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January 1996, Volume 46, Issue 1



Madam, We read with interest the comments by Professor Essa Abdullah on our submission on “An audit of Ciprofloxacin use in severe life threatening infection at the AKUH”.
Professor Abdullah makes several valid comments pertaining to proofreading, which are pertinent. The correct spellings are indeed ‘gentarnicin’ and ‘prokaryotic’. Similarly the reason we expressed resistancefiguresas percentage for all isolates, was to avoid presenting data ma complex table or two different tables. These minor points do not detract from the main message of our paper.
Notwithstanding, the aforementioned points, the main issue that Professor Abdullah raises is one that should be debated actively now. We disagree with the contention that sufficient data exists to give a carte-blanche approval for quinolone use in the paediatric age group. We firmly believe that the use of quinolones in childhood should be restricted to severe, life threatening illnesses where alternative therapy is either not possible or feasible. Our audit with the abysmal results of follow-up, strongly supports our contention that ciprofloxacin and other quinolone use in children should be restricted to hospitals and strict therapeutic and follow-up guidelines enforced.
It is incorrect to equate Nalidi.xic Acid, a first genenation quinolone, with other newer agents Which may have entirely different pharmacokinetics and toxicity1. Notwithstanding the apparent lack of cartilage toxicity on MRI scanning, many of the changes may be subtle and only apparent after longterm follow-up. Irrespective of several retrospective reviews of quinolone toxicity, these agents are still not registered for routine use in the paediatric age group in the West, as strict growthand follow-up criteria need to be followed. The longest follow-up reported from India on longitudinal studies todate, is only 2 years and although there is no significant growth stunting, the investigators themselves request caution in interpreting any lack of potential toxicity2. It is also interesting to note recent data on fluoride accumulation in the body with fluroquinolone use in children, another potential source of bone toxicity2. Fluroquinolones are also not as innocuous as the manufactures would make out, as a high rate (upto 1.3%) of arthralgias in children has been reported in the literature3,4, alongwith dental staining in neonates5, as well as interstitial nephritis6.
The most important lesson from our audit at a teaching hospital with major communication resources, was that the overall voluntary follow-up rate was extremely low. We have thus major problems with widespread use of quinolones, such as ciprofloxacin, in children, in situations where stringent criteria for follow up are not maintained. It is important here to note that some workers from India using the doctrine of compassionate use in sick children, have reported ciproflox­acin therapeutic data in ‘thildren with only a three month follow-up, and no growth information7. We and others8-10. would therefore, take the cautious route of waiting for further experience and follow-up with these agents. The use of cipmfloxacin should therefore, continue to be restricted to supervised hospital use in children as the last resort agent, when there is no alternative. Additionally, where physicians have rushed into indiscriminate prescribing of these agents, the result has also been a remarkably rapid emergence of drug resistance11,12.
We thank Dr. Essa for his interest in our article and look forward to his continued support in encouraging rational therapeutics in children.

Zulfiqar A. Bhutta
Department of Paediatrics, The Aga Khan University, Karachi.


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2.  Pradhan, KM., Arora, N,K., Jena, A. et a! Safety of ciprofloxacin therapy in children: Magnetic resonance images, body fluid levels of fluoride and linear growth. Acts Paediatr., 1995 ;84: 555-60.
3. Biswal, N., Mathai, Bhatia, B.D. P-fioxacin induced arthropathy. Indian Pediatr., 1993;30:718-19.
4. Chysky, V., Kapila, K., Huliman, R. et al. Safety of ciprolloxacin in children Worldwide clinical experience based on compassionate use. Emphasis on joint evaluation. Infection, 1991;19:329-32
5. Lumbiganon, P., Pengssa, K., Sookprantee, T Ciprofioxacin in neonates and its possible adverse effect on the teeth. Ped iatr. Infect. Dis. J., 1991;10:619-20.
6. Simpson, J., Watson, AR., Mellersh, A. et al. Typhoid fever, ciprofioxacin and renal failure. Arch. Dis. Child., 1991 ;66: 1083-4.
7. Dutta, P., Rasaily, R., Saha, M.R. et al. Ciprofloxacin for treatment of severe typhoid fever in children. Antimicrob. Agents and Chemother., 1993;11 97.99.
8. Douidar, SM., Snodgrass, W.R. Potential role of fluroquinolone in paediatric infection. Rev. Infect. Dis., 1989;11 :878- 89.
9. Khadikar, V. V. Quinolones in pediatric practice. Academy Today, 1990, 9.
10. Bennish. M. Should oral quinolones be licensed for use in children ofdeveloping countries? Seminar on quinolone use in paediatric age group. Fifth International Meeting, Society for Infectious Diseases, Nairobi, Kenya. June 1990.
11. Biswal, N., Mathai, B., Bhatia, B. D. eta!. Enteric Fever: A changing perspective. Indian Pediatr,, 1993;813-19.
12 .Mushtaq, D., Bhutta, Z.A. Ciprofioxacin in multi-resistant infections in childhood. An audit. J. Pak. Med, Assoc., 1995;45:147-150.

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