Effects of antibiotic treatment in the subset of common-cold patients who have bacteria in nasopharyngeal secretions

Identifying Children Likely to Benefit From Antibiotics for Acute Sinusitis: A Randomized Clinical Trial

Importance

The large overlap between symptoms of acute sinusitis and viral upper respiratory tract infection suggests that certain subgroups of children being diagnosed with acute sinusitis, and subsequently treated with antibiotics, derive little benefit from antibiotic use.

Objective

To assess if antibiotic therapy could be appropriately withheld in prespecified subgroups.

Design, Setting, and Participants

Randomized clinical trial including 515 children aged 2 to 11 years diagnosed with acute sinusitis based on clinical criteria. The trial was conducted between February 2016 and April 2022 at primary care offices affiliated with 6 US institutions and was designed to evaluate whether symptom burden differed in subgroups defined by nasopharyngeal Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis on bacterial culture and by the presence of colored nasal discharge.

Interventions

Oral amoxicillin (90 mg/kg/d) and clavulanate (6.4 mg/kg/d) (n = 254) or placebo (n = 256) for 10 days.

Main Outcomes and Measures

The primary outcome was symptom burden based on daily symptom scores on a validated scale (range, 0-40) during the 10 days after diagnosis. Secondary outcomes included treatment failure, adverse events including clinically significant diarrhea, and resource use by families.

Results

Most of the 510 included children were aged 2 to 5 years (64%), male (54%), White (52%), and not Hispanic (89%). The mean symptom scores were significantly lower in children in the amoxicillin and clavulanate group (9.04 [95% CI, 8.71 to 9.37]) compared with those in the placebo group (10.60 [95% CI, 10.27 to 10.93]) (between-group difference, -1.69 [95% CI, -2.07 to -1.31]). The length of time to symptom resolution was significantly lower for children in the antibiotic group (7.0 days) than in the placebo group (9.0 days) (P = .003). Children without nasopharyngeal pathogens detected did not benefit from antibiotic treatment as much as those with pathogens detected; the between-group difference in mean symptom scores was -0.88 (95% CI, -1.63 to -0.12) in those without pathogens detected compared with -1.95 (95% CI, -2.40 to -1.51) in those with pathogens detected. Efficacy did not differ significantly according to whether colored nasal discharge was present (the between-group difference was -1.62 [95% CI, -2.09 to -1.16] for colored nasal discharge vs -1.70 [95% CI, -2.38 to -1.03] for clear nasal discharge; P = .52 for the interaction between treatment group and the presence of colored nasal discharge).

Conclusions

In children with acute sinusitis, antibiotic treatment had minimal benefit for those without nasopharyngeal bacterial pathogens on presentation, and its effects did not depend on the color of nasal discharge. Testing for specific bacteria on presentation may represent a strategy to reduce antibiotic use in this condition.

Trial Registration

ClinicalTrials.gov Identifier: NCT02554383.

Basic clinical management of preschool wheeze

Preschool wheeze is very common and often difficult to treat. Most children do not require any investigations; only a detailed history and physical examination to ensure an alternative diagnosis is not being missed; and the differential diagnosis, and hence investigation protocols for the child in whom a major illness is suspected, shows geographical variation. The pattern of symptoms may be divided into episodic viral and multiple trigger to guide treatment, but the pattern of symptoms must be re-assessed regularly. However, symptom patterns are a poor guide to underlying pathology. Attention to the proper use of spacers, and adverse environmental exposures such as tobacco smoke exposure, is essential. There are no disease-modifying therapies, so therapy is symptomatic. This paper reviews recent advances in treatment, including new data on the place of leukotriene receptor antagonists, prednisolone for acute attacks of wheeze, and antibiotics, based on new attempts to understand the underlying pathology in a way that is clinically practical.

Maternal Vitamin D Supplementation for the Prevention of Respiratory Tract Infections in Offspring: A Meta-Analysis

BACKGROUND

Vitamin D may enhance immune system function and provide a protective effect against infections. Feto-maternal circulation plays an important role in supplying the developing fetus with nutrients and antibodies for its development and health during pregnancy and for its early years of life after birth. This meta-analysis aimed to determine the effectiveness of maternal vitamin D supplementation in preventing respiratory tract infections (RTIs) in children.

METHODS

We searched the Central and MEDLINE databases and went through all the reference lists in the related articles. We also searched for ongoing trials at http://www.who.int/ictrp/en/ and www.clinicaltrials.gov. Randomized controlled trials comparing vitamin D supplementation with a placebo or no treatment in pregnant women published in the English language up to March 2019 were included. Two reviewers extracted data independently using a predefined protocol and assessed the risk of bias using the Cochrane risk of bias tool, with differences agreed upon by consensus. The predefined primary outcome was the number of offspring who had RTIs. The secondary outcome was the presence of measurable serum immunoglobulin E levels.

RESULTS

Three trials involving 3,224 participants (mother-child pairs) met the inclusion criteria and were included in this review. The present analysis reported that maternal supplementation with vitamin D had no effect on RTIs among children (n=1,486 offspring; risk ratio, 0.95; 95% confidence interval, 0.82-1.11; random effects; I2 statistics, 0%).

CONCLUSION

Maternal vitamin D supplementation had no effect on RTIs in children. Therefore, consideration of other prevention methods in this regard is recommended.

[The effectiveness of complex drugs in the treatment of acute rhinitis]

Purpose of the study. Generalization of data on the value of alternative and additional treatment of acute infectious rhinitis with Korizalia.

MATERIAL AND METHODS

The material of scientific publications included in the Cochrane Library, information bases of the RSCI, MEDLINE, PubMed was used as a data source. The choice of material was carried out using the key words: colds, acute rhinitis, herbal medicine, homeopathic remedies.

RESULTS

Analysis of published clinical trial descriptions suggests the potential value of homeopathic medicines, in particular Korizalia, in improving the effectiveness of the treatment of acute rhinitis. The use of Korizalia in acute infectious rhinitis was more effective in relation to the main symptoms of ARI compared with placebo.

CONCLUSION

The lack of optimal drugs for the etiotropic treatment of viral acute respiratory infections determines the relevance of alternative and complementary methods of treatment using drugs of natural origin. The drug Korizalia can be used for acute respiratory infections (acute infectious rhinitis) as an alternative drug or in combination with other drugs.

Single-use device endoscopy for the diagnosis of acute bacterial rhinosinusitis in primary care: A pilot and feasibility study

OBJECTIVE

Antibiotics are largely overprescribed for acute rhinosinusitis in primary care, mainly due to the lack of diagnostic tests to confirm or rule out bacterial infection. The study objective was to assess the on-site applicability and safety of the newly developed JGG endoscope^® for the diagnosis of acute bacterial rhinosinusitis in primary care.

DESIGN

Five Swiss primary care centres and one university-affiliated ENT unit participated in this single-arm pilot study.

PARTICIPANTS

Adults with acute suspected bacterial rhinosinusitis. The newly developed JGG endoscope^® , which is attached to a pocket otoscope, was used to inspect after local anaesthesia the nasal cavity and middle meatus and to gain material for bacterial culture from paranasal sinuses draining ostium.

MAIN OUTCOME MEASURES

Applicability and safety.

RESULTS

The visualisation of the middle meatus was successful in 16 of 21 patients (13 in both sides and three in one side), and unclear or unsuccessful in five patients. Sample collection from the middle meatus was successful in 10 patients (six on both and four on one side) and unclear or unsuccessful in the remaining patients. Only one culture-confirmed bacterial rhinosinusitis and 11 PCR-confirmed viral infections were identified from collected samples. After a 2-week follow-up, no serious adverse events were observed.

CONCLUSIONS

The on-site use of the JGG endoscope® in daily primary care routine is feasible and safe and was well accepted by the trial physicians and patients (assessed with structured questionnaires). The JGG endoscope® may support general practitioners to differentiate between bacterial and viral rhinosinusitis.

The early use of Antibiotics for at Risk CHildren with InfluEnza-like illness (ARCHIE): a double-blind randomised placebo-controlled trial

INTRODUCTION

The UK government stockpiles co-amoxiclav to treat bacterial complications during influenza pandemics. This pragmatic trial examines whether early co-amoxiclav use reduces re-consultation due to clinical deterioration in "at risk" children presenting with influenza-like illness (ILI) in primary or ambulatory care.

METHODS

"At risk" children aged 6 months to 12 years presenting within f5 days of ILI onset were randomly assigned to oral co-amoxiclav 400/57 or placebo twice daily for 5 days (dosing based on age±weight). "At risk" groups included children with respiratory, cardiac, and neurological conditions. Randomisation was stratified by region and used a non-deterministic minimisation algorithm to balance age and current seasonal influenza vaccination status. Our target sample size was 650 children, which would have allowed us to detect a reduction in the proportion of children re-consulting due to clinical deterioration from 40% to 26% with 90% power and 5% two-tailed alpha error, including allowance for 25% loss to follow-up and an inflation factor of 1.041. Participants, caregivers and investigators were blinded to treatment allocation. Intention-to-treat analysis included all randomised participants with primary outcome data on re-consultation due to clinical deterioration within 28 days. Safety analysis included all randomised participants.

TRIAL REGISTRATION

ISRCTN 70714783. EudraCT 2013-002822-21.

RESULTS

We recruited 271 children between February 11, 2015 and April 20, 2018. Primary outcome data were available for 265 children. Only 61/265 children (23.0%) re-consulted due to clinical deterioration. No evidence of a treatment effect was observed for re-consultation due to clinical deterioration (co-amoxiclav 33/133 (24.8%), placebo 28/132 (21.2%), adjusted risk ratio [RR] 1.16, 95% confidence interval [CI] 0.75 to 1.80). There was also no evidence of a difference between groups in the proportion of children for whom one or more adverse events were reported (co-amoxiclav 32/136 (23.5%), placebo 22/135 (16.3%), adjusted RR 1.45, 95% CI 0.90 to 2.34). Sixty-six adverse events were reported in total (co-amoxiclav n=37, placebo n=29). Nine serious adverse events were reported per group; none were considered related to study medication.

CONCLUSION

Our trial did not find evidence that treatment with co-amoxiclav reduces risk of re-consultation due to clinical deterioration in "at risk" children who present early with ILI during influenza season. Our findings therefore do not support early co-amoxiclav use in children with seasonal ILI.

Vitamin C as a Supplementary Therapy in Relieving Symptoms of the Common Cold: A Meta-Analysis of 10 Randomized Controlled Trials

Aim

To investigate whether vitamin C performs well as a supplemental treatment for common cold.

Method

After systematically searching through the National Library of Medicine (PubMed), Cochrane Library, Elsevier, China National Knowledge Infrastructure (CNKI), VIP databases, and Wanfang databases, 10 randomized controlled trials were selected for our meta-analysis with RevMan 5.3 software. Published in China, all 10 studies evaluated the effect of combined vitamin C and antiviral therapy for the treatment of common cold.

Results

The total efficacy (RR = 1.27, 95% CI (1.08, 1.48), P = 0.003), the time for symptom amelioration (MD = −15.84, 95% CI (-17.02, -14.66), P < 0.00001), and the time for healing (I, 95% CI (-14.98, -4.22), P = 0.0005) were better with vitamin C supplementation than with antiviral therapy alone.

Conclusions

Vitamin C could be used as a supplementary therapy along with antiviral regimens to relieve patients from the symptoms of common cold.

Patients' and Clinicians' Perceptions of Antibiotic Prescribing for Upper Respiratory Infections in the Acute Care Setting

Reducing inappropriate prescribing is key to mitigating antibiotic resistance, particularly in acute care settings. Clinicians' prescribing decisions are influenced by their judgments and actual or perceived patient expectations. Fuzzy trace theory predicts that patients and clinicians base such decisions on categorical gist representations that reflect the bottom-line understanding of information about antibiotics. However, due to clinicians' specialized training, the categorical gists driving clinicians' and patients' decisions might differ, which could result in mismatched expectations and inefficiencies in targeting interventions. We surveyed clinicians and patients from 2 large urban academic hospital emergency departments (EDs) and a sample of nonpatient subjects regarding their gist representations of antibiotic decisions, as well as relevant knowledge and expectations. Results were analyzed using exploratory factor analysis (EFA) and multifactor regression. In total, 149 clinicians (47% female; 74% white), 519 online subjects (45% female; 78% white), and 225 ED patients (61% female; 56% black) completed the survey. While clinicians demonstrated greater knowledge of antibiotics and concern about side effects than patients, the predominant categorical gist for both patients and clinicians was "why not take a risk," which compares the status quo of remaining sick to the possibility of benefit from antibiotics. This gist also predicted expectations and prior prescribing in the nonpatient sample. Other representations reflected the gist that "germs are germs" conflating bacteria and viruses, as well as perceptions of side effects and efficacy. Although individually rational, reliance on the "why not take a risk" representation can lead to socially suboptimal results, including antibiotic resistance and individual patient harm due to adverse events. Changing this representation could alter clinicians' and patients' expectations, suggesting opportunities to reduce overprescribing.

Nasopharyngeal Reservoir of Bacterial Otitis Media and Sinusitis Pathogens in Adults during Wellness and Viral Respiratory Illness

Background

The carriage rate of pathogenic bacteria in the nasopharynx (NP) was determined using three separate techniques for obtaining samples.

Methods

The NP of 99 healthy adults was sampled with (1) nasal swab, (2) oral swab, and (3) nasal aspiration; 49 adults with common cold were sampled with an oral swab and nasal aspiration. Three selective agars were used to detect Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis.

Results

Seventy-three percent of healthy adults and 74% of cold sufferers had at least one pathogen detected in the NP. Detection rates were 65% (oral NP swab), 38% (catheter aspiration), and 28% (nasal swab; p < 0.001). Carriage rates for S. pneumoniae, M. catarrhalis, and H. influenzae were 45, 33, and 30%, respectively. Both a nasal and an oral sample were required for optimal detection.

Conclusion

Bacterial pathogens were present in the NP of three-quarters of adults during wellness and during colds.

Antibiotics for acute bronchitis

BACKGROUND

The benefits and risks of antibiotics for acute bronchitis remain unclear despite it being one of the most common illnesses seen in primary care.

OBJECTIVES

To assess the effects of antibiotics in improving outcomes and to assess adverse effects of antibiotic therapy for people with a clinical diagnosis of acute bronchitis.

SEARCH METHODS

We searched CENTRAL 2016, Issue 11 (accessed 13 January 2017), MEDLINE (1966 to January week 1, 2017), Embase (1974 to 13 January 2017), and LILACS (1982 to 13 January 2017). We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 5 April 2017.

SELECTION CRITERIA

Randomised controlled trials comparing any antibiotic therapy with placebo or no treatment in acute bronchitis or acute productive cough, in people without underlying pulmonary disease.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and assessed trial quality.

MAIN RESULTS

We did not identify any new trials for inclusion in this 2017 update. We included 17 trials with 5099 participants in the primary analysis. The quality of trials was generally good. At follow-up there was no difference in participants described as being clinically improved between the antibiotic and placebo groups (11 studies with 3841 participants, risk ratio (RR) 1.07, 95% confidence interval (CI) 0.99 to 1.15). Participants given antibiotics were less likely to have a cough (4 studies with 275 participants, RR 0.64, 95% CI 0.49 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) 6) and a night cough (4 studies with 538 participants, RR 0.67, 95% CI 0.54 to 0.83; NNTB 7). Participants given antibiotics had a shorter mean cough duration (7 studies with 2776 participants, mean difference (MD) -0.46 days, 95% CI -0.87 to -0.04). The differences in presence of a productive cough at follow-up and MD of productive cough did not reach statistical significance.Antibiotic-treated participants were more likely to be improved according to clinician's global assessment (6 studies with 891 participants, RR 0.61, 95% CI 0.48 to 0.79; NNTB 11) and were less likely to have an abnormal lung exam (5 studies with 613 participants, RR 0.54, 95% CI 0.41 to 0.70; NNTB 6). Antibiotic-treated participants also had a reduction in days feeling ill (5 studies with 809 participants, MD -0.64 days, 95% CI -1.16 to -0.13) and days with impaired activity (6 studies with 767 participants, MD -0.49 days, 95% CI -0.94 to -0.04). The differences in proportions with activity limitations at follow-up did not reach statistical significance. There was a significant trend towards an increase in adverse effects in the antibiotic group (12 studies with 3496 participants, RR 1.20, 95% CI 1.05 to 1.36; NNT for an additional harmful outcome 24).

AUTHORS' CONCLUSIONS

There is limited evidence of clinical benefit to support the use of antibiotics in acute bronchitis. Antibiotics may have a modest beneficial effect in some patients such as frail, elderly people with multimorbidity who may not have been included in trials to date. However, the magnitude of this benefit needs to be considered in the broader context of potential side effects, medicalisation for a self limiting condition, increased resistance to respiratory pathogens, and cost of antibiotic treatment.

Microorganisms Causing Community-Acquired Acute Bronchitis: The Role of Bacterial Infection

BACKGROUND

Although acute bronchitis is quite common, there is relatively limited information regarding the microorganisms that are involved in this illness.

METHODS

We performed a prospective study of acute bronchitis at 31 hospitals and clinics in Korea from July 2011 to June 2012. Sputum specimens were collected for polymerase chain reaction (PCR) and culture of microorganisms.

RESULTS

Of the 811 enrolled patients, 291 had acceptable sputum specimens that were included for analysis of the etiologic distribution. With multiplex PCR testing, viruses were identified in 36.1% (105/291), most commonly rhinovirus (25.8%) and coronavirus (3.8%). Typical bacteria were isolated in 126/291 (43.3%) patients. Among these patients Haemophilus influenzae (n = 39) and Streptococcus pneumoniae (n = 30) were isolated most commonly; atypical bacteria were identified in 44 (15.1%) patients. Bacteria-only, virus-only, and mixed infections (bacteria plus virus) accounted for 36.7% (98/291), 17.2% (50/291), and 18.9% (55/291) of infections, respectively. In particular, 52.4% of patients with viral infection had a concurrent bacterial infection, and rhinovirus was the most common virus in mixed infections (40/55). Additionally, infections with typical bacteria were more common in patients with chronic lung disease (p = 0.029), and typical bacterial infections showed a trend towards a higher prevalence with older age (p = 0.001).

CONCLUSIONS

Bacteria were associated with almost half of community-acquired acute bronchitis cases. Additional studies are required to further illuminate the role of bacteria and to identify patient groups most likely to benefit from antibiotic treatment.

Dynamics of Nasopharyngitis in Children

PURPOSE: Our goal was to characterize the dynamics and bacterial interaction of the aerobic and anaerobic flora of nasal discharge of children at different stages of uncomplicated nasopharyngitis.

METHODS AND PATIENTS: Serial semiquantitative nasopharyngeal (NP) and quantitative nasal discharge (ND) cultures were taken every 3 to 5 days from 20 children in whom purulent discharge eventually developed (group 1), and a single culture was obtained from a group of 20 who had only clear discharge (group 2).

RESULTS: Aerobic and anaerobic bacteria were isolated from all NP cultures. Bacterial growth was present in 8 (40%) NDs of group 2. Only 7 (35%) of the clear NDs of group 1 showed bacterial growth; the number increased to 14 (70%) at the mucoid stage and 20 (100%) at the purulent stage. It declined to 6 (30%) at the final clear stage. The number of species and total number of organisms increased in the NDs of group 1. Group 1 patients had higher recovery rates of Streptococcus pneumoniae and Haemophilus influenzae in their NP cultures than group 2 patients (P > 0.05). During the purulent stage, Peptostreptococcus species were isolated in 15 (75%), Fusobacterium species in 10 (50%), Prevotella species in 9 (45%), H influenzae in 8 (40%), S pneumoniae in 6 (30%), and β-hemolytic streptococci in 5 (25%) of group 1 NDs. This was higher than their recovery in the clear stages of both groups and the mucoid stage of group 1. A total of 8 organisms capable of interfering with the growth of potential pathogens were isolated from the NPs of group 1, as compared with 35 from group 2 ( P > 0.001).

CONCLUSIONS: The development of purulent nasopharyngitis is associated with the pre-existing presence of potential pathogens and the absence of interfering organisms.

Corticosteroids for the common cold

BACKGROUND

The common cold is a frequent illness, which, although benign and self limiting, results in many consultations to primary care and considerable loss of school or work days. Current symptomatic treatments have limited benefit. Corticosteroids are an effective treatment in other upper respiratory tract infections and their anti-inflammatory effects may also be beneficial in the common cold. This updated review has included one additional study.

OBJECTIVES

To compare corticosteroids versus usual care for the common cold on measures of symptom resolution and improvement in children and adults.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 4), which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects (DARE) (2015, Issue 2), NHS Health Economics Database (2015, Issue 2), MEDLINE (1948 to May week 3, 2015) and EMBASE (January 2010 to May 2015).

SELECTION CRITERIA

Randomised, double-blind, controlled trials comparing corticosteroids to placebo or to standard clinical management.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We were unable to perform meta-analysis and instead present a narrative description of the available evidence.

MAIN RESULTS

We included three trials (353 participants). Two trials compared intranasal corticosteroids to placebo and one trial compared intranasal corticosteroids to usual care; no trials studied oral corticosteroids. In the two placebo-controlled trials, no benefit of intranasal corticosteroids was demonstrated for duration or severity of symptoms. The risk of bias overall was low or unclear in these two trials. In a trial of 54 participants, the mean number of symptomatic days was 10.3 in the placebo group, compared to 10.7 in those using intranasal corticosteroids (P value = 0.72). A second trial of 199 participants reported no significant differences in the duration of symptoms. The single-blind trial in children aged two to 14 years, who were also receiving oral antibiotics, had inadequate reporting of outcome measures regarding symptom resolution. The overall risk of bias was high for this trial. Mean symptom severity scores were significantly lower in the group receiving intranasal steroids in addition to oral amoxicillin. One placebo-controlled trial reported the presence of rhinovirus in nasal aspirates and found no differences. Only one of the three trials reported on adverse events; no differences were found. Two trials reported secondary bacterial infections (one case of sinusitis, one case of acute otitis media; both in the corticosteroid groups). A lack of comparable outcome measures meant that we were unable to combine the data.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of intranasal corticosteroids for symptomatic relief from the common cold. However, there were only three trials, one of which was very poor quality, and there was limited statistical power overall. Further large, randomised, double-blind, placebo-controlled trials in adults and children are required to answer this question.

Role of Nasopharyngeal Bacteria and Respiratory Viruses in Acute Symptoms of Young Children

BACKGROUND

The spectrum of acute symptoms in young outpatient children with respiratory tract infection (RTI) is variable, and it cannot be explained by the diagnosis of acute otitis media (AOM) versus uncomplicated RTI. We studied that the variation of symptoms is explained by the nasopharyngeal bacteria and/or respiratory viruses.

METHODS

Children aged 6-35 months with acute symptoms with AOM (n = 201) or without AOM (n = 225) were eligible in this cross-sectional study. We analyzed their nasopharyngeal samples for pathogenic bacteria by culture and for respiratory viruses by polymerase chain reaction. We surveyed 17 symptoms (fever, respiratory, ear related, nonspecific, gastrointestinal) with a structured questionnaire.

RESULTS

Fever had a positive association with influenza viruses [odds ratio (OR): 6.61; 95% confidence interval (CI): 1.66-26.27], human metapneumovirus (OR: 3.84; 95% CI: 1.25-11.77), coronaviruses (OR: 3.45; 95% CI: 1.53-7.75) and parainfluenza viruses (OR: 2.18; 95% CI: 1.07-4.47). Rhinitis (OR: 5.07; 95% CI: 1.93-13.36), nasal congestion (OR: 2.03; 95% CI: 1.25-3.31) and cough (OR: 1.91; 95% CI: 1.15-3.17) had positive associations with Moraxella catarrhalis. Furthermore, cough had a positive association with respiratory syncytial virus (OR: 7.20; 95% CI: 1.59-32.71) and parainfluenza viruses (OR: 2.79; 95% CI: 1.02-7.69).

CONCLUSIONS

The variation of acute symptoms in young children may be influenced by both nasopharyngeal bacteria and respiratory viruses. Our results showed a strong association between fever and respiratory viruses; rhinitis, nasal congestion and cough were associated with M. catarrhalis in the presence of viruses. Further studies are required to determine the possible synergistic role of M. catarrhalis in symptoms of RTI.

Common harms from amoxicillin: a systematic review and meta-analysis of randomized placebo-controlled trials for any indication

BACKGROUND

When prescribing antibiotics for common indications, clinicians need information about both harms and benefits, information that is currently available only from observational studies. We quantified the common harms of the most frequently prescribed antibiotic, amoxicillin, from randomized placebo-controlled trials.

METHODS

For this systematic review, we searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials, without language restriction, for any randomized, participant-blinded, placebo-controlled trials of amoxicillin or amoxicillin-clavulanic acid for any indication, in any setting. Our main outcome was any reported adverse event.

RESULTS

Of 730 studies identified, we included 45 trials: 27 involving amoxicillin, 17 involving amoxicillin-clavulanic acid and 1 involving both. The indications for antibiotic therapy were variable. The risk of bias was low, although only 25 trials provided data suitable for assessment of harms, which suggested under-reporting. Diarrhea was attributed to amoxicillin only in the form of amoxicillin-clavulanic acid (Peto odds ratio [OR] 3.30, 95% confidence interval [CI] 2.23-4.87). The OR for candidiasis (3 trials) was significantly higher (OR 7.77, 95% CI 2.23-27.11). Rashes, nausea, itching, vomiting and abnormal results on liver function tests were not significantly increased. The results were not altered by sensitivity analyses, nor did funnel plots suggest publication bias. The number of courses of antibiotics needed to harm was 10 (95% CI 6-17) for diarrhea with amoxicillin-clavulanic acid and 27 (95% CI 24-42) for candidiasis with amoxicillin (with or without clavulanic acid).

INTERPRETATION

Diarrhea was caused by use of amoxicillin-clavulanic acid, and candidiasis was caused by both amoxicillin and amoxicillin-clavulanic acid. Harms were poorly reported in most trials, and their true incidence may have been higher than reported. Nevertheless, these rates of common harms associated with amoxicillin therapy may inform decisions by helping clinicians to balance harms against benefits.

The role of microbes in the pathogenesis of acute rhinosinusitis in young adults

Objectives/Hypothesis

To provide information on the course of acute rhinosinusitis (ARS) with sequential nasal and paranasal microbiological data and their correlation with clinical outcomes.

Study Design

We conducted a prospective cohort study among 50 Finnish military recruits with clinically diagnosed ARS in spring 2012.

Methods

We collected symptom, nasal endoscopy, and cone‐beam CT (CBCT) scores during the early (2–3 days from onset) and later phases (9–10 days). We took viral samples from the nasopharynx (multiplex respiratory virus polymerase chain reaction [PCR]), bacterial culture from the middle meatus during both phases, and both viral and bacterial samples from the maxillary sinus aspirate (respiratory virus PCR, bacterial culture, broad‐range bacterial PCR) during the later phase. Cilia destruction and microbial biofilms were sought from a nasal mucosal biopsy sample.

Results

We found that 42 (84%) of the subjects had viral nucleic acid in the nasopharynx during ARS. During the early phase, 28 (56%) of the subjects had nontypeable H. influenzae (NTHi) in the middle meatus, which was associated with wider paranasal mucosal changes in CBCT scans and increased symptoms during the study period. After 9 to 10 days from the onset, NTHi was found in the maxillary sinus in eight subjects (40%, 8/20) and led to prolonged symptoms. Bacterial biofilm was ruled out in 39 (78%) cases, and cilia destruction did not correlate with microbiological or clinical outcomes.

Conclusion

Nasal and paranasal H. influenzae coinfection during viral infection may modify the symptoms and the extent of sinonasal mucosal disease observed in CBCT scans already from the beginning of the ARS episode.

Level of Evidence

N/A. Laryngoscope, 125:E1–E7, 2015

Predicting response to antimicrobial therapy in children with acute sinusitis

OBJECTIVE

To determine prognostic factors that independently predict response to antimicrobial therapy in children with acute sinusitis.

STUDY DESIGN

A total of 206 children meeting a priori clinical criteria for acute sinusitis who were prescribed antimicrobial therapy by their primary care provider were included. The severity of symptoms in the 8-12 days after treatment was initiated was followed with the use of a validated scale. We examined the univariate and multivariate association between factors present at the time of diagnosis (symptoms, signs, nasopharyngeal culture result, radiograph results) and time to resolution of symptoms. This study was conducted 8-10 years after the 7-valent pneumococcal conjugate vaccination was introduced but before introduction of the 13-valent pneumococcal conjugate vaccination.

RESULTS

Children with proven nasopharyngeal colonization with Streptococcus pneumoniae improved more rapidly (6.5 vs 8.5 median days to symptom resolution) than those who were not colonized with S pneumoniae. Age and radiograph findings did not predict time to symptom resolution.

CONCLUSIONS

In children with acute sinusitis, proven nasopharyngeal colonization with S pneumoniae at presentation independently predicted time to symptom resolution. Future randomized, placebo-controlled trials could investigate the usefulness of testing for the presence of nasopharyngeal pathogens as a predictor of response to treatment.

Antibiotics for acute bronchitis

BACKGROUND

The benefits and risks of antibiotics for acute bronchitis remain unclear despite it being one of the most common illnesses seen in primary care.

OBJECTIVES

To assess the effects of antibiotics in improving outcomes and assess adverse effects of antibiotic therapy for patients with a clinical diagnosis of acute bronchitis.

SEARCH METHODS

We searched CENTRAL 2013, Issue 12, MEDLINE (1966 to January week 1, 2014), EMBASE (1974 to January 2014) and LILACS (1982 to January 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antibiotic therapy with placebo or no treatment in acute bronchitis or acute productive cough, in patients without underlying pulmonary disease.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and assessed trial quality.

MAIN RESULTS

Seventeen trials with 3936 participants were included in the primary analysis. The quality of trials was generally good. There was limited evidence to support the use of antibiotics in acute bronchitis. At follow-up, there was no difference in participants described as being clinically improved between antibiotic and placebo groups (11 studies with 3841 participants, risk ratio (RR) 1.07, 95% confidence interval (CI) 0.99 to 1.15; number needed to treat for an additional beneficial outcome (NNTB) 22. Participants given antibiotics were less likely to have a cough (four studies with 275 participants, RR 0.64, 95% CI 0.49 to 0.85; NNTB 6); have a night cough (four studies with 538 participants, RR 0.67, 95% CI 0.54 to 0.83; NNTB 7) and a shorter mean cough duration (seven studies with 2776 participants, mean difference (MD) -0.46 days, 95% CI -0.87 to -0.04). The differences in presence of a productive cough at follow-up and MD of productive cough did not reach statistical significance.Antibiotic-treated patients were more likely to be unimproved according to clinician's global assessment (six studies with 891 participants, RR 0.61, 95% CI 0.48 to 0.79; NNTB 25); have an abnormal lung exam (five studies with 613 participants, RR 0.54, 95% CI 0.41 to 0.70; NNTB 6); have a reduction in days feeling ill (five studies with 809 participants, MD -0.64 days, 95% CI -1.16 to -0.13) and a reduction in days with limited activity (six studies with 767 participants MD -0.49 days, 95% CI -0.94 to -0.04). The differences in proportions with activity limitations at follow-up did not reach statistical significance. There was a significant trend towards an increase in adverse effects in the antibiotic group (12 studies with 3496 participants) (RR 1.20, 95% CI 1.05 to 1.36; NNT for an additional adverse effect 5).

AUTHORS' CONCLUSIONS

There is limited evidence to support the use of antibiotics in acute bronchitis. Antibiotics may have a modest beneficial effect in some patients such as frail, elderly people with multimorbidity who may not have been included in trials to date. However, the magnitude of this benefit needs to be considered in the broader context of potential side effects, medicalisation for a self-limiting condition, increased resistance to respiratory pathogens and cost of antibiotic treatment.

Detection of viral and bacterial pathogens in acute respiratory infections

OBJECTIVES

The role of bacteria in acute respiratory illnesses (ARI) of adults and interactions with viral infections is incompletely understood. This study tested the hypothesis that bacterial co-infection during ARI adds to airway inflammation and illness severity.

METHODS

Two groups of 97 specimens each were randomly selected from multiplex-PCR identified virus-positive and virus-negative nasal specimens obtained from adults with new onset ARI, and 40 control specimens were collected from healthy adults. All specimens were analyzed for Haemophilus influenzae(HI), Moraxella catarrhalis(MC) and Streptococcus pneumoniae(SP) by quantitative-PCR. General linear models tested for relationships between respiratory pathogens, biomarkers (nasal wash neutrophils and CXCL8), and ARI-severity.

RESULTS

Nasal specimens from adults with ARIs were more likely to contain bacteria (37% overall; HI = 28%, MC = 14%, SP = 7%) compared to specimens from healthy adults (5% overall; HI = 0%, MC = 2.5%, SP = 2.5%; p < 0.001). Among ARI specimens, bacteria were more likely to be detected among virus-negative specimens compared to virus-positive specimens (46% vs. 27%; p = 0.0046). The presence of bacteria was significantly associated with increased CXCL8 and neutrophils, but not increased symptoms.

CONCLUSION

Pathogenic bacteria were more often detected in virus-negative ARI, and also associated with increased inflammatory biomarkers. These findings suggest the possibility that bacteria may augment virus-induced ARI and contribute to airway inflammation.

The TARGET cohort study protocol: a prospective primary care cohort study to derive and validate a clinical prediction rule to improve the targeting of antibiotics in children with respiratory tract illnesses

Background

Children with respiratory tract infections are the single most frequent patient group to make use of primary care health care resources. The use of antibiotics remains highly prevalent in young children, but can lead to antimicrobial resistance as well as reinforcing the idea that parents should re-consult for similar symptoms. One of the main drivers of indiscriminate antimicrobial use is the lack of evidence for, and therefore uncertainty regarding, which children are at risk of poor outcome. This paper describes the protocol for the TARGET cohort study, which aims to derive and validate a clinical prediction rule to identify children presenting to primary care with respiratory tract infections who are at risk of hospitalisation.

Methods/design

The TARGET cohort study is a large, multicentre prospective observational study aiming to recruit 8,300 children aged ≥3 months and <16 years presenting to primary care with a cough and respiratory tract infection symptoms from 4 study centres (Bristol, London, Oxford and Southampton). Following informed consent, symptoms, signs and demographics will be measured. In around a quarter of children from the Bristol centre, a single sweep, dual bacterial-viral throat swab will be taken and parents asked to complete a symptom diary until the child is completely well or for 28 days, whichever is sooner. A review of medical notes including clinical history, re-consultation and hospitalisations will be undertaken. Multivariable logistic regression will be used to identify the independent clinical predictors of hospitalisation as well as the prognostic significance of upper respiratory tract microbes. The clinical prediction rule will be internally validated using various methods including bootstrapping.

Discussion

The clinical prediction rule for hospitalisation has the potential to help identify a small group of children for hospitalisation and a much larger group where hospitalisation is very unlikely and antibiotic prescribing would be less warranted. This study will also be the largest natural history study to date of children presenting to primary care with acute cough and respiratory tract infections, and will provide important information on symptom duration, re-consultations and the microbiology of the upper respiratory tract.

Bacteria in the nose of young adults during wellness and rhinovirus colds: detection by culture and microarray methods in 100 nasal lavage specimens

BACKGROUND

Patients  with  viral respiratory infections/viral rhinitis/common colds are often treated with antibiotic; however, there is little information on whether or how bacterial microbiota in the nose and nasopharynx might influence the course of viral illnesses.

METHODS

To initiate investigation of possible interaction between viral respiratory illness and microbiota of the nose/nasopharynx, we used microarray technology to examine 100 nasal lavage fluid (NLF) samples for bacterial species and recorded the bacterial titer of culturable bacteria. Rhinovirus illnesses were induced by self-inoculation using the "finger to nose or eye natural transmission route" in 10 otherwise healthy young adults. NLF samples were collected during wellness and at specific time points following experimental rhinovirus inoculation.

RESULTS

The rhinovirus infection rate was 70%. There were no consistent changes in the prevalence of different bacterial species determined by microarray and bacterial titer by culture methods during rhinovirus infection. The bacterial profile in NLF samples showed high variability between volunteers but low variability in multiple NLFs obtained before and following infection from the same volunteer. Streptococcus epidermidis/coagulase-negative staphylococcus (CNS) were identified in all 10 subjects. One or more bacterial sinus/otitis pathogens were identified by microarray in 6 of the 10 volunteers. The microarray identified a few bacteria not included in traditional bacterial cultures.

CONCLUSION

Our pilot study showed that each of the 10 volunteers had a unique bacterial profile in the nose by microarray analysis and that bacterial load did not change during experimental rhinovirus colds. Larger scale studies are warranted.

Antibiotics for the common cold and acute purulent rhinitis

BACKGROUND

It has long been believed that antibiotics have no role in the treatment of common colds yet they are often prescribed in the belief that they may prevent secondary bacterial infections.

OBJECTIVES

To determine the efficacy of antibiotics compared with placebo for reducing general and specific nasopharyngeal symptoms of acute upper respiratory tract infections (URTIs) (common colds).To determine if antibiotics have any influence on the outcomes for acute purulent rhinitis and acute clear rhinitis lasting less than 10 days before the intervention.To determine whether there are significant adverse outcomes associated with antibiotic therapy for participants with a clinical diagnosis of acute URTI or acute purulent rhinitis.

SEARCH METHODS

For this 2013 update we searched CENTRAL 2013, Issue 1, MEDLINE (March 2005 to February week 2, 2013), EMBASE (January 2010 to February 2013), CINAHL (2005 to February 2013), LILACS (2005 to February 2013) and Biosis Previews (2005 to February 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antibiotic therapy against placebo in people with symptoms of acute upper respiratory tract infection for less than seven days, or acute purulent rhinitis less than 10 days in duration.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed trial quality and extracted data.

MAIN RESULTS

This updated review included 11 studies. Six studies contributed to one or more analyses related to the common cold, with up to 1047 participants. Five studies contributed to one or more analyses relating to purulent rhinitis, with up to 791 participants. One study contributed only to data on adverse events and one met the inclusion criteria but reported only summary statistics without providing any numerical data that could be included in the meta-analyses. Interpretation of the combined data is limited because some studies included only children, or only adults, or only males; a wide range of antibiotics were used and outcomes were measured in different ways. There was a moderate risk of bias because of unreported methods details or because an unknown number of participants were likely to have chest or sinus infections.Participants receiving antibiotics for the common cold did no better in terms of lack of cure or persistence of symptoms than those on placebo (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.59 to 1.51, (random-effects)), based on a pooled analysis of six trials with a total of 1047 participants. The RR of adverse effects in the antibiotic group was 1.8, 95% CI 1.01 to 3.21, (random-effects). Adult participants had a significantly greater risk of adverse effects with antibiotics than with placebo (RR 2.62, 95% CI 1.32 to 5.18) (random-effects) while there was no greater risk in children (RR 0.91, 95% CI 0.51 to 1.63).The pooled RR for persisting acute purulent rhinitis with antibiotics compared to placebo was 0.73 (95% CI 0.47 to 1.13) (random-effects), based on four studies with 723 participants. There was an increase in adverse effects in the studies of antibiotics for acute purulent rhinitis (RR 1.46, 95% CI 1.10 to 1.94).

AUTHORS' CONCLUSIONS

There is no evidence of benefit from antibiotics for the common cold or for persisting acute purulent rhinitis in children or adults. There is evidence that antibiotics cause significant adverse effects in adults when given for the common cold and in all ages when given for acute purulent rhinitis. Routine use of antibiotics for these conditions is not recommended.

Earache

Earache, a common emergency department presentation, may be caused by a variety of conditions, some distant from the ear. This article discusses the diagnosis and treatment of acute otitis media, otitis media with effusion, otitis externa, otitis media with ruptured tympanic membrane or tympanostomy tubes, malignant otitis externa, mastoiditis and petrositis, traumatic ruptured tympanic membrane, cerumen impactions, and foreign bodies in the ears.

Use of nasopharyngeal culture to determine appropriateness of antibiotic therapy in acute bacterial rhinosinusitis

BACKGROUND

Rhinosinusitis is one of the top 5 diagnoses for which an antibiotic is prescribed, often without a clear bacterial etiology. This study evaluated whether nasopharyngeal culture and gram stain could serve as a surrogate for endoscopically obtained middle meatal cultures in directing appropriate therapy for acute bacterial rhinosinusitis (ABRS). This study also investigated the utility of a rapid sinus test screen in differentiating bacterial from nonbacterial rhinosinusitis.

METHODS

Thirty-one adult patients met inclusion criteria for ABRS. Samples were obtained from both the middle meatus and nasopharynx for Gram stain and culture. Nasal mucous samples were tested with a rapid sinus test strip measuring pH, levels of protein, nitrites, and leukocyte esterase.

RESULTS

Sixty-one percent (61%) of nasopharyngeal and 48% of middle meatal samples grew pathogenic bacteria. The concordance rate was 84% between the 2 sites (p = 0.0006). The following pathogenic organisms were detected: Moraxella catarrhalis, Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, and Staphylococcus aureus. For nasopharyngeal samples, reliance on Gram stain alone exhibited a sensitivity of 31% and specificity of 100% and, similarly, for middle meatus samples, 47% and 93%, respectively. The rapid sinus test revealed a sensitivity of 83% and specificity of 7%.

CONCLUSION

Nasopharyngeal and middle meatal cultures exhibited high concordance for pathogenic bacteria. Gram stain exhibited moderate sensitivity and excellent specificity. Nasopharyngeal cultures could provide a viable method, especially in a primary care setting, for determining the appropriateness of antibiotic therapy. The rapid sinus test's lack of specificity precluded its utility in the differentiation between bacterial and nonbacterial rhinosinusitis.

Corticosteroids for the common cold

BACKGROUND

The common cold is a frequent illness, which, although benign and self-limiting, results in many consultations to primary care and considerable loss of school or work days. Current symptomatic treatments have limited benefit. Corticosteroids are an effective treatment in other upper respiratory tract infections and their anti-inflammatory effects may also be beneficial in the common cold.

OBJECTIVES

To compare corticosteroids versus usual care for the common cold on clinical response rates in children and adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 5 which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects (DARE) 2012, Issue 4 and the NHS Health Economics Database 2012, Issue 5; MEDLINE (1948 to May week 2, 2012) and EMBASE (January 2010 to May 2012).

SELECTION CRITERIA

Randomised, double-blind, controlled trials comparing corticosteroids to placebo or to standard clinical management.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We were unable to perform meta-analysis and instead analysed results using narrative description of the available evidence.

MAIN RESULTS

We included two trials (253 participants). Both compared intranasal corticosteroids to placebo; no trials studied oral corticosteroids. No benefit of intranasal corticosteroids was demonstrated for duration or severity of symptoms. In one trial of 54 participants, the number of symptomatic days was 10.3 in the placebo group, compared to 10.7 in those using intranasal corticosteroids (P = 0.72). A second trial of 199 participants reported no significant differences in duration of symptoms. There were no differences reported in terms of: adverse events; complications (one case of sinusitis, one case of acute otitis media, both in corticosteroid groups); presence of rhinovirus in nasal aspirates; or treatment for secondary infections. Neither trial reported our primary outcome measure of percentage of participants with resolution at different time points. A lack of comparable outcome measures meant we were unable to combine the data.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of intranasal corticosteroids for symptomatic relief from the common cold. However, there were only two trials and limited statistical power. Further large randomised placebo-controlled trials in adults and children are required to answer this question.

Bacterial pathogens of acute sinusitis in the osteomeatal complex during common colds and wellness

BACKGROUND

Pathogenic bacteria have been cultured from the osteomeatal complex (OMC) in one-third of adults with apparent acute bacterial sinusitis; however, it is not known whether bacteria are present in the OMC during uncomplicated viral colds in adults.

METHODS

Adult volunteers were recruited for a study during wellness and at the time of acute common cold. Swab cultures were obtained from the OMC and from the nasopharynx by 2 routes (through the nose and through the mouth). Swab eluates were inoculated on selective agars to detect S. pneumoniae, H. influenzae, and M. catarrhalis.

RESULTS

Bacterial pathogens were detected in the OMC more frequently during common colds than during wellness (31% vs 8%, p < 0.008). Pathogens detected in the OMC were always present in the nasopharynx of the subject.

CONCLUSION

Bacterial pathogens are present in the OMC in a subgroup of adult patients with uncomplicated upper respiratory illness/common cold. The nasopharynx appears to be the reservoir for bacterial pathogens in the OMC.

Upper Respiratory Infections and Acute Bronchitis

Upper respiratory infections include the following: uncomplicated upper respiratory infections also known as the “common cold,” acute otitis media, pharyngitis/tonsillitis, and acute sinusitis. These conditions, along with acute bronchitis, are very common illnesses that are commonly seen in outpatient settings and are widely treated with antibiotics. In fact, these conditions are the primary indications for outpatient antibiotic prescriptions. These conditions tend to have overlapping clinical characteristics yet evidence regarding the utility of antimicrobial treatments varies across conditions.

Intervention strategies for an influenza pandemic taking into account secondary bacterial infections

Influenza infections often predispose individuals to consecutive bacterial infections. Both during seasonal and pandemic influenza outbreaks, morbidity and mortality due to secondary bacterial infections can be substantial. With the help of a mathematical model, we investigate the potential impact of such bacterial infections during an influenza pandemic, and we analyze how antiviral and antibacterial treatment or prophylaxis affect morbidity and mortality. We consider different scenarios for the spread of bacteria, the emergence of antiviral resistance, and different levels of severity for influenza infections (1918-like and 2009-like). We find that while antibacterial intervention strategies are unlikely to play an important role in reducing the overall number of cases, such interventions can lead to a significant reduction in mortality and in the number of bacterial infections. Antibacterial interventions become even more important if one considers the--very likely--scenario that during a pandemic outbreak, influenza strains resistant to antivirals emerge. Overall, our study suggests that pandemic preparedness plans should consider intervention strategies based on antibacterial treatment or prophylaxis through drugs or vaccines as part of the overall control strategy. A major caveat for our results is the lack of data that would allow precise estimation of many of the model parameters. As our results show, this leads to very large uncertainty in model outcomes. As we discuss, precise assessment of the impact of antibacterial strategies during an influenza pandemic will require the collection of further data to better estimate key parameters, especially those related to the bacterial infections and the impact of antibacterial intervention strategies.

Use of antibiotics by primary care doctors in Hong Kong

OBJECTIVES

To determine the use of antibiotics by primary care doctors.

METHODS

General practitioners in Hong Kong were invited to fill in a short questionnaire on every patient with infection that they had seen on the first full working day once every three months for four consecutive quarters starting from December 2005.

RESULTS

Forty six primary care doctors took part and a total of 3096 completed questionnaires were returned. The top three diagnoses were upper respiratory tract infection (46.7%), gastrointestinal infection (8.2%) and pharyngitis (7.1%). Thirty percent of patient encounters with infections were prescribed antibiotics but only 5.2% of patient encounters with upper respiratory tract infection (URTI) were prescribed antibiotics. Amino-penicillins were the most commonly used antibiotics while beta-lactam/beta-lactamase inhibitor combinations (BLBLIs) were the second most commonly used antibiotics and they accounted for 16.5% and 14.0% of all antibiotics used respectively. Of all patients or their carers, those who demanded or wished for antibiotics were far more likely to be prescribed antibiotics (Pearson chi-square test, p < 0.0001). Those patients who were attending the doctors for follow-up consultations were also more likely to be prescribed antibiotics (Pearson chi-square test, p < 0.001).

CONCLUSION

The antibiotic prescribing patterns of primary care doctors in Hong Kong are broadly similar to primary care doctors in other developed countries but a relatively low rate of antibiotics is used for URTI.

Accuracy of physician billing claims for identifying acute respiratory infections in primary care

OBJECTIVE

To assess the accuracy of physician billing claims for identifying acute respiratory infections in primary care. STUDY SETTING. Nine primary care physician practices in Montreal, Canada (2002-2005).

STUDY DESIGN

A validation study was carried out to compare diagnoses in 3,526 physician billing claims with diagnoses documented in the corresponding patient medical records.

DATA COLLECTION

In-office medical record abstraction.

PRINCIPAL FINDINGS

Claims had a high positive predictive value (PPV), negative predictive value, and specificity for identifying respiratory infections; however, their sensitivity was below 50 percent. Large variation in sensitivity and PPV was observed among physicians.

CONCLUSIONS

Because claims data are now routinely used to monitor antibiotic prescribing in primary care, future research should determine if acute respiratory infection diagnoses are missing from claims at random, or if bias is present.

Antibiotics for nasopharyngitis are associated with a lower risk of office-based physician visit for acute otitis media within 14 days for 3- to 6-year-old children

OBJECTIVES

This study was designed to analyse factors potentially influencing children's return visits to physicians for symptoms of acute otitis media (AOM) within 14 days after being diagnosed with nasopharyngitis (NP), and the impact of recent antibiotic use.

DESIGN

A controlled population-based pharmaco-epidemiological trial in 3- to 6-year-old children conducted from January to May 2000.

SETTING

Three different geographical regions in France.

PARTICIPANTS

Among 2507 eligible children, 2456 could be analysed and 505 children had 634 office-based physician visits (OBPV) for NP symptoms.

INTERVENTIONS

The statistical associations between antibiotics prescribed for NP and an OBPV for AOM within 14 days in a population-based study were analysed along with risk factors of AOM.

MAIN OUTCOMES MEASURE

Clinical events and antibiotic use.

RESULTS

During the 2 weeks following physician-diagnosed NP, antibiotic use, especially a beta-lactam, significantly decreased the risk of OBPV for AOM in children (odds ratio=0.2; 95% confidence interval=0.09-0.7; P=0.002).

CONCLUSION

Antibiotics prescribed to children for NP seem to protect during the following 2 weeks against the risk of OBPV for AOM. It remains to be determined whether a subgroup at high risk of developing AOM after a viral infection exists and what might be the best strategy to adopt for NP in a national programme of optimal antibiotic use.

WITHDRAWN: Antibiotics for persistent nasal discharge (rhinosinusitis) in children

BACKGROUND

Nasal discharge (rhinosinusitis) is extremely common in children. It is the result of inflammation of the mucosa of the upper respiratory tract, and is usually due to either infection or allergy. Infections may be caused by bacteria.

OBJECTIVES

To determine the effectiveness of antibiotics versus placebo or standard therapy in treating children with persistent nasal discharge (rhinosinusitis) for at least 10 days.

SEARCH STRATEGY

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005) which includes the ARI Group's specialised trials register; MEDLINE (1966 to April Week 3, 2005) EMBASE (1997 to December 2004), and the references of relevant articles were searched. Authors and pharmaceutical companies were contacted.

SELECTION CRITERIA

All randomised controlled trials that compared antibiotics versus placebo or standard therapy. Trials which included the use of other medications were included if all participants were allowed equal access to such medications or if the additional or alternative therapies were regarded as ineffective. Trials that only combined or compared antibiotics with surgery, or sinus puncture and lavage, were not included in the review.

DATA COLLECTION AND ANALYSIS

Data were extracted by a single author for the following eight outcomes: overall clinical failure (primary outcome), failure to cure, failure to improve, clinical improvement, time to resolution, complications, side-effects and bacteriologic failure. For the dichotomous outcome variables of each individual study, proportional and absolute risk reductions were calculated using a modified intention-to-treat analysis. The summary weighted risk ratio and 95% confidence interval (CI) (fixed effect model) were calculated using the inverse of the variance of each study result for weighting (Cochrane statistical package, RevMan version 4.2).

MAIN RESULTS

A total of six studies involving 562 children compared antibiotics with placebo or standard therapy. All studies were randomised but most were still susceptible to bias. Five of the studies were conducted in emergency, allergy or ENT clinics. Four of the studies required children to have x-ray changes consistent with sinusitis. Only the primary outcome (overall clinical failure) was reported in all studies. Around 40% of all randomised children did not have a clinical success documented when reviewed two to six weeks after randomisation. The control event rate varied from to 22 to 71% (mean 46%). The risk ratio estimated using a fixed effects model was 0.75 (95% CI 0.61 to 0.92). There was no evidence of statistical heterogeneity. Side effects (sufficient to cease treatment) occurred in 4 of 189 control group children (four studies). More children treated with antibiotics had side effects (17 of 330), but this difference was not statistically significant (RR 1.75, 95% CI 0.63 to 4.82).

AUTHORS' CONCLUSIONS

For children with persistent nasal discharge or older children with radiographically confirmed sinusitis, the available evidence suggests that antibiotics will reduce the probability of persistence in the short to medium-term. The benefits appear to be modest and around eight children must be treated in order to achieve one additional cure (number needed to treat (NNT) 8, 95% CI 5 to 29). No long term benefits have been documented. These conclusions are based on a small number of small randomised controlled trials and may require revision as additional data become available.

Pinimenthol ointment in patients suffering from upper respiratory tract infections - a post-marketing observational study

In order to gain further experience regarding the tolerability of Pinimenthol ointment(1) in adolescents (> or = 12 years) and adults suffering from upper respiratory tract infections, a post-marketing observational study was performed. In this study, data of 3060 patients were collected (64.9% prospectively over an individual observation period of 5-14 days, 35.1% retrospectively). The prospective documentation also comprised data concerning treatment effects. Sample size of the post-marketing observational study was calculated in the way that adverse drug reactions with an event probability of at least 1:1000 would occur within the study at least once with a probability of 95%. Most patients suffered from cold, acute or chronic bronchitis, bronchial catarrh or hoarseness. Pinimenthol ointment was prescribed to inunction (29.6%), inhalation (17.3%) or inunction and inhalation (53.1%), respectively. The mean duration of study participation was 8.0 +/- 3.4 days. The tolerability was rated as excellent or good by 96.7% of physicians and 95.7% of patients. A total of 22 patients (0.7%) reported adverse drug reactions which mostly affected the skin or mucus membrane and therefore correspond to the expected adverse effects profile of Pinimenthol ointment. The treatment effect was mostly judged as excellent or good (physicians: 88.3%; patients: 88.1%). In conclusion, the study confirms Pinimenthol ointment as a well tolerated therapy option for upper respiratory tract infections in both adolescents and adults.

Study of nasopharyngeal bacterial flora. Variations in nasopharyngeal bacterial flora in schoolchildren and adults when administered antimicrobial agents

Changes in nasopharyngeal bacterial flora in adults with acute upper respiratory tract infection on administration of antimicrobial agents were investigated, and how these changes contrasted with those in children. Many patients with acute sinusitis due to allergies, and patients with malignancy and diabetes mellitus were included in the investigation. The detection rates of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, the major bacteria of acute otitis media (AOM), were 22%, 10%, and 7% respectively, which were significantly lower than those for children. Gram stain examination of nasopharyngeal swab samples showed a significant relation between leukocyte infiltration and the detection amount of S. pneumoniae (P = 0.0086). A significant relation (P = 0.0134) was also observed when H. influenzae was simultaneously detected. No significant change in the three major AOM bacteria present in nasopharyngeal bacterial flora after administration of antimicrobial agents was observed. However, all S. pneumoniae and H. influenzae detected after antimicrobial agent administration had the beta-lactam-resistance gene. It was observed that a significant improvement in leukocyte infiltration occurred 6 to 10 days after antimicrobial agent administration. In contrast, a significant improvement in children was observed at 2 to 5 days. In the adult subjects, this improvement was probably due to spontaneous remission rather than the effect of the antimicrobial agents. Although investigation of the long-term administration of antimicrobial agents was also conducted, its benefits for the patients were not elucidated.

WITHDRAWN: Antibiotics for persistent nasal discharge (rhinosinusitis) in children

BACKGROUND

Nasal discharge (rhinosinusitis) is extremely common in children. It is the result of inflammation of the mucosa of the upper respiratory tract, and is usually due to either infection or allergy. Infections may be caused by bacteria.

OBJECTIVES

To determine the effectiveness of antibiotics versus placebo or standard therapy in treating children with persistent nasal discharge (rhinosinusitis) for at least 10 days.

SEARCH STRATEGY

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005) which includes the ARI Group's specialised trials register; MEDLINE (1966 to April Week 3, 2005) EMBASE (1997 to December 2004), and the references of relevant articles were searched. Authors and pharmaceutical companies were contacted.

SELECTION CRITERIA

All randomised controlled trials that compared antibiotics versus placebo or standard therapy. Trials which included the use of other medications were included if all participants were allowed equal access to such medications or if the additional or alternative therapies were regarded as ineffective. Trials that only combined or compared antibiotics with surgery, or sinus puncture and lavage, were not included in the review.

DATA COLLECTION AND ANALYSIS

Data were extracted by a single author for the following eight outcomes: overall clinical failure (primary outcome), failure to cure, failure to improve, clinical improvement, time to resolution, complications, side-effects and bacteriologic failure. For the dichotomous outcome variables of each individual study, proportional and absolute risk reductions were calculated using a modified intention-to-treat analysis. The summary weighted risk ratio and 95% confidence interval (CI) (fixed effect model) were calculated using the inverse of the variance of each study result for weighting (Cochrane statistical package, RevMan version 4.2).

MAIN RESULTS

A total of six studies involving 562 children compared antibiotics with placebo or standard therapy. All studies were randomised but most were still susceptible to bias. Five of the studies were conducted in emergency, allergy or ENT clinics. Four of the studies required children to have x-ray changes consistent with sinusitis. Only the primary outcome (overall clinical failure) was reported in all studies. Around 40% of all randomised children did not have a clinical success documented when reviewed two to six weeks after randomisation. The control event rate varied from to 22 to 71% (mean 46%). The risk ratio estimated using a fixed effects model was 0.75 (95% CI 0.61 to 0.92). There was no evidence of statistical heterogeneity. Side effects (sufficient to cease treatment) occurred in 4 of 189 control group children (four studies). More children treated with antibiotics had side effects (17 of 330), but this difference was not statistically significant (RR 1.75, 95% CI 0.63 to 4.82).

AUTHORS' CONCLUSIONS

For children with persistent nasal discharge or older children with radiographically confirmed sinusitis, the available evidence suggests that antibiotics will reduce the probability of persistence in the short to medium-term. The benefits appear to be modest and around eight children must be treated in order to achieve one additional cure (number needed to treat (NNT) 8, 95% CI 5 to 29). No long term benefits have been documented. These conclusions are based on a small number of small randomised controlled trials and may require revision as additional data become available.

[Drug-resistant bacteria isolated from pharyngeal swab cultures and urine in acutely or chronically febrile elderly nursing home inmates]

AIM

Patients in nursing homes are becoming more and more elderly and also prone to infectious diseases. It is important to select proper antimicrobial agents in treating such patients because of the increase in drug-resistant bacteria in recent years.

METHODS

Pathogenic aerobic bacteria were isolated from cultures of the pharyngeal swab obtained from patients with acute febrile episodes and those with chronic febrile conditions with a repetition of fever or continuing low-grade fever. Isolation of pathogens was also carried out in patients with a urinary tract infection that was resistant to treatment. Isolated bacteria were tested for sensitivity to commonly used antimicrobial agents.

RESULTS

Pathogenic bacteria were isolated from 33% of the patients with acute febrile episodes, while they were isolated from 75% of the patients with chronic febrile conditions. The number of major pathogenic bacteria from 85 isolates were methicillin-resistant staphylococcus aureus (MRSA) 13, methicillin-sensitive staphylococcus aureus (MSSA) 6, Streptococcus pneumoniae 8, beta-hemolytic streptococcus 5, Klebsiella pneumoniae 10, and Enterobacter cloacae 6. Only two isolates of Streptococcus pneumoniae were penicillin-sensitive (PSSP), while the others were penicillin-resistant (PRSP) (1) or penicillin-insensitive (PISP) (5). Among these 8 isolates, 5 were resistant to levofloxacin (LVFX). Escherichia coli was isolated from the pharyngeal swab of 2 patients, one of the 2 isolates being resistant to LVFX. Escherichia coli was isolated from 5 patients with urinary tract infection and 5 of the 6 isolates were resistant to LVFX; with one of them being extended spectrum beta-lactamases (ESBL).

CONCLUSION

The frequency of isolation of antimicrobial-resistant pathogens was extremely high among elderly patients in our nursing home compared to values reported from a nation-wide survey recently carried out in Japan. In particular, attention should be focused on the resistance of bacteria to fluoroquinolones.

Microbiology of acute otitis media in children with tympanostomy tubes: prevalences of bacteria and viruses

Background. Bacteria are found in 50%–90% of cases of acute otitis media (AOM) with or without otorrhea, and viruses are found in 20%–49% of cases. However, for at least 15% of patients with AOM, the microbiological etiology is never determined. Our aim was to specify the full etiology of acute middle ear infection by using modern microbiological methods concomitantly for bacterial and viral detection.

Methods. The subjects were 79 young children having AOM with new onset (<48 h) of otorrhea through a tympanostomy tube. Middle ear fluid samples were suctioned from the middle ear through the tympanostomy tube. Bacteria were sought by culture and polymerase chain reaction; viruses were analyzed by culture, antigen detection, and polymerase chain reaction.

Results. At least 1 respiratory tract pathogen was noted in 76 children (96%). Bacteria were found in 73 cases (92%), and viruses were found in 55 (70%). In 52 patients (66%), both bacteria and viruses were found. Bacteria typical of AOM were detected in 86% of patients. Picornaviruses accounted for 60% of all viral findings.

Conclusions. In the great majority of children, AOM is a coinfection with bacteria and viruses. The patent tympanostomy tube does not change the spectrum of causative agents in AOM. A microbiological etiology can be established in practically all cases.

Nasal middle meatal specimen bacteriology as a predictor of the course of acute respiratory infection in children

AIMS

To test our hypothesis that children with potentially pathogenic bacteria (Streptococcus pneumoniae, Haemophilus influenzae or Moraxella catarrhalis) in the nasal middle meatus might have more prolonged symptoms of acute respiratory infection than children without such bacteria, we conducted a prospective cohort study of such children.

MATERIALS AND METHODS

We recruited prospectively child volunteers between 6 and 13 years of age with acute respiratory infections present for fewer than 10 days. Nasal middle meatal bacterial culture was taken with a rigid endoscope at enrollment and again after 3 weeks and evaluated for presence or absence of 3 potential pathogens: S. pneumoniae, H. influenzae and M. catarrhalis. The subsequent persistence of acute symptoms (nasal discharge: clear/colored, nasal obstruction and cough) was determined by means of a diary. Viral etiology was studied with polymerase chain reaction methods.

RESULTS

The 82 children had had symptoms for an average of 4 days (range, 1-10) at entry, and viruses were detected in 54% (39 of 72). The endoscopic procedure and bacteriologic sampling succeeded in all cases. Thirty-eight children (46%) had at least 1 of the 3 pathogens in the middle meatus specimen. The children with nasal pathogens present at entry had a significantly longer mean duration of symptoms than those with nonpathogenic bacteria (difference, 3.6 days; 95% confidence interval, 0.7-6.5; P = 0.025). The effect remained significant after adjustment for age, sex, allergic symptoms and the presence of virus (adjusted relative hazard of delayed recovery, 2.0; 95% confidence interval, 1.1-3.6).

CONCLUSIONS

We found that the use of endoscopic swab culture sampling from the nasal middle meatus is well-tolerated by children older than 6 years of age and that it can be useful in selected situations to determine pathogenic bacteria in the culture of these specimens.

The Use of Antibiotics for Viral Upper Respiratory Tract Infections: An Analysis of Nurse Practitioner and Physician Prescribing Practices in Ambulatory Care, 1997-2001

PURPOSE

There are extensive data that describe the prescriptive behaviors of physicians (MDs) for upper respiratory tract infections; however, there is a paucity of data on the antibiotic-prescribing patterns of nurse practitioners (NPs). The purpose of this study was to describe and predict factors that are associated with antibiotic prescribing by NPs and MDs for viral upper respiratory infections in the ambulatory setting.

DATA SOURCES

The study utilized a cross-sectional retrospective design of data from the National Hospital Ambulatory Medical Care Survey and the National Ambulatory Medical Care Survey between 1997 and 2001. Data were collected on a national probability sample of 506 NP and 13,692 MD visits for patients with nonspecific upper respiratory tract infection, viral pharyngitis, and bronchitis.

CONCLUSIONS

Bivariate analysis found no significant differences in antibiotic prescribing for viral upper respiratory tract infections by NPs (50.4%) and MDs (53%). Broad-spectrum antibiotics accounted for 36.6% of the NP antibiotic prescriptions and for 33.2% of the MD antibiotic prescriptions. Multivariate analysis identified several clinical and nonclinical factors that are associated with NP antibiotic prescribing. The strongest positive predictors of NP antibiotic prescribing were black race, Medicaid insurance, Northeast region, and diagnoses of viral pharyngitis and bronchitis. The significant negative predictor was Medicaid insurance status. The strongest positive predictors of MD prescribing were viral pharyngitis, bronchitis, and non-antibiotic prescription.

IMPLICATION FOR PRACTICE

The excessive use of antibiotics for upper respiratory infections of viral etiology by both NPs and MDs suggests the continuing need for educational initiatives such as "academic detailing" as well as increasing involvement by both groups of providers in the dissemination of clinical guidelines and system-based quality assurance programs. Also, the lower rate of antibiotic prescribing for viral infections by NPs for patients with Medicaid insurance suggests more appropriate cost-effective care in this population of patients. More study is needed in general on prescribing by NPs for Medicaid patients. Finally, the strong association of nonclinical factors suggests the need for awareness and improvement of prescribing decisions by both NPs and MDs.

Cefuroxime axetil versus placebo for children with acute respiratory infection and imaging evidence of sinusitis: a randomized, controlled trial

AIM

To evaluate the efficacy of antibiotic treatment in children who presented in medical care with respiratory infection and had imaging evidence of sinusitis.

METHODS

Eighty-two children (4-10 y) with acute respiratory symptoms and ultrasonography findings suggestive of acute rhinosinusitis were enrolled in a randomized, double-blind trial. The sinus findings were confirmed with plain radiographs. The children received either cefuroxime axetil in 125-mg capsules twice a day for 10 d or placebo. Main outcome measures were complete cure in 2 wk and absence of prolonged symptoms or complications.

RESULTS

A total of 72 children (88%) completed follow-up. The sinusitis findings in the ultrasound could be confirmed with plain radiographs in 65 of the 72 patients (90%). The proportion of children completely cured by day 14 was similar in both groups (difference 6%, 95% confidence interval -16% to 29%). Similarly, there was no significant difference in the proportions of children who escaped prolonged disease and complications between the groups (difference 7%, -9% to 24%).

CONCLUSION

A 10-d course of cefuroxime axetil offered no clinical benefit to children with an acute respiratory illness and imaging evidence of acute sinusitis.

Antibiotics for the common cold and acute purulent rhinitis

BACKGROUND

It has long been believed that antibiotics have no role in treating common colds yet they are often prescribed in the belief that they may prevent secondary bacterial infections. Given the increasing concerns about antibiotic resistance it is important to examine the evidence for the benefit of antibiotics for the common cold.

OBJECTIVES

To determine:(1) the efficacy of antibiotics, in comparison with placebo, for reducing general symptoms and specific nasopharyngeal symptoms of acute upper respiratory tract infections; (2) if antibiotics have any influence on acute purulent rhinitis; (3) whether antibiotics cause significant adverse outcomes in patients with acute upper respiratory tract infections.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005); MEDLINE (January 1966 to March, Week 1, 2005); EMBASE (1980 to December 2004), the Family Medicine Database (1908, volume 1 to 1993, volume 13; this database was discontinued in 1993), and reference lists of articles, and we contacted principal investigators.

SELECTION CRITERIA

Randomised trials comparing any antibiotic therapy against placebo in people with acute upper respiratory tract infections and with less than seven days of symptoms, or acute purulent rhinitis less than ten days in duration.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed trial quality and extracted data.

MAIN RESULTS

All analyses used the fixed-effect model unless otherwise stated. The overall quality of the included trials was variable. People receiving antibiotics did no better in terms of lack of cure or persistence of symptoms than those on placebo (relative risk (RR) 0.89, 95% confidence interval (CI) 0.77 to 1.04), based on a pooled analysis of six trials with a total of 1147 patients. Overall, the relative risk of adverse effects in the antibiotic group was RR 1.8 (95% CI 1.01 to 3.21), using a random-effects model. Adult patients had a significantly greater risk of adverse effects with antibiotics than with placebo (RR 2.62, 95% CI 1.32 to 5.18) (random-effects model) while there was no greater risk in children (RR 0.91, 95% CI 0.51 to 1.63). The pooled relative risk for persisting acute purulent rhinitis with antibiotics compared to placebo was 0.57 (95% CI 0.37 to 0.87) (random-effects model), based on 6 studies with 772 participants.

AUTHORS' CONCLUSIONS

There is insufficient evidence of benefit to warrant the use of antibiotics for upper respiratory tract infections in children or adults. Antibiotics cause significant adverse effects in adults. The evidence on acute purulent rhinitis and acute clear rhinitis suggests a benefit for antibiotics for these conditions but their routine use is not recommended.

Current management of acute bacterial rhinosinusitis and the role of moxifloxacin

Episodes of acute rhinosinusitis are common among adults and are associated with a significant amount of morbidity. The symptoms of rhinosinusitis are nasal drainage, congestion, and sinus pressure. A bacterial sinus infection is more likely if these symptoms worsen after 5-7 days or do not improve after 10-14 days. The majority of bacterial episodes have been associated with Streptococcus pneumoniae and Haemophilus influenzae. In the current era of increasing resistance to beta -lactams and macrolides, treatment guidelines have been formulated worldwide to assist clinicians in the selection of antibacterials. According to one model, the following antibacterials are most likely to provide desired outcomes (90%-92% predicted clinical efficacy) for adults: respiratory fluoroquinolones (i.e., moxifloxacin, gatifloxacin, and levofloxacin), ceftriaxone, and high-dose amoxicillin-clavulanate (4 g of amoxicillin/day and 250 mg of clavulanate/day). Although the role of the fluoroquinolones in the treatment of this condition is evolving, fluoroquinolones are often recommended as second-line therapy or as first-line therapy for selected patients (e.g., those who received antibacterials in the previous 4-6 weeks or adults with moderate-to-severe disease).