ABC
Infezioni delle vie respiratorie e antibiotico: sì, no, quando?
RESPIRATORY TRACT INFECTIONS AND ANTIBIOTICS: YES, NO, WHEN?
Federico Marchetti1, Franco Panizon2
1Clinica Pediatrica, IRCCS “Burlo Garofolo”, Trieste
2Professore Emerito, Dipartimento di Scienze della Riproduzione e dello Sviluppo, Università di Trieste
Novembre 2010 - pagg. 577 -584
Abstract
It is reasonable to delay the antibiotic treatment of a few days in all the apparently not
serious cases of upper respiratory infection. “Risk” groups, in which antibiotics should
be used to treat each fever, are: chronic pulmonary, kidney and heart diseases, immunodeficiency,
cystic fibrosis, muscular diseases and prematurity. In case of a child with
sore throat, if there are other concomitant signs of respiratory infection (nasal secretion,
cough) it is certainly a viral disease. If pharyngitis is not accompanied by signs of infection
to the upper respiratory tract, perform rapid strep test, it should come out positive in
half of cases. Antibiotics are of little help in sinusitis. If the cough that accompanies fever
is very severe and the outcome of auscultation is not significant, respiratory rate must be
counted. If it is not higher than 45/m (under 2 years) it is not bronchopneumonitis, or at
least, the latter is neither significant nor worrying. Waiting is still reasonable. The problem
of antibiotic resistance for excessive use is real; it certainly concerns more macrolides
than amoxicillin and it is proportional to the antibiotic pressure (which is very high
in Italy). The problem of methicillin-resistant Staphylococcus pathology, though quantitatively
limited, is growing and may have tragic outcomes. The “complete” resistance of
Pneumococcus to amoxicillin is assessed at about 2-3%. An intermediate resistance
(between 10% and 15%) can be easily overcome by using, when needed, higher doses
of amoxicillin.
Parole chiave
Classificazione MeSH
Bibliografia
1. Rossignoli A, Clavenna A, Bonati M. Antibiotic
prescription and prevalence rate in
the outpatient paediatric population: analysis
of surveys published during 2000-2005. Eur J
Clin Pharmacol 2007;63:1099-106.
2. Sharland M, Kendall H, Yeates D, et al.
Antibiotic prescribing in general practice and
hospital admissions for peritonsillar abscess,
mastoiditis, and rheumatic fever in children:
time trend analysis. BMJ 2005;331:328-9.
3. Ronfani L, Conti Nibali S, Marchetti F, per
il Gruppo di Lavoro OMA-ACP. Il trattamento
sintomatico dell’otite media acuta: uno studio
collaborativo in Pediatria ambulatoriale.
Medico e Bambino 2002;21:170-8.
4. Marchetti F, Ronfani L, Conti Nibali S,
Tamburlini G; Italian Study Group on Acute
Otitis Media. Delayed prescription may reduce
the use of antibiotics for acute otitis media:
a prospective observational study in primary
care. Arch Pediatr Adolesc Med 2005;
159:679-84.
5. Siegel RM, Kiely M, Bien JP, et al. Treatment
of otitis media with observation and a
safety-net antibiotic prescription. Pediatrics
2003;112:527-31.
6. Spiro DM, Tay KY, Arnold DH, Dziura JD,
Baker MD, Shapiro ED. Wait-and-see prescription
for the treatment of acute otitis media:
a randomized controlled trial. JAMA
2006;296:1235-41.
7. Subcommittee on Management of Acute
Otitis Media. Diagnosis and management of
acute otitis media. Pediatrics 2004;113:1451-65.
8. Rovers MM, Glasziou P, Appelman CL, et
al. Antibiotics for acute otitis media: a metaanalysis
with individual patient data. Lancet
2006;368:1429-35.
9. Rovers MM, Glasziou P, Appelman CL, et
al. Predictors of pain and/or fever at 3 to 7
days for children with acute otitis media not
treated initially with antibiotics: a meta-analysis
of individual patient data. Pediatrics 2007;
119:579-85.
10. Tan T, Little P, Stokes T; Guideline Development
Group. Antibiotic prescribing for
self limiting respiratory tract infections in primary
care: summary of NICE guidance. BMJ
2008;337:a437.doi: 10.1136/bmj.a437.
11. Di Mario S, Gagliotti C, Asciano M, Moro
ML, per il Comitato tecnico-scientifico regionale
dei pediatri. La faringotonsillite e l’otite media acuta in età pediatrica. La guida
rapida sviluppata dalla Regione Emilia-Romagna.
Medico e Bambino 2008;27:38-42.
12. Marchisio P. Principi N, Bellussi L (coordinatori).
Otite Media Acuta: dalla diagnosi
alla prevenzione. Linee Guida della Società
Italiana di Pediatria. http://www.sip.it/documenti/
otite.pdf.
13. Thompson PL, Gilbert RE, Long PF, Saxena
S, Sharland M, Wong IC. Effect of antibiotics
for otitis media on mastoiditis in children:
a retrospective cohort study using the
United Kingdom general practice research
database. Pediatrics 2009;123:424-30.
14. Marchetti F. Otite, mastoidite e vigile attesa.
Medico e Bambino pagine elettroniche
2009;12(3). http://www.medicoebambino.
com/?id=CM0903_10.html.
15. Gaynes RP. Preserving the effectiveness
of antibiotics. JAMA 2010;303:2293-4.
16. Wise R, Piddock L. The need for new antibiotics.
Lancet 2010;375:638.
17. Deleo FR, Otto M, Kreiswirth BN, Chambers
HF. Community-associated meticillin-resistant
Staphylococcus aureus. Lancet 2010;
375:1557-68.
18. ECDC/EMEA Joint Technical Report.
The bacterial challenge: time to react. EMEA
doc. ref. EMEA/576176/2009. Stockholm,
September 2009. http://www.ema.europa.
eu/docs/en_GB/document_library/Report/
2009/11/WC500008770.pdf.
19. Boccia D, Alegiani SS, Pantosti A, Moro
ML, Traversa G. The geographic relationship
between the use of antimicrobial drugs and
the pattern of resistance for Streptococcus
pneumoniae in Italy. Eur J Clin Pharmacol
2004;60:115-9.
20. van der Poll T, Opal SM. Pathogenesis,
treatment, and prevention of pneumococcal
pneumonia. Lancet 2009;374:1543-56.
21. Don M, Canciani M, Korppi M. Community-
acquired pneumonia in children: what’s old?
What’s new? Acta Paediatr 2010;99:1602-8.
22. Kabra SK, Lodha R, Pandey RM. Antibiotics
for community-acquired pneumonia in
children. Cochrane Database Syst Rev 2010;
(3):CD004874.
23. Clifford V, Tebruegge M, Vandeleur M,
Curtis N. Question 3: can pneumonia caused
by penicillin-resistant Streptococcus pneumoniae
be treated with penicillin? Arch Dis
Child 2010;9:73-7.
24. Servizio Nazionale per le Linee Guida. La
gestione della sindrome influenzale. Documento
16. Maggio 2008. http://www.snlgiss.
it/cms/files/LG_Influenza_unico_2008.pdf.
25. Leone V, Panizon F. Streptococco: tra il
dire e il fare, ovvero sulla conflittualità tra le
raccomandazioni ufficiali e la pratica quotidiana.
Medico e Bambino 2002;21:377-82.
26. Bergamini M, Bussi R, Buzzetti R, et al.
Una vecchia “conoscenza” (la faringotonsillite)
e i nuovi dubbi: trattare, non trattare.
Medico e Bambino 2006;25:570-6.
27. Panizon F. La terapia della faringotonsillite:
tra evidenze scientifiche e pragmatismo ragionevole.
Medico e Bambino 2006;25:577-8.
28. Esposito S, Principi N (estensori). La rinosinusite
acuta e subacuta in età pediatrica:
linee guida per l’approccio diagnostico-terapeutico.
http://www.sip.it/documenti/1601.
pdf.
29. Morris PS, Leach AJ. Antibiotics for persistent
nasal discharge (rhinosinusitis) in
children. Cochrane Database Syst Rev 2008;
(2):CD001094.
30. Don M, Canciani M. Nuovi patogeni respiratori.
Medico e Bambino 2010;29:363-70.
31. Fahey T, Smucny J, Becker L, Glazier R.
Antibiotics for acute bronchitis. Cochrane
Database of Syst Rev 2004;4:CD000245.
32. Moro ML, Marchi M, Gagliotti C, Di
Mario S, Resi D. “Progetto Bambini e Antibiotici
[ProBA]” Regional Group. Why do
paediatricians prescribe antibiotics? Results
of an Italian regional project. BMC Pediatr
2009;9:69.
33. Benoni G, Cuzzolin L, Chiamenti G, et al.,
per il Gruppo di Lavoro dei Pediatri della Regione
Veneto. Ruolo della comunicazione
nelle attitudini prescrittive del pediatria di
famiglia nella Regione Veneto. Medico e
Bambino pagine elettroniche 2003;6(10).
http://www.medicoebambino.com/?id=RI03
10_10.html.
Corrispondenza: marchetti@burlo.trieste.it