, enterobacteriaceae, and legionella . In certain situations and in a certain patient population, community-acquired pneumonia can also be caused by other microorganisms, such as anaerobes or viruses . Thus, anaerobes (Bacteroiodas, Prevotella и Fusobacterium) are often found in children with concomitant respiratory diseases – chronic tonsillitis and sinusitis, occurring in the elderly [11,12]. Approximately 50% of patients fail to establish the etiology of community-acquired pneumonia, even with intensive research. The reason for this is the lack of a test capable of identifying all potential pathogens, the limitations of each test separately, and the possibility of mixed infection, such as a combination of typical and atypical pathogens (M. pneumoniae, C. pneumoniae, Legionella spp.), occurring in 10–40% of cases .

In the vast majority of cases, treatment is started empirically. Its success is largely determined by the correct choice of antibiotic. One of the main requirements for an antimicrobial agent for initial therapy is sufficient breadth of action, covering common pathogens. Other important criteria for antibiotic selection include: efficacy and safety proven in adequate clinical trials; favorable pharmacokinetic properties; convenient mode of administration to ensure compliance with prescribed treatment; cost-effectiveness. Given the latter criterion, in severe and moderate forms of pneumonia, an important factor is the availability of drug forms for parenteral and enteral administration, which allows for a stepwise therapy. In many countries, due to high levels of antibiotic resistance S. pneumoniae, High activity against pneumococci is added to these criteria.

One of the most satisfying the above criteria of antibacterial agents is amoxicillin/clavulanate. In addition to a broad spectrum of antibacterial action, including common Gram-positive and Gram-negative pathogens of community-acquired pneumonia, it is active against microorganisms with acquired resistance due to the production of beta-lactamases (Klebsiella spp., staphylococci, M. catarrhalis, Haemophilus spp. и E. coli), anaerobes, and is superior to benzylpenicillin and ampicillin in activity against pneumococcus.

Amoxicillin/clavulanate has high bioavailability (90%) when administered orally, generates high concentrations in the lungs and pleural fluid, penetrates quickly into sputum and accumulates in the bronchial mucosa, and the content of both components of the drug significantly exceeds the concentration required to suppress the growth of most pathogens that cause respiratory tract infections, including beta-lactamase-producing strains H. influenzae и M. catarrhalis . The advantages of amoxicillin/clavulanate include the availability of dosage forms for oral administration and intravenous administration, which allows it to be successfully used for staggered therapy, thereby reducing the period of hospitalization and financial costs of treatment.

Amoxicillin/clavulanate is well tolerated. According to clinical trials, side effects are rare (8-14%), are mild and do not usually require discontinuation of treatment. When taken orally, they manifest themselves mainly in gastrointestinal. Their frequency is significantly reduced when the drug is taken with food. Allergic reactions (erythema, urticaria) are very rare.

High activity against pneumococci, Haemophilus influenzae and staphylococci, along with good tolerability, served as a reason for including amoxicillin/clavulanate in the majority of international and domestic standards for treatment of community-acquired pneumonia and bronchitis in adults and children. In clinical trials it is used as a standard reference drug in determining the effectiveness of new antibiotics in patients with bronchopulmonary diseases. Currently, amoxicillin/clavulanate is regarded as the leading drug in the treatment of community-acquired respiratory tract infections and as one of the most active antibiotics against S. pneumoniae, including strains with reduced sensitivity to penicillins .

Expert committees dealing with problems of management of community-acquired pneumonia in the context of the development of pneumococcal «epidemics», recommend amoxicillin/clavulanate as a first-line drug for adults and children [24,25]. The basis for this is, first, the results of experimental studies showing that the drug’s activity against S. pneumoniae with varying degrees of sensitivity to penicillin . According to a large collaborative international study (The Alexander Project) among a large number of studied antibiotics only amoxicillin/clavulanate and ceftriaxone created concentrations in blood serum and tissues needed to inhibit 90% of pathogens with moderate and high resistance to penicillin . Second, the activity of amoxicillin/clavulanate against resistant strains of S. pneumoniae can be increased by increasing the dose of the drug . Third, the results of randomized clinical trials suggest that amoxicillin/clavulanate is effective in approximately 90% of patients with pneumococcal pneumoniae, in t.ч. caused by penicillin- and cephalosporin-resistant strains of the microorganism . Fourth, data from large studies on antibiotic resistance also indicate that the level of resistance to S. pneumoniae to amoxicillin/clavulanate is significantly lower than to other antibiotics. Thus, in a study conducted in Spain – In a country that is home to penicillin-resistant clones S. pneumoniae , where the level of antibiotic resistance is highest, resistance to amoxicillin/clavulanate was 3.68%, while resistance to penicillin – 32.11%, azithromycin – 24.41%, cefpodoxime – 32.44%, cefuroxime – 34.11% and cefaclor – 69,9% . Similar results were obtained in a national multicenter prospective study in Portugal, in which 1,071 strains of S. pneumoniae, isolated in patients with community-acquired lower respiratory tract infections . Amoxicillin/clavulanate exhibited the highest activity in vitro among the antibiotics studied against S. pneumoniae, H. influenzae и M. catarrhalis.

According to experts, inhibitor-protected aminopenicillins, which include amoxicillin/clavulanate, are best suited for empirical antibacterial therapy of community-acquired pneumonia that requires hospitalization for the severity of the patient . Since they are not active against pathogens of atypical pneumonia (mycoplasmas, chlamydia, legionella), it is recommended to combine inhibitor-proof aminopenicillins with macrolides when the latter are suspected.

Amoxicillin/clavulanate is assigned a significant place by the scientific community of pulmonologists in practical recommendations for diagnosis, treatment and prevention of community-acquired pneumonia in adults . Oral medication is considered the drug of choice in the outpatient treatment of community-acquired pneumonia, both in patients with non-serious pneumonia under 60 years of age without comorbidities and over 60 years of age and/or with comorbidities. Hospitalized patients with community-acquired pneumonia are recommended intravenous drug administration or step therapy (intravenous administration followed by switch to oral administration when the condition stabilizes). When the patient is stable and the pneumonia is not severe, oral amoxicillin/clavulanate can be administered immediately. For severe pneumonia, the combination of intravenous amoxicillin/clavulanate with intravenous macrolide is recommended as the regimen of choice.

Amoxicillin/clavulanate is the drug of choice for the treatment of community-acquired lower respiratory tract infections in special clinical situations, including.ч. in patients with alcohol abuse, diabetes mellitus, destructive and abscessed, the potential pathogens of which are Enterobacteriaceae, S. aureus, K. pneumoniae and anaerobes . It is also recommended for patients with community-acquired pneumonia, running in the background of chronic obstructive pulmonary disease, etiological factors of which are H. influenzae, S. pneumoniae и M. catarrhalis, as well as with pneumonia developed with influenza and other viral infections. The results of a recent study have clearly demonstrated the rationality of amoxicillin/clavulanate for the treatment of anaerobic infections and related complications, such as lung abscess and necrotizing pneumonia . Amoxicillin/clavulanate are also among the drugs of choice for the treatment of pneumonia in individuals living in organized communities (nursing homes, orphanages, etc.).д.) .

Amoxicillin/clavulanate is FDA Category B for the risk of pregnancy, t.е. Studies in animals have not revealed any risk of adverse effects of the drug on the fetus . There are no reports of toxic effects of amoxicillin/clavulanate on the human fetus. Thus, it is not contraindicated for the treatment of community-acquired pneumonia in pregnant women.

Pharmacoeconomic data based on the results of randomized, double-blind studies involving a total of more than 2,000 patients indicate that amoxicillin/clavulanate is more cost-effective for lower respiratory tract infections than erythromycin, cefuroxime, ampicillin, and cefaclor .

Thus, despite the changing epidemiological situation, amoxicillin/clavulanate continues to be one of the most effective agents for treatment of community-acquired pneumonia in different categories of patients.

The use of amoxicillin in the treatment of upper respiratory tract diseases

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The review of the literature, devoted to the prevalence of etiopathogenetic mechanisms, clinical picture, methods of diagnostics and treatment of inflammatory diseases of ENT organs is presented – Acute rhinosinusitis and acute purulent otitis media. There is convincing evidence of the necessity of antibacterial therapy for these pathologies. It is emphasized that the drug of first choice for inflammatory diseases of ENT organs is a semi-synthetic antibiotic of aminopenicillin group – Amoxicillin, which holds its positions due to good tolerability, favorable safety profile, convenient regimen, the possibility of step therapy and low cost.

Acute respiratory viral infections (ARI) account for up to 90% of cases of infectious diseases. Temporary disability due to acute respiratory infections reaches 30% of total temporary disability. ARI can have a severe course and provoke life-threatening conditions, such as ENT-organ damage, pneumonia, myocarditis, especially in weakened patients and elderly patients.

According to modern epidemiological studies, rhinosinusitis occupies the leading position in the overall disease incidence in the USA and Western Europe. Rhinosinusitis has been shown to affect between 17 and 36% of patients who are hospitalized in otorhinolaryngology departments. Sinusitis accounts for an even larger proportion among outpatient upper respiratory tract diseases.

Rhinosinusitis is the most common chronic condition in the United States, according to the National Center for Disease Statistics. In Germany, between 7 and 10 million cases of acute or chronic sinusitis have been diagnosed each year over the last decade. Acute respiratory infections are complicated by bacterial rhinosinusitis in 0.5–2% of cases in adults and 5–10% of cases in children.

European Position Paperon Rhino sinusitis and Nasal Polyps (EPOS) of 2012. The following forms of rhinosinusitis are distinguished:

  • acute – duration not more than 12 weeks;
  • Chronic – Duration more than 12 weeks.

Classical signs of acute bacterial rhinosinusitis: increase in body temperature to subfebrile digits, purulent or mucopurulent nasal discharge, headaches in the perinasal projection, which persist for 3–4 days, or syndrome «double-sickening» (the appearance of the above symptoms after a passed viral rhinosinusitis, which lasted 5–6 days).

The most common pathogens of acute bacterial rhinosinusitis include Streptococcus pneumoniae and Haemophilus influenzae. In pathogenesis of acute bacterial rhinosinusitis the damage of perinasal sinus epithelium caused by cytotoxic action of viruses plays a major role, which as a rule leads to malfunctioning of epithelial cell cilia due to desquamation of surface layers of nasal cavity mucosa. This leads to inhibition of mucociliary clearance, which in turn creates favorable conditions for secondary bacterial infection with the formation of purulent exudate.

Another frequent complication in the practice of a general practitioner and otorhinolaryngologist is acute suppurative otitis media. It is now one of the most common childhood illnesses: about 71% of children have acute suppurative media otitis by the age of three. 95% of children have at least one episode of acute bacterial rhinosinusitis during the first 7 years of life. According to the Health Maintenance Organization, 48% of children have a single episode of perforative or nonperforative acute bacterial rhinosinusitis in the first six months of life or ≥2 cases in the first year of life. Increased incidence of exudative otitis media, including.ч. The following is an important indicator of the recurrent course of middle ear infections in children, which has been observed for several decades. In acute bacterial rhinosinusitis, the inflammatory process is not only in the tympanic cavity.

Amoxicillin and bladder infection. Cystitis

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Cystitis

Cystitis — Is inflammation of the bladder mucosa.

Cystitis can be acute and recurrent, infectious and noninfectious, complicated and uncomplicated. The most common form of the disease — Acute uncomplicated cystitis. Uncomplicated cystitis refers to cystitis in non-pregnant women without anatomical and functional abnormalities of the urinary system, without serious concomitant diseases.

Acute cystitis — one of the most common diseases in women. More than 50% of women have been diagnosed with this condition at least once in their lives.

Anatomy

Anatomically, the female urethra is much shorter and wider than the male urethra, is 2-4 cm long and is located close to natural possible sources of infection, such as the vagina and anus. In men, the length of the urethra is about 20 cm and is anatomically divided into several sections. Before entering the bladder, the urethra passes through the prostate gland, which is a natural barrier that prevents the entry of infection into the bladder.

Predisposing factors

Predisposing factors for the development of cystitis are:

  • Anatomo-physiological features of the female body, a change in the location of the urethra;
  • Excessive sexual activity;
  • A new sexual partner, frequent change of sexual partners;
  • Use of spermicides;
  • An episode of urinary tract infection (UTI) in childhood;
  • A history of urinary tract infections in the mother.

The causative agent of acute cystitis in 70-95% of cases is E.coli — Escherichia coli. Other pathogens, such as staphylococcus, Klebsiella, protei, are much less common.

Symptoms of acute cystitis

Symptoms of cystitis most commonly include:

  • frequent painful urination (dysuria); ;
  • Unpleasant urine odor.

These complaints alone or in combination occur in 90% of women with acute cystitis. Body temperature over 37.3°C is not characteristic of cystitis and may indicate a more serious inflammatory process in the kidneys — acute pyelonephritis.

Blood in the urine — hematuria — Usually causes panic fear in women, but is most often a sign of common cystitis.

The combination of pain during urination and an admixture of blood in the urine suggested acute bladder inflammation (hemorrhagic cystitis) rather than other, more serious urologic pathology — For example, a tumor of the urinary tract, in the presence of which dysuria is uncharacteristic.

Blood in the urine may also appear due to chronic cystitis, leading to an increase in the number of blood vessels (hypervascularization) in the submucosal layer of the bladder, their fragility and tendency to hemorrhage.

Other possible causes of hemorrhagic cystitis: radiation therapy, chemotherapy, use of certain medications.

Cystitis accompanied by blood in the urine may occur acutely, without signs of chronic inflammation and the preceding factors. The treatment algorithm is usually limited to the same measures as in acute cystitis without hematuria.

Diagnosis

The diagnosis of acute cystitis is established on the basis of the patient’s complaints. To clarify the diagnosis, a general urinalysis is used, ideally — urinalysis with test strips.

The prescription of treatment for acute cystitis is also possible only on the basis of the patient’s complaints (so-called empirical therapy), without obtaining the results of urinalysis. Urine sampling for culture (bacteriological study) is not obligatory for patients with uncomplicated cystitis. Urine culture is only necessary in a number of cases, such as: the presence of pregnancy, suspected acute pyelonephritis, a prolonged course of cystitis (more than 2 weeks), atypical course of the disease. In the presence of bacteria in the urine culture — more than 10? — The diagnosis of acute cystitis may be confirmed microbiologically.

The ultrasound or other imaging techniques are not included in the algorithm for diagnosing acute cystitis. There may be no specific findings on ultrasound of the bladder. Ultrasound signs such as «Thickening of the bladder wall» и «The presence of bladder suspension», Do not talk about the mandatory inflammation of its mucosa. The purpose of ultrasound most often is to rule out bladder tumors and ureteric stones.

Cystoscopy is contraindicated in acute cystitis.

Differential diagnosis

Vaginitis. Characterized by frequent urination associated with vaginal irritation. A mild, sluggish course. Predisposing factors may be excessive sexual activity, frequent changes in sexual partners (new sex partner). Blood in the urine, pain during urination, pain in the lower abdomen is usually absent. Examination may reveal a vaginal discharge that reveals an inflammatory process.

Urethritis. This disease is also characterized by frequent, painful urination, but the severity of symptoms is usually weaker than in acute cystitis. The most common causes of urethritis are gonorrhea, trichomoniasis, chlamydia and herpes simplex virus. The disease may also occur due to a change in sexual partner. urethral discharge is more common in men.

Treatment of cystitis

The basis of treatment of acute cystitis is antibacterial therapy.

It has been proven that 90% of women have symptoms of acute cystitis within 72 hours after starting antibiotic therapy.

First-line drugs for acute cystitis are those that create a high concentration of the active substance in the urine and a low concentration in the blood, that is, drugs that act primarily in the urinary tract.

Fosfomycin. A broad-spectrum antibacterial drug (granules for oral administration) with a high concentration of the active substance. In acute cystitis, its peculiarity is a single dose — One dose of the drug is enough (3 g for adults). Used for initial manifestations of cystitis. If there are signs of bladder inflammation within a few days, another dose may be used (24 hours after the first dose).

Nitrofurantoin macrocrystalline. Nitrofurantoin is one of the oldest antimicrobial drugs, but, nevertheless, the level of resistance to it has remained low for several decades. However, it should be remembered that the overly broad use of nitrofurantoin in the treatment of acute cystitis is unwarranted due to the relatively high frequency of adverse drug reactions to this drug, primarily acute and chronic pulmonary syndromes, which are often seen in the elderly. The recommended dose and duration of treatment of uncomplicated acute cystitis with nitrofurantoin is 50-100 mg x 4 times daily, 5-7 days for acute infection, 50-100 mg at night for prevention of recurrence.

Antibacterial drugs that act systemically, Are not recommended for the treatment of acute uncomplicated cystitis as first-line drugs, and can only be used as Possible alternative.

Cephalosporins. A group of broad-spectrum antibiotics. Produce high concentrations of the active substance not only in the urine but also in the blood. There are 4 generations of cephalosporins. Used for a variety of conditions: from sinusitis to peritonitis. In the treatment of acute cystitis, tablet forms of the antibiotic are most commonly used. Dosage: 400 mg (1 tablet).) x 1 time a day for 3-5 days.

Alternative antibacterial drugs:

Fluoroquinolones. A highly effective group of antibiotics, widely used in urological practice. Most commonly prescribed Ciprofloxacin, Levofloxacin. Used in the treatment of acute cystitis, but not currently recommended for empirical therapy due to increasing resistance in patients. Prescribed according to the results of bacteriological urine culture in the presence of sensitivity to them, more often used in the treatment of pyelonephritis, prostatitis. Contraindicated in pregnant women and patients under 18 years of age. Regimen: Ciprofloxacin (Ciprobacin, Ciprolet) — 250 mg x 2 times a day for 3-5 days.

Penicillins. The very first, artificially synthesized group of antibiotics. Representative: Amoxicillin. Not recommended for empirical therapy of acute cystitis due to increased E. coli resistance worldwide. However, the combination of Amoxicillin and clavulanic acid can be used in some cases, for example, in the presence of inflammation of the bladder mucosa in pregnant women. Regimen: Amoxicillin + clavulanic acid (Amoxiclav, Augmentin) 625 mg x 3 times a day for 7 days.

The basis of treatment cystitis in pregnant women is also the prescription of antibiotic therapy, but not all drugs are approved for use. Monural, Furamag and a penicillin antibiotic or cephalosporin group is acceptable.

The use of other drugs, herbal remedies, dietary supplements in the treatment of acute cystitis is ineffective, because there is a high probability of preservation of the pathogen and the occurrence of relapse of the disease.

Earlier recommendations to use a natural uroantiseptic have been encountered — Cranberries (plenty of cranberry juice). There is evidence in several studies of the effectiveness of cranberry in reducing the incidence of urinary tract infections in women. However, in a meta-analysis involving 24 studies and 4,473 patients, it was shown that foods containing cranberries, Do not statistically significantly reduce Frequency of urinary system infections, including acute cystitis in women.

If the patient for some reason demonstrates reluctance to drink antibiotics, it is allowed to prescribe anti-inflammatory drugs and analgesics to reduce the severity of dysuria and discomfort in the lower abdomen.

Phenazopyridine — Refers to analgesics for pain relief in inflammatory diseases of the bladder and urinary tract. Excreted with urine, providing local analgesic effect on urinary tract mucosa. Does not, by itself, get rid of bacteria or damage to the mucosa, is used only for symptom reduction. Can be used in conjunction with antibiotics to reduce discomfort. It is recommended to use no more than 2 days, as a longer treatment may mask the symptoms of the disease. Also used for elimination of discomfort, cutting during urination after bladder catheterization, endoscopic interventions, urethral surgeries.

Nonsteroidal anti-inflammatory drugs — Have a pronounced anti-inflammatory, analgesic, and moderate antipyretic effect. Widely used in urological practice, often in the form of rectal suppositories. The most popular: Diclofenac, Indomethacin, Ketoprofen. In special cases, in the absence of the possibility of taking an antibiotic and the presence of recurrent cystitis, can serve as the main medication for a short time.

Cystitis in men

Extremely rare. This is due to the longer urethra than in women, the smaller number of bacteria in the periurethral zone, the presence of antibacterial components in the prostate secretion. Factors contributing to cystitis in men include diagnostic manipulations and surgical procedures on the urinary tract, radiation therapy, chemotherapy, unprotected anal intercourse. Treatment is carried out with antibacterial drugs that are also used in the treatment of prostate inflammation: Ciprofloxacin 500 mg x 2 times a day, for at least 7 days.

After an episode of acute cystitis. Preventive measures

After adequate treatment of acute cystitis there is no need for additional examinations. Adequate fluid intake, avoidance of hypothermia, personal hygiene, hygiene of sexual life, timely treatment of gynecological diseases, sexually transmitted infections are recommended. Prophylactic use of any drugs after a single episode of acute cystitis is not indicated.

If the symptoms of cystitis occur within two weeks after treatment and the therapeutic effect is absent, the urine should be examined for culture and the sensitivity of the isolated pathogens to antibiotics should be determined (take a urine culture). According to the results of the bacteriological culture is recommended the appointment of an antibacterial drug according to the sensitivity to it of the pathogen.

Amoxicillin in the treatment of acute otitis media in children. Effectiveness

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Currently Amoxicillin remains the remedy of first choice for uncomplicated acute otitis media due to its safety, comparative effectiveness, pleasant taste, and low cost. In particular, amoxicillin is the most effective among available oral antimicrobials against both penicillin-insensitive strains and S. pneumoniae susceptible to it.

Increase doses From the traditional 40 to 80-100 mg/kg/day usually provides a good effect against strains — penicillin intermediates and some penicillin-resistant. The increased dose should be used especially in children under 2 years of age and those who have recently been treated with b-lactams or who are in a large pediatric population because, as noted earlier, in these children the prevalence of resistant S strains. pneumoniae are the highest.

Limitation of use amoxicillin is due to the fact that it can be inactivated by the b-lactamases of many strains that are nontypical of H. influenzae, and by most strains of M. catarrhalis. Fortunately, cases of acute otitis media caused by these pathogens often, but not always, resolve spontaneously. For children who are allergic to b-lactams or for whom taste or convenience of administration is important, azithromycin, which also has an excellent safety record, is a suitable first-line choice.

Resistance to Trimethoprim/sulfamethoxazole Many strains of H. influenzae, S. pneumoniae and the reported high rate of adverse outcome of acute otitis media in children initially treated with this drug suggest its unacceptability as a first-line treatment.

Often the duration of the treatment of acute otitis media is 10 days with an apparent extrapolation of the optimal duration of treatment of streptococcal pharyngitis with penicillin. However, 10 days may be excessive for some children and insufficient for others. Studies comparing a shorter treatment period to a longer treatment period suggest that a short course is often inadequate for children under 6 years of age, especially under 2 years of age.

Thus, in most cases treatment, which ensures concentration of antimicrobial agents in the tissues, for at least 10 days seems appropriate. A short course, 3-5 days, may be appropriate for older children in relatively mild cases who are improving rapidly, while treatment longer than 10 days is often required for very young children, or for severe acute otitis media, or those with a history of otitis media problems.

Main purpose dynamic observation Is to assess treatment outcome and differentiate between inadequate response to treatment and early relapse. Accordingly, the required period of dynamic observation should be individualized. Observation for several days is appropriate for children in early infancy with severe illness or children of any age with persistent pain. Follow-up for 2 weeks. Necessary in infants or young children with frequent relapses.

Perhaps, eardrum (BP) has not returned to normal, but a significant improvement in her appearance should be evident. For children with a single episode of acute otitis media and rapid improvement in her appearance, observation within 1 month. after the initial examination is insufficient, and for older children, it may not be necessary at all.

In essence acute otitis media — Is an infectious, confined space disease, and its resolution depends on both elimination of the pathogen and restoration of middle ear ventilation.

Contributing factors unsatisfactory response to first-line treatment in addition to antimicrobial ineffectiveness include inadequate treatment regimens, current or mixed viral infection, persistent auditory tube dysfunction and insufficient aeration, reinfection from other foci, or immature or compromised patient immunity.

Despite this, switching to an alternative or second-line remedy will seem appropriate, If there is inadequate positive trend in the symptoms or condition of the middle ear, as reflected in the appearance of the eardrum (OA), or persistent purulent nasal discharge indicates that the antimicrobial agent used is ineffective. Second-line products may also be used for acute otitis media in a child already receiving antimicrobial prophylaxis, or in a child with immunodeficiency, or in a child with a history of severe symptoms and problems with otitis media.

Does amoxil work good for urinary tract infection?

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Amoxicillin is a highly effective treatment for a urinary tract infection (UTI). This drug is an antibiotic That helps fight infections by interfering with the ability to multiply of bacteria. In most cases, a practitioner will prescribe amoxicillin to treat a urinary tract infection that’s somewhat straightforward. If the infection has become complicated or is threatening the patient’s health, however, it may not be as effective. In instances in which amoxicillin and antibiotics cannot be used, the individual may need to be hospitalized and treated intravenously.

Typically, amoxicillin is regarded as a treatment for a Simple urinary tract disease. When a person has a infection, this means he or she is otherwise healthy and symptoms are not being caused by the UTI or affecting other parts of the human body. Whereas a disease that has resulted in kidney problems may necessitate another type of treatment by way of example, a mild-to-moderate urinary tract disease may be treated with amoxicillin.
Tract disease, it is usually important to take this antibiotic as the healthcare practitioner has prescribed. This usually means taking it and finishing the whole course of medication. Often, people think it is okay to stop taking drugs once their symptoms have subsided. This is a bad idea, but as doing may lead to a worse infection and a resistance to the antibiotic and this allows the bacteria to grow again.

When prescribing amoxicillin caregivers, for a UTI usually Prescribe it. As food won’t interfere with its effectiveness, A patient can take the medicine with or without food. Lots of folks prefer to take it to avoid the stomach if they take amoxicillin on an empty belly, some notice.

Though amoxicillin is proven to be effective for treating a Urinary tract infection, there could be instances where it fails to work as expected. This may happen when an illness has gone untreated for a Significant period of progresses and time to impact the patient’s kidneys. In this case, the individual may require a stronger antibio

Amoxicillin for Treatment of Helicobacter pylori Infection

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Alternate amoxicillin dosing schedule improved H. pylori eradication rates

Amoxicillin dosing schedules of three or four four times every day in conventional November therapy worked better in the eradication of Helicobacter pylori infection when compared with this conventional, empirically dosed twice-daily regimen utilised in Japan, based on info presented in endothelial Illness Week.

“Triple therapy using a proton pump inhibitor, amoxicillin and Clarithromycin or metronidazole is actually the conventional regimen in Japan, and also the regimens are generally dosed twice each day,” Takahisa Furuta, MD, PhD, of this Center for Clinical Investigation in Hamamatsu University School of Medicine at Japan, stated here during his demo. “But the effectiveness of amoxicillin is determined by time-above-MIC [minimal inhibitory concentrations], and ought to be dosed regularly to create time-above-MIC longer”

Furuta and colleagues assessed distinct dosing programs of amoxicillin at 312 patients using H. pylori. Patients were delegated 750 milligrams of amoxicillin 500 milligrams three times each day or 500 milligrams four times daily. Patients with clarithromycin-sensitive breeds (n=187) additionally obtained a proton pump inhibitor and also 200 milligrams of clarithromycin twice each day. Patients who have clarithromycin-resistant (aka=125) breeds received a proton pump inhibitor and also 250 milligrams metronidazole twice each day.

One of the clarithromycin-sensitive patients, the H. pylori Eradication rates were 80.3percent, 96.7percent and 95 percent for your 750 mg twice daily, 500 mg three times each week as well as the 500 mg four times per day amoxicillin groups, respectively. One of the clarithromycin-resistant patients, the eradication rates were 82.5percent, 95 percent and 97.6percent, respectively. There was no gap in the incidence of adverse events involving the groups that are dosing.

“Dosing plot of amoxicillin affects the eradication speeds of H. pylori,” Furuta explained. “The twice-daily dosing is substandard for amoxicillin to implement its bactericidal impact. Three times or even four times each day dosing of amoxicillin enhances eradication speeds without raises of adverse incidents in amoxicillin-based regimens.”

Furuta T. #245. Effects of Distinct Dosing Schedules of Amoxicillin about the Eradication Rates of Helicobacter Pylori by Triple Treatment with Proton Pump Inhibitor, Amoxicillin and also Either Clarithromycin or Metronidazole.

Usual Adult Dose for Helicobacter pylori Disease

1000 mg amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, orally twice each day (daytime and night) for 10 to 14 days.

Renal Dose Adjustments

Amoxicillin/clarithromycin/lansoprazole (Prevpac) isn’t advocated in patients using CrCl less compared to 30 mL/min.

Liver Dose Adjustments

In patients with acute disease, a decrease in the dosage of lansoprazole ought to be considered.

Precautions

Amoxicillin/clarithromycin/lansoprazole is contraindicated in patients that are getting drugs to be used. Administration using astemizole, pimozide, cisapride, terfenadine, ergotamine or dihydroergotamine is contraindicated. There happen to be postmarketing reports of medication interactions when clarithromycin or erythromycin are administered concomitantly using cisapride, pimozide, astemizole, or terfenadine leading to cardiac arrhythmias (QT prolongation, ventricular tachycardia, ventricular fibrillation, and also torsades de pointes). Fatalities have been reported.

Serious and sometimes fatal hypersensitivity reactions are documented in patients on penicillin treatment. Before initiating amoxicillin treatment, a cautious evaluation ought to be made regarding previous hypersensitivity reactions to cephalosporins, penicillins, or alternative allergens. The medication ought to be discontinued immediately at the first appearance of a skin rash or other signs of hypersensitivity. Severe hypersensitivity reactions may require treatment with epinephrine and other resuscitative measures including management, intravenous fluids, antihistamines, corticosteroids disease and oxygen as medically indicated.

Proton pump fillers might interfere with the discovery of H pylori from the urea breath assessment. Therefore, testing for H pylori using all the urea breath test isn’t advised in patients that have received proton pump inhibitors.

Clarithromycin shouldn’t be utilised in pregnant girls except in clinical conditions where no alternate therapy is suitable. The patient ought to be apprised of the possible risk if pregnancy occurs while taking clarithromycin.

Pseudomembranous colitis was reported with antibiotics and might potentially be life-threatening. It is necessary to consider this diagnosis in patients who present with diarrhea whilst obtaining clarithromycin treatment and amoxicillin. While serious cases may need treatment and therapy with an agent effective against Clostridium difficile mild cases improve with discontinuation of the medication.

Clarithromycin is mostly excreted through the liver and kidneys. In patients with normal renal function and hepatic impairment, clarithromycin might be administered without dosage adjustment. But decreased dosage or dosing intervals may be appropriate in the presence of renal impairment with or without.

The prospect of creating a superinfection using mycotic or antiviral pathogens ought to be held in your mind. If superinfections occur, amoxicillin/clarithromycin/lansoprazole ought to be discontinued and proper therapy began.

Symptomatic reaction to treatment with amoxicillin/clarithromycin/lansoprazole doesn’t preclude the existence of gastric malignancy.

Proton pump fillers ought to be utilized with caution in patients that have hypocalcemia and/or hypoparathyroidism.

Calcium absorption is diminished in patients using achlorhydria.

Proton pump fillers could donate to the maturation of vitamin B12 lack with prolonged usage.

Dialysis

Amoxicillin is dialyzable. Lansoprazole and clarithromycin aren’t dialyzable.

Rescue therapy for Helicobacter pylori

Remark statement

  • Up to 35 percent of patients infected with Helicobacter pylori neglect to react to conventional anti-H. pylori treatment.
  • With the prevalence antimicrobial immunity, the failure rates of proton pump treatment are anticipated to rise. Antibiotic immunity testing ought to be done whenever potential to permit for tailoring of this therapy regimens.
  • The info about rescue or second-line treatment are restricted and are subjected to several biases and confounding aspects. Switching between metronidazole and also clarithromycin ought to be thought about if classes of proton pump therapy function as treatment in the lack of ulcerative sensitivity examining.
  • The prolongation of treatment length using clarithromycin, amoxicillin, and proton pump inhibitor is ineffective for strains.
  • The quadruple treatment is the salvage therapy in the lack of pretreatment susceptibility.
  • Furazolidone quadruple therapy (in which accessible) and also rifabutin triple therapy are salvage therapies of last hotel. Culture and susceptibility testing is necessary, if these regimens fail.

High-dose proton pump inhibitor plus amoxycillin for the treatment or retreatment of Helicobacter pylori infection.

BACKGROUND:

The Mixture of 120 milligrams of omeprazole (40 milligrams t.d.s.) and also amoxycillin was reported to work for treating H. pylori diseases.

METHODS:

Normal Volunteers with H. pylori infection got high-dose omeprazole (40 milligrams t.d.s.) or lansoprazole (60 milligrams t.d.s.) and amoxycillin 750 milligrams t.d.s. to get 14 days. The studies have been open label and never randomized as people receiving omeprazole and amoxycillin had formerly neglected lower dose omeprazole (20 milligrams b.d.) and amoxycillin treatment over 6 months before. Those receiving lansoprazole and amoxycillin hadn’t been treated. Four to 6 weeks after completion antimicrobial therapy, H. pylori status was ascertained by Genta stain of gastric mucosal biopsies.

RESULTS:

Forty-three Volunteers entered 41 and the study completed it. The total success with high-dose proton pump inhibitor and also amoxycillin has been 34.9\%. For the person regimens that the per-protocol outcomes were 48 percent (95 percent CI = 28-69percent) using lansoprazole and 12.5percent (95 percent CI = 2-38percent) using omeprazole. Compliance was > 95 percent for the two regimens. Four lansoprazole and three subjects that were omeprazole experienced side-effects, and induced two topics to withdraw. Rates were comparable among various races and ethnic groups, between women and men, and between smokers and non-smokers. This urea breath test’s level did not predict outcome.

CONCLUSION:

High-dose Proton pump inhibitor and amoxycillin combinations for treatment of H. Benefits that were adverse were yielded by infection, as the confidence Periods didn’t incorporate an 80\% cure speed. These combinations don’t Yield results and cannot be recommended as main therapy.

REFERENCES: https://www.ncbi.nlm.nih.gov/pubmed/8971301

How to eradicate Helicobacter pylori using amoxicillin and omeprazole in the remnant stomach.

BACKGROUND/AIMS:

We formerly investigated the ramifications of amoxicillin/omeprazole combined treatment on patients that were Helicobacter pylori (H. pylori) favorable after gastrectomy to get the therapy of gastric cancer, plus we ascertained that the gap in amoxicillin dosage involving the curative failures and successes. At the current study, presuming that amoxicillin dosage ought to be set on the grounds of human anatomy weight of every individual, we analyzed whether the eradication of H. pylori could be made better by utilizing this book dose-selection technique.

METHODOLOGY:

We’ve formerly mentioned about eradication of all H. pylori of remnant belly as follows. Patients who underwent gastrectomy for the therapy of gastric cancer were enrolled when H. pylori was discovered within their imaginations stomach after the surgery. 22 were treated with amoxicillin in 20 mg/day for 8 weeks in 750 mg/day for omeprazole and also 2 weeks. For the analysis of H. pylori eradication, endoscopic assessment and 13C-urea breath test have been completed 12 weeks after the initiation of this therapy. The amoxicillin dosage from the curative successes was in comparison to that at the therapeutic failures, and also we discovered that the dosage was 14.1 +/- 1.5 and 12.5 +/- 1.5 mg/kg/day from the successes and the failures, respectively. Obeying these outcomes, the following 10 H. pylori-positive patients had been treated using amoxicillin more than 16 mg/kg/day for 2 weeks and also omeprazole in 20 mg/day for 8 weeks, and H. pylori eradication was appraised as mentioned previously. The efficacy of this medication treatment on H. pylori infection was compared between both classes which one group (Group A) is treated with amoxicillin 750 mg/day for 2 weeks and also omeprazole in 20 mg/day for 8 weeks and another group (Group B) is handled using 1250 mg/day for 2 weeks and also omeprazole in 20 mg/day for 8 weeks.

RESULTS:

The eradication speed of H. pylori at Group B (84.6percent) has been greater compared to that in Group A (42.1percent). There was significant difference between the 2 groups (p = 0.028).

CONCLUSIONS:

We guessed the best dose of amoxicillin was above 15.6 mg/kg/day to get omeprazole-amoxicillin combined treatment for gastrectomized patients that were H. pylori favorable, and also the positive therapeutic effects can be obtained by applying this amoxicillin dose into the eradication of H. pylori.

REFERENCES: https://www.ncbi.nlm.nih.gov/pubmed/14696514