Management of upper respiratory tract infections in children

The Epidemiology of Influenza Virus Infection and Group A Streptococcal Pharyngitis in Children Between 2011 and 2018 in an Outpatient Pediatric Clinic

Background The frequency of influenza virus infections and group A beta-hemolytic streptococcus (GAS) pharyngitis varies according to populations. We aimed to investigate the frequency of influenza virus and streptococcal pharyngitis infections in a pediatric outpatient cohort with many pediatric admissions in Istanbul. Materials and methods Children with upper respiratory tract infection (URTI) symptoms between 2011 and 2018 who underwent rapid diagnostic tests for influenza virus or streptococcal infection were evaluated retrospectively. Results The total number of pediatric cases admitted between 2011 and 2018 was 185,228, of which 119,928 were under five years old and 66,300 were children over five years old. The mean frequency of the influenza virus was 1,283 per 100,000 children, and the mean frequency of streptococcal pharyngitis was 1,764 per 100,000 children. The frequency of influenza has increased over the years. The frequency of streptococcal infection is higher in children over five years of age, and its frequency has decreased in this group. Conclusions The frequency of influenza virus infection and GAS pharyngitis varies according to years and seasons. Winter and spring were the seasons with the most frequent positive influenza virus and GAS pharyngitis. Although influenza frequency increased annually, this phenomenon was not observed in the frequency of GAS pharyngitis.

Bacillus clausii UBBC-07 in the symptom management of upper respiratory tract infections in children: a double blind, placebo-controlled randomised study

In children, upper respiratory tract infections (URTIs) are one of the most common causes of infections which often require outpatient consultations with the doctor. The purpose of this study was to evaluate the effect of probiotic Bacillus clausii UBBC-07 on symptom management of URTIs in children. In this double blind, randomised, placebo-controlled study, 90 children (age 4-7 years) with URTIs were equally divided into two groups, the probiotic and placebo. The children were instructed to take B. clausii UBBC-07 spores (2×109 per 5 ml vial) or placebo suspension daily twice for three months. The total duration of the study was 6 months, 3 months treatment and 3 months follow-up period. The parameters assessed were the mean number of URTIs, duration and severity of URTIs, absenteeism from school/childcare and immunity parameters, such as immunoglobulin (Ig)M, IgG, IgE and salivary IgA levels. At the end of treatment, there was a significant decrease in the number, duration and severity of URTIs in the probiotic treated group as compared to the baseline and placebo. IgE levels were significantly decreased and salivary IgA levels were significantly increased in the probiotic treated group suggesting probiotic mediated Th1/Th2 immune homeostasis to alleviate URTIs in children. In conclusion, B. clausii UBBC-07 may help in the reduction of symptoms of URTIs. The trial was registered prospectively with the Clinical Trial Registry of India (CTRI Reg. No: CTRI/2018/08/015282).

Acquisition and Classification of Lung Sounds for Improving the Efficacy of Auscultation Diagnosis of Pulmonary Diseases

Purpose

Lung diseases are the third leading cause of death worldwide. Stethoscope-based auscultation is the most commonly used, non-invasive, inexpensive, and primary diagnostic approach for assessing lung conditions. However, the manual auscultation-based diagnosis procedure is prone to error, and its accuracy is dependent on the physician’s experience and hearing capacity. Moreover, the stethoscope recording is vulnerable to different noises that can mask the important features of lung sounds which may lead to misdiagnosis. In this paper, a method for the acquisition of lung sound signals and classification of the top 7 lung diseases has been proposed for improving the efficacy of auscultation diagnosis of pulmonary disease.

Methods

An electronic stethoscope has been constructed for signal acquisition. Lung sound signals were then collected from people with COPD, upper respiratory tract infections (URTI), lower respiratory tract infections (LRTI), pneumonia, bronchiectasis, bronchiolitis, asthma, and healthy people. Lung sounds were analyzed using a wavelet multiresolution analysis. To choose the most relevant features, feature selection using one-way ANOVA was performed. The classification accuracy of various machine learning classifiers was compared, and the Fine Gaussian SVM was chosen for final classification due to its superior performance. Model optimization was accomplished through the application of Bayesian optimization techniques.

Results

A test classification accuracy of 99%, specificity of 99.2%, and sensitivity of 99.04%, have been achieved for the 7 lung diseases using the optimized Fine Gaussian SVM classifier.

Conclusion

Our experimental results demonstrate that the proposed method has the potential to be used as a decision support system for the classification of lung diseases, especially in those areas where the expertise and the means are limited.

Amoxicillin-associated Stevens-Johnson syndrome or toxic epidermal necrolysis: systematic review

Our aim was to explore and summarize available cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) suspected to be associated with amoxicillin reported in the literature. Electronic searches were conducted in several databases. Fifty-one publications describing a total of 64 patients who satisfied inclusion criteria were included in the review. The age of the patients ranged from 1.5-80 years (median: 24.5 years). TEN, SJS and SJS/TEN overlap were diagnosed in 30 (46.9%), 28 (43.8%) and 1 (1.6%) patients, respectively. SJS/TEN may occur promptly after administration of amoxicillin, but it could also be a delayed adverse effect. The total length of hospital stay ranged from 3-70 days (median: 16 days). Amoxicillin-induced SJS/TEN is accompanied by frequent occurrence of serious complications, long-term ocular and skin sequelae and high mortality rate. Clinicians should be aware that amoxicillin alone or combined with clavulanic acid can cause SJS/TEN in patients of all ages.

Effect of Jiuwei Zhuhuang Powder on Cough Resolution in Children with Upper Respiratory Tract Infections: A Multicenter Randomized Controlled Trial

OBJECTIVE

To assess the effectiveness of Jiuwei Zhuhuang Powder (JWZH), a Tibetan patent medicine in treating upper respiratory tract infection (URTI) associated cough in children.

METHODS

The study was a multicenter, randomized, open-label, controlled trial. A total of 142 children aged 2 to 14 years old, with URTI-associated cough within 48 h of onset, were randomly assigned to two groups at a 1:1 ratio by computer-generated randomization sequence. Children were treated with JWZH (1 to 1.5 g, twice to thrice daily) in the treatment group or conventional treatment (Pediatric Paracetamol, Artificial Cow-bezoar and Chlorphenamine Maleate Granules, 0.25 to 1 g, thrice daily) in the control group for 5 days. The primary endpoints were the time to cough resolution and 4-day cough resolution rate. The secondary endpoints were the daily improvement in symptom scores and cough resolution rate during the study period.

RESULTS

A total of 138 children were included in the intention-to-treat analysis, with 71 cases in the treatment group and 67 cases in the control group. Compared with the conventional treatment, the children receiving JWZH had a shorter time to cough resolution [hazard ratio, 2.10; 95% confidence interval (CI), 1.29-3.40; P=0.003]. The median time to cough resolution for children receiving JWZH was shorter than that of the conventional treatment (2 days vs. 3 days; P<0.001). The 4-day cough resolution rate in the JWZH group was higher than that of the control group (94.4% vs. 74.6%; risk difference: 19.8%, 95% CI: 8.1%-31.5%; relative risk: 1.265, 95% CI: 1.088-1.470; P=0.001). There were no statistically significant differences in the improvement of other symptoms caused by URTI (P>0.05). Adverse events was reported in 5.6% (4/71) and 4.5% (3/67) in participants of JWZH and PPACCM groups (P>0.05), respectively, which were all mild and resolved without treatment.

CONCLUSION

JWZH seemed to be a safe and effective therapy for URTI-associated cough in children. (Trial registration No. ChiCTR2000039421).

Lacticaseibacillus rhamnosus GG DSM 33156 effects on pathogen defence in the upper respiratory tract: a randomised, double-blind, placebo-controlled paediatric trial

Acute upper respiratory tract infections (URTIs) are caused by numerous viruses and bacteria. URTIs can be a cause of morbidity and are among the most common reasons for visiting healthcare practitioners and prescribing antibiotics to children in addition to causing absenteeism from school and work. Oral intake of Lacticaseibacillus rhamnosus GG DSM 33156 has shown beneficial health effects in several clinical trials, primarily relating to immune function and gastrointestinal health in children and adults. It has also been suggested that oral intake of L. rhamnosus GG DSM 33156 can reduce the incidence rate and alleviate symptoms of URTIs in children. We here report the results of a randomised, double-blind, placebo-controlled trial of 619 children aged 2-6 years conducted at a single centre in Scotland. The children, who were in day care or primary school, were followed over a 16-week intervention period with 309 randomised in the active group and 310 in the placebo group. The parents or guardians reported a daily healthcare status and any presumed episodes of URTI, which were subsequently confirmed by a general practitioner. The investigational product was well tolerated in the trial. Although a general trend towards a beneficial effect was observed, this trial did not demonstrate that L. rhamnosus GG DSM 33156 significantly reduced the incidence of URTIs, diagnosed by a general practitioner according to prespecified criteria (primary endpoint). Moreover, none of the secondary efficacy endpoints were met. Applying a Ward's hierarchical clustering, two separate clusters, focussing on four quality of life-related endpoints, were identified. Cluster 1 was associated with more severe URTI characteristics than cluster 2. Cluster 2 was significantly enriched with children who consumed the product, indicating that the symptoms children experience during an URTI are alleviated by the intake of L. rhamnosus GG DSM 33156. The study is registered at ClinicalTrials.gov ID: NCT03636191.

Management of acute upper respiratory tract infection: the role of early intervention

INTRODUCTION

Upper respiratory tract infection (URTI) is an illness caused by an acute infection by viruses or bacteria of the nose, sinuses, pharynx, and larynx. Most URTIs are short, mild, and self-limiting, but some can lead to serious complications, resulting in heavy social and economic burden on individuals and society.

AREAS COVERED

This article presents the management guidelines and consensus established through the Delphi method during an expert roundtable conducted in November 2020 and results of a targeted literature review.

EXPERT OPINION

The current acute URTI management strategies aim toward symptom alleviation and prevention of URTI virus transmission. The effectiveness of these strategies is highly increased with early intervention, administered prior to the peaking of viral shedding. This reduces the chances of developing a full-blown acute URTI, decreases symptom severity, and reduces viral transmission. Mucoadhesive gel nasal sprays have shown promising results for early intervention of acute URTI. They act by creating a barrier that can trap virus particles, thereby preventing invasion of the mucosa by the virus. Additionally, they deliver broad spectrum activity that is effective against a wide variety of pathogens that cause acute URTI. Acute URTI warrants greater attention and proactive management in reducing its burden.

Parental Knowledge, Attitudes and Practices Regarding Antibiotic Use for Upper Respiratory Tract Infections in Children

Objectives

This study aimed to assess parental knowledge, attitudes and practices regarding antibiotic use for children with upper respiratory tract infections (URTIs).

Methods

A multi-centre cross-sectional study was conducted from September 2018 to April 2019 at 15 randomly selected primary health centres in Muscat, Oman. A total of 384 parents with children under 12 years old were recruited. A validated questionnaire was utilised to determine knowledge, attitudes and practices regarding antibiotic use for children with URTIs.

Results

All 384 parents participated in the study (response rate: 100%). Almost half of the participants (n = 173; 45.1%) agreed that antibiotics were the first and best treatment for URTIs in children, with 184 parents (47.9%) reporting that influenza symptoms in children improved more rapidly after the administration of antibiotics and 203 (52.9%) believing that antibiotics prevented complications. The majority (n = 219; 57.0%) of parents never gave their children antibiotics without a prescription, and 291 (75.8%) never used leftover antibiotics. Most participants (n = 233; 60.7%) stated that it was the doctor’s decision to prescribe antibiotics, 192 (50.0%) had never asked a physician to prescribe antibiotics for their child and 256 (66.7%) had never changed doctors because they did not prescribe antibiotics.

Conclusion

This study found that parents had confidence in their healthcare providers; however, it also showed the extent of their lack of knowledge regarding the use of antibiotics for children with URTIs. There is a need for both public- and healthcare professional-oriented educational initiatives to promote rational antibiotic usage in Oman.

Recent advances in gold nanoparticle-based lateral flow immunoassay for the detection of bacterial infection

Diagnosis of bacterial infections (BI) is becoming an increasingly difficult task in clinical practice due to their high prevalence and frequency, as well as the growth of antibiotic resistance worldwide. World Health Organization (WHO) reported antibiotic resistance is a major public health problem. BI becomes difficult or impossible to treat when the bacteria acquire immunity against antibiotics. Thus, there is a need for a quick and accurate technique to detect infection. Lateral flow immunoassay (LFIA) is an ideal technique for point-of-care testing of a disease or pathological changes inside the human body. In recent years, several LFIA based strips are being used for the detection of BI by targeting specific analytes which may range from the causative bacterium, whole-cell, DNA, or biomarker. Numerous nanoparticles like lipid-based nanoparticles, polymeric nanoparticles, and inorganic nanoparticles such as quantum dots, magnetic, ceramic, and metallic nanoparticles (copper, silver gold, iron) are widely being used in the advanced treatment of BI. Out of these gold nanoparticle (AuNPs), is being used for detection BI more effectively than other nanoparticles due to their surface functionalization, extraordinary chemical stability, biorecognition, and signal amplification properties and help to improve in conjugation with capture antibodies, and act as a color marker with unique optical properties on LFIA strips. Herein, a review that provides an overview of the principle of LFIA, how LFIA based strip is developed, and how it is helpful to detect a specific biomarker for bedside detection of the BI.

Occurrence of respiratory viruses on school desks

BACKGROUND

Schools represent high occupancy environments and well-documented high-risk locations for the transmission of respiratory viruses. The goal of this study was to report on the area density, occurrence, and type of respiratory viruses on desks in primary school classrooms.

METHODS

Quantitative reverse transcription polymerase chain reaction (qPCR) techniques were employed to measure nucleic acid area densities from a broad range of human adenoviruses and rhinoviruses, as well as coronavirus OC43, influenza A, and norovirus GI. Every two weeks, virus monitoring was conducted on the desks of four primary school classrooms in Colorado, USA, during the 2019 respiratory virus season.

RESULTS

DNA and RNA from respiratory viruses and norovirus were recovered from more than 20% of the desks sampled; occurrence patterns that indicate a greater than 60% probability of encountering any virus, if more than five desks were occupied in a day. Rhinoviruses and adenoviruses were the most commonly detected viruses as judged by the composite of occurrence and number of gene copies recovered. Desktop adenosine triphosphate monitoring did not predict the recovery of viral genomic materials on desks. School desks can be commonly contaminated with respiratory viruses.

CONCLUSIONS

Genomic surveys of the identity, distribution and abundance of human viruses on "high-touch" surfaces, can help inform risk assessments, design cleaning interventions, and may be useful for infection surveillance.

Training load characteristics and injury and illness risk identification in elite youth ski racing: A prospective study

PURPOSE

The study aimed to investigate the role of training load characteristics and injury and illness risk in youth ski racing.

METHODS

The training load characteristics as well as traumatic injuries, overuse injuries, and illnesses of 91 elite youth ski racers (age = 12.1 ± 1.3 years, mean ± SD) were prospectively recorded over a period of 1 season by using a sport-specific online database. Multiple linear regression analyses were performed to monitor the influence of training load on injuries and illnesses. Differences in mean training load characteristics between preseason, in-season, and post-season were calculated using multivariate analyses of variance.

RESULTS

Differences were discovered in the number of weekly training sessions (p = 0.005) between pre-season (4.97 ± 1.57) and post-season (3.24 ± 0.71), in the mean training volume (p = 0.022) between in-season (865.8 ± 197.8 min) and post-season (497.0 ± 225.5 min) and in the mean weekly training intensity (Index) (p = 0.012) between in-season (11.7 ± 1.8) and post-season (8.9 ± 1.7). A total of 185 medical problems were reported (41 traumatic injuries, 12 overuse injuries, and 132 illnesses). The weekly training volume and training intensity was not a significant risk factor for injuries (p > 0.05). Training intensity was found to be a significant risk factor for illnesses in the same week (β = 0.348; p = 0.044; R² = 0.121) and training volume represents a risk factor for illnesses in the following week (β = 0.397; p = 0.027; R² = 0.157).

CONCLUSION

A higher training intensity and volume were associated with increased illnesses, but not with a higher risk of injury. Monitoring training and ensuring appropriate progression of training load between weeks may decrease incidents of illness in-season.

The emerging role of probiotics as a mitigation strategy against coronavirus disease 2019 (COVID-19)

COVID-19 is an acute respiratory infection accompanied by pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has affected millions of people globally. To date, there are no highly efficient therapies for this infection. Probiotic bacteria can interact with the gut microbiome to strengthen the immune system, enhance immune responses, and induce appropriate immune signaling pathways. Several probiotics have been confirmed to reduce the duration of bacterial or viral infections. Immune fitness may be one of the approaches by which protection against viral infections can be reinforced. In general, prevention is more efficient than therapy in fighting viral infections. Thus, probiotics have emerged as suitable candidates for controlling these infections. During the COVID-19 pandemic, any approach with the capacity to induce mucosal and systemic reactions could potentially be useful. Here, we summarize findings regarding the effectiveness of various probiotics for preventing virus-induced respiratory infectious diseases, especially those that could be employed for COVID-19 patients. However, the benefits of probiotics are strain-specific, and it is necessary to identify the bacterial strains that are scientifically established to be beneficial.

Diagnosis of inaccessible infections using infrared microscopy of white blood cells and machine learning algorithms

Physicians diagnose subjectively the etiology of inaccessible infections where sampling is not feasible (such as, pneumonia, sinusitis, cholecystitis, peritonitis), as bacterial or viral. The diagnosis is based on their experience with some medical markers like blood counts and medical symptoms since it is harder to obtain swabs and reliable laboratory results for most cases. In this study, infrared spectroscopy with machine learning algorithms was used for the rapid and objective diagnosis of the etiology of inaccessible infections and enables an assessment of the error for the subjective diagnosis of the etiology of these infections by physicians. Our approach allows for diagnoses of the etiology of both accessible and inaccessible infections as based on an analysis of the innate immune system response through infrared spectroscopy measurements of white blood cell (WBC) samples. In the present study, we examined 343 individuals involving 113 controls, 89 inaccessible bacterial infections, 54 accessible bacterial infections, 60 inaccessible viral infections, and 27 accessible viral infections. Using our approach, the results show that it is possible to differentiate between controls and infections (combined bacterial and viral) with 95% accuracy, and enabling the diagnosis of the etiology of accessible infections as bacterial or viral with >94% sensitivity and > 90% specificity within one hour after the collection of the blood sample with error rate <6%. Based on our approach, the error rate of the physicians' subjective diagnosis of the etiology of inaccessible infections was found to be >23%.

Surveillance of respiratory viruses among children attending a primary school in rural coastal Kenya

Background: Respiratory viruses are primary agents of respiratory tract diseases. Knowledge on the types and frequency of respiratory viruses affecting school-children is important in determining the role of schools in transmission in the community and identifying targets for interventions.

Methods: We conducted a one-year (term-time) surveillance of respiratory viruses in a rural primary school in Kilifi County, coastal Kenya between May 2017 and April 2018. A sample of 60 students with symptoms of ARI were targeted for nasopharyngeal swab (NPS) collection weekly.  Swabs were screened for 15 respiratory virus targets using real time PCR diagnostics. Data from respiratory virus surveillance at the local primary healthcare facility was used for comparison.

Results: Overall, 469 students aged 2-19 years were followed up for 220 days. A total of 1726 samples were collected from 325 symptomatic students; median age of 7 years (IQR 5-11). At least one virus target was detected in 384 (22%) of the samples with a frequency of 288 (16.7%) for rhinovirus, 47 (2.7%) parainfluenza virus, 35 (2.0%) coronavirus, 15 (0.9%) adenovirus, 11 (0.6%) respiratory syncytial virus (RSV) and 5 (0.3%) influenza virus.  The proportion of virus positive samples was higher among lower grades compared to upper grades (25.9% vs 17.5% respectively; χ ² = 17.2, P -value <0.001). Individual virus target frequencies did not differ by age, sex, grade, school term or class size. Rhinovirus was predominant in both the school and outpatient setting.

Conclusion: Multiple respiratory viruses circulated in this rural school population.  Rhinovirus was dominant in both the school and outpatient setting and RSV was of notably low frequency in the school. The role of school children in transmitting viruses to the household setting is still unclear and further studies linking molecular data to contact patterns between the school children and their households are required.

Assessing the appropriateness of paediatric antibiotic overuse in Australian children: a population-based sample survey

Background

Infections caused by antibiotic resistant pathogens are increasing, with antibiotic overuse a key contributing factor.

Objective

The CareTrack Kids (CTK) team assessed the care of children in Australia aged 0–15 years in 2012 and 2013 to determine the proportion of care in line with clinical practice guidelines (CPGs) for 17 common conditions. This study analyses indicators relating to paediatric antibiotic overuse to identify those which should be prioritised by antimicrobial stewardship and clinical improvement programs.

Method

A systematic search was undertaken for national and international CPGs relevant to 17 target conditions for Australian paediatric care in 2012–2013. Recommendations were screened and ratified by reviewers. The sampling frame comprised three states containing 60% of the Australian paediatric population (South Australia, New South Wales and Queensland). Multi-stage cluster sampling was used to select general practices, specialist paediatric practices, emergency departments and hospital inpatient services, and medical records within these. Medical records were reviewed by experienced paediatric nurses, trained to assess eligibility for indicator assessment and compliance with indicators. Adherence rates were estimated.

Results

Ten antibiotic overuse indicators were identified; three for tonsillitis and one each for seven other conditions. A total of 2621 children were assessed. Estimated adherence for indicators ranged from 13.8 to 99.5% while the overall estimate of compliance was 61.9% (95% CI: 47.8–74.7). Conditions with high levels of appropriate avoidance of antibiotics were gastroenteritis and atopic eczema without signs of infection, bronchiolitis and croup. Indicators with less than 50% adherence were asthma exacerbation in children aged > 2 years (47.1%; 95% CI: 33.4–61.1), sore throat with no other signs of tonsillitis (40.9%; 95% CI: 16.9, 68.6), acute otitis media in children aged > 12 months who were mildly unwell (13.8%; 95% CI: 5.1, 28.0), and sore throat and associated cough in children aged < 4 years (14.3%; 95% CI: 9.9, 19.7).

Conclusion

The results of this study identify four candidate indicators (two for tonsillitis, one for otitis media and one for asthma) for monitoring by antibiotic stewardship and clinical improvement programs in ambulatory and hospital paediatric care, and intervention if needed.

Surveillance of respiratory viruses among children attending a primary school in rural coastal Kenya

Background: Respiratory viruses are primary agents of respiratory tract diseases. Knowledge on the types and frequency of respiratory viruses affecting school-children is important in determining the role of schools in transmission in the community and identifying targets for interventions. Methods: We conducted a one-year (term-time) surveillance of respiratory viruses in a rural primary school in Kilifi County, coastal Kenya between May 2017 and April 2018. A sample of 60 students with symptoms of ARI were targeted for nasopharyngeal swab (NPS) collection weekly.  Swabs were screened for 15 respiratory virus targets using real time PCR diagnostics. Data from respiratory virus surveillance at the local primary healthcare facility was used for comparison. Results: Overall, 469 students aged 2-19 years were followed up for 220 days. A total of 1726 samples were collected from 325 symptomatic students; median age of 7 years (IQR 5-11). At least one virus target was detected in 384 (22%) of the samples with a frequency of 288 (16.7%) for rhinovirus, 47 (2.7%) parainfluenza virus, 35 (2.0%) coronavirus, 15 (0.9%) adenovirus, 11 (0.6%) respiratory syncytial virus (RSV) and 5 (0.3%) influenza virus.  The proportion of virus positive samples was higher among lower grades compared to upper grades (25.9% vs 17.5% respectively; χ2 = 17.2, P -value <0.001). Individual virus target frequencies did not differ by age, sex, grade, school term or class size. Rhinovirus was predominant in both the school and outpatient setting. Conclusion: Multiple respiratory viruses circulated in this rural school population.  Rhinovirus was dominant in both the school and outpatient setting and RSV was of notably low frequency in the school. The role of school children in transmitting viruses to the household setting is still unclear and further studies linking molecular data to contact patterns between the school children and their households are required.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

Introduction: Antibiotics are indispensable to maintaining human health; however, their overuse has resulted in resistant organisms, increasing morbidity, mortality and costs. Increasing antimicrobial resistance (AMR) is a major public health threat, resulting in multiple campaigns across countries to improve appropriate antimicrobial use. This includes addressing the overuse of antimicrobials for self-limiting infections, such as upper respiratory tract infections (URTIs), particularly in lower- and middle-income countries (LMICs) where there is the greatest inappropriate use and where antibiotic utilization has increased the most in recent years. Consequently, there is a need to document current practices and successful initiatives in LMICs to improve future antimicrobial use.Methodology: Documentation of current epidemiology and management of URTIs, particularly in LMICs, as well as campaigns to improve future antimicrobial use and their influence where known.Results: Much concern remains regarding the prescribing and dispensing of antibiotics for URTIs among LMICs. This includes considerable self-purchasing, up to 100% of pharmacies in some LMICs. However, multiple activities are now ongoing to improve future use. These incorporate educational initiatives among all key stakeholder groups, as well as legislation and other activities to reduce self-purchasing as part of National Action Plans (NAPs). Further activities are still needed however. These include increased physician and pharmacist education, starting in medical and pharmacy schools; greater monitoring of prescribing and dispensing practices, including the development of pertinent quality indicators; and targeted patient information and health education campaigns. It is recognized that such activities are more challenging in LMICs given more limited resources and a lack of healthcare professionals.Conclusion: Initiatives will grow across LMICs to reduce inappropriate prescribing and dispensing of antimicrobials for URTIs as part of NAPs and other activities, and these will be monitored.

Comparison of antibiotic prescriptions in adults and children with upper respiratory tract infections in Bangka Tengah primary health care centers

Background Inappropriate antibiotic therapy is accelerating the development of antimicrobial resistance (AMR). Upper respiratory tract infections (URTIs) are predominantly caused by viruses, resulting in the prescription of antibiotics to a few selected patients. Previous studies in primary health care centers (PHCCs) in Indonesia have shown a high percentage of antibiotic therapy for URTIs. This study tries to analyze the difference in profiles of antibiotic prescription in the treatment of children and adults with URTI in Bangka Tengah, Indonesia. Methods Random prescriptions from patients diagnosed with URTIs (sinusitis, bronchitis, common cold, and pharyngitis) from all PHCCs in Bangka Tengah were collected from January to February 2018. Prescriptions from patients with overlapping diagnoses, such as URTI with diarrhea or typhoid, were excluded. Results During the two months of data collection, 1348 prescriptions for adults and children with URTIs were studied. Children were 1.30 (95% CI, 1.03-1.58) times more likely to be treated with antibiotics compared to adults. Amoxicillin was the most commonly prescribed antibiotic both in children (92.3%) and adults (78.6%). Ciprofloxacin was commonly prescribed in adults (14.6%) but not in children (0.3%). Conclusions This study confirms the major antibiotic overuse in patients with URTI, especially in children. Owing to the fact that children are more likely to get URTI of viral origin, they receive high percentage of antibiotic therapy. These findings support the need for collaborated intervention to decrease unnecessary prescription of antibiotics in Bangka Tengah.

Bacillus coagulans GBI-30, 6068 decreases upper respiratory and gastrointestinal tract symptoms in healthy Mexican scholar-aged children by modulating immune-related proteins

This randomized, double-blind, parallel and placebo-controlled study aimed to evaluate the effect of Bacillus coagulans GBI-30, 6086® probiotic (GanedenBC³⁰®) against upper respiratory tract infections (URTI) and gastrointestinal tract infections (GITI) in eighty healthy school-aged children (6-8 years old). The participants received daily a sachet containing either GanedenBC³⁰ (1 × 10⁹ colony-forming units) or placebo (maltodextrin) for three months. GanedenBC³⁰ significantly decreased the incidence of URTI symptoms including nasal congestion, bloody nasal mucus, itchy nose, and hoarseness. The duration of the URTI-associated symptoms of hoarseness, headache, red eyes, and fatigue was also decreased. GanedenBC³⁰ supplementation also significantly reduced the incidence rate of flatulence. These beneficial effects were associated with the modulation of serum TNFα, CD163, G-CSF, ICAM-1, IL-6, IL-8, MCP-2, RAGE, uPAR, and PF4. Therefore, probiotic B. coagulans GBI-30, 6086 modulated immune-related proteins in healthy children, decreasing several URTI and GITI symptoms, thus, this functional ingredient may contribute to a healthier lifestyle.

Antibiotic Prescribing Practices and Errors among Hospitalized Pediatric Patients Suffering from Acute Respiratory Tract Infections: A Multicenter, Cross-Sectional Study in Pakistan

Background and objective: The noncompliance of treatment guidelines by healthcare professionals, along with physiological variations, makes the pediatric population more prone to antibiotic prescribing errors. The present study aims to evaluate the prescribing practices and errors of the most frequently prescribed antibiotics among pediatric patients suffering from acute respiratory tract infections who had different lengths of stay (LOS) in public hospitals. Methods: A retrospective, cross-sectional study was conducted in five tertiary-care public hospitals of Lahore, Pakistan, between 1 January 2017 and 30 June 2017. The study population consisted of pediatric inpatients aged 0 to 9 years. Results: Among the 11,892 pediatric inpatients, 82.8% were suffering from lower acute respiratory tract infections and had long LOS (53.1%) in hospital. Penicillins (52.4%), cephalosporins (16.8%), and macrolides (8.9%) were the most frequently prescribed antibiotics. Overall, 40.8% of the cases had antibiotic prescribing errors related to wrong dose (19.9%), wrong frequency (18.9%), and duplicate therapy (18.1%). Most of these errors were found in the records of patients who had long LOS in hospital (53.1%). Logistic regression analysis revealed that the odds of prescribing errors were lower in female patients (OR = 0.6, 95% CI = 0.1⁻0.9, p-value = 0.012). Patients who were prescribed with ≥3 antibiotics per prescription (OR = 1.724, 95% CI = 1.1⁻2.1, p-value = 0.020), had long LOS (OR = 12.5, 95% CI = 10.1⁻17.6, p-value < 0.001), and were suffering from upper respiratory tract infections (URTI) (OR = 2.8, 95% CI = 1.7⁻3.9, p-value < 0.001) were more likely to experience prescribing errors. Conclusion: Antibiotics were commonly prescribed to patients who had long LOS. Prescribing errors (wrong dose, wrong frequency, and duplicate therapy) were commonly found in cases of lower respiratory tract infections (LRTIs), especially among those who had prolonged stay in hospital.

The importance of hand hygiene education on primary schoolgirls' absence due to upper respiratory infections in Saudi Arabia. A cluster randomized controlled trial

Objectives:

To quantify the reduction in absence due to upper respiratory infections (URIs) among primary schoolgirls attending Riyadh’s schools after delivering a hand hygiene workshop intervention over a period of 5 weeks.

Methods:

A cluster randomized trial was conducted among girls attending 4 primary schools between January and March 2018. The participants attended a hand hygiene workshop. The schoolgirls’ absences were followed up for 5 weeks. Incidence rate, percentage of absence days, and absence rate were calculated for total and URIs absences.

Result:

Total number of participating schoolgirls was 496. Upper respiratory infections accounted for 15.3% of absence episodes. Schoolgirls lost 521 days of school and 19.4% of them were URIs-related. Absence rate due to URIs were 12.4 and 23.4 as well as 5.62 and 11.72 per 100 schoolgirls in the control (CG) and experimental (EG) groups, respectively. Percentage of absence days were lower in the experimental group (CG: 0.86% and 1.39% versus EG: 0.39% and 0.72%). Incidence rates of absence due to URIs were 0.54 and 1.02 in CG versus 0.24 and 0.51 in EG per 100 schoolgirls per day.

Conclusion:

There could be further reduction in school absences if education was accompanied by hand soap dissemination. The study could serve as a pilot for major studies in the future. Sustainability of the intervention can be tested in studies with longer durations.

Upper respiratory tract microbiota in health and disease – a minireview

A most common infection is that the upper respiratory tract. The human body is inhabited by millions of microorganisms, most of which enable the proper functioning of some systems and constitute a barrier protecting against harmful external factors. Due to the continuous contact of the upper airway microbiota with the external environment, it may seem to be extremely unstable and very diverse. A number of studies have been conducted that have assessed the effect of various factors on the composition of the upper respiratory tract microbiota. This paper presents a literature analysis which showed that the anatomical area is rich in terms of the microbiota that forms it, and despite the constant changes in many parameters, including physical – very stable.

Rational prescribing of antibiotics in children under 5 years with upper respiratory tract infections in Kintampo Municipal Hospital in Brong Ahafo Region of Ghana

OBJECTIVE

The aim of the study was to assess the rational use of antibiotics in children with URTIs in the Kintampo Municipal Hospital in Ghana.

RESULTS

A total of 839 medicines were prescribed, 237 were antibiotics. The mean number of medicines prescribed per patient encounter was 3.1. The percentage of patient encounters with antibiotics was 28.2 and 0.4% for injections. The percentage of medicines prescribed by generic was 93.8% and from the essential medicines list was 94.9%. Ninety-two of patients received amoxicillin. Polypharmacy was common as prescriptions with five to six medicines per patient encounter was found. Some prescribers are not following the WHO/INRUD requirement of prescribing medicines in their generic and from the essential medicine list of the country.

IFN-λ prevents influenza virus spread from the upper airways to the lungs and limits virus transmission

Host factors restricting the transmission of respiratory viruses are poorly characterized. We analyzed the contribution of type I and type III interferon (IFN) using a mouse model in which the virus is selectively administered to the upper airways, mimicking a natural respiratory virus infection. Mice lacking functional IFN-λ receptors (Ifnlr1^−/−) no longer restricted virus dissemination from the upper airways to the lungs. Ifnlr1^−/− mice shed significantly more infectious virus particles via the nostrils and transmitted the virus much more efficiently to naïve contacts compared with wild-type mice or mice lacking functional type I IFN receptors. Prophylactic treatment with IFN-α or IFN-λ inhibited initial virus replication in all parts of the respiratory tract, but only IFN-λ conferred long-lasting antiviral protection in the upper airways and blocked virus transmission. Thus, IFN-λ has a decisive and non-redundant function in the upper airways that greatly limits transmission of respiratory viruses to naïve contacts.

Influenza (‘the flu’) and other respiratory viruses make millions of people ill every year, placing a large burden on the healthcare system and the economy. Unfortunately, few options for preventing or treating these infections currently exist.

The flu virus spreads from infected individuals, enters a new host through the nose and establishes an infection in the upper airways. If the infection stays restricted to this region of the respiratory tract – which consists of the nasal cavity, sinuses, throat and larynx – it causes a rather mild disease. However, if it spreads to the lungs it can cause potentially life-threatening viral pneumonia.

Epithelial cells line the upper respiratory tract, forming a physical border between the outside world and the human body. These cells are therefore the first to face the incoming virus. In response, the epithelial cells release messenger molecules termed interferons that warn nearby cells to increase their antiviral defenses.

There are several subtypes of interferons, such as IFN-α, IFN-β and IFN-λ, but it was not known how each subtype helps to combat respiratory viruses. To investigate, Klinkhammer, Schnepf et al. exposed mice to flu viruses in a way that mimicked how an infection would naturally start in the upper airways in humans. Some of the mice were genetically engineered so that they could not respond to either IFN-α/β or IFN-λ.

The virus spread most effectively from the nasal cavity to the lungs in mice whose IFN-λ system was defective. Infections in mice that lacked IFN-λ were also more likely to spread to other individuals. Furthermore, treating mice with IFN-λ, but not IFN-α, gave their upper respiratory tract long-lasting protection against flu infections and prevented the spread of the virus.

IFN-λ therefore has a specific and significant role in protecting the upper airways against viruses, and could potentially be used as a drug to block the spread of infections between humans. Currently, IFN-λ is in clinical trials as a potential treatment for hepatitis D. To repurpose it for upper respiratory tract infections, its effectiveness against specific respiratory viruses will first have to be evaluated.

EPs 7630 is effective and safe in children under 6 years with acute respiratory tract infections: clinical studies revisited

OBJECTIVE

Pelargonium sidoides preparation EPs 7630 has been proven safe and effective in acute respiratory tract infections (aRTIs), but data for young children have not been presented separately. This study reviewed clinical studies and presents an overview of known and newly analyzed data from children <6 years.

METHODS

MEDLINE and EMBASE were searched for interventional and non-interventional studies which investigated the effects of EPs 7630 in aRTIs and included children <6 years of age. Sub-group analyses for this age range were performed for symptom scales, global efficacy or effectiveness assessments, and safety outcomes.

RESULTS

Seven studies with 1067 children <6 years exposed to EPs 7630 were identified. Efficacy of EPs 7630 was significantly superior to placebo in reducing symptom intensity and time until complete recovery in two randomized, double-blind trials in patients with acute bronchitis (AB). Similar symptom time courses were observed in two non-comparative observational studies in AB. One non-comparative, open-label study was identified in acute tonsillopharyngitis (ATP), and one in acute rhinosinusitis (ARS). In both indications, nearly all children showed complete recovery or major symptom improvements during the treatment period, with changes that were similar to those observed in controlled trials investigating older patient populations. The results were supported by an additional observational study including children with various diagnoses of aRTIs. EPs 7630 was safe and well-tolerated.

CONCLUSIONS

EPs 7630 is efficacious in children <6 years suffering from AB. The analyses also support the effectiveness of the product in ATP and in ARS. No safety concerns were identified.

The Role of the Human Bocavirus (HBoV) in Respiratory Infections

The human bocavirus is one of the most common respiratory viruses and occurs in all age groups. Because Koch’s postulates have been fulfilled unintendedly, it is currently accepted that the virus is a real pathogen associated with upper and lower respiratory tract infections causing clinical symptoms ranging from a mild common cold to life-threatening respiratory diseases. In order to exclude a viremia, serological analysis should be included during laboratory diagnostics, as acute and chronic infections cannot be differentiated by detection of viral nucleic acids in respiratory specimen alone due to prolonged viral shedding. Besides its ability to persist, the virus appears to trigger chronic lung disease and increases clinical symptoms by causing fibrotic lung diseases. Due to the lack of an animal model, clinical trials remain the major method for studying the long-term effects of HBoV infections.

Minimal to no transfer of certolizumab pegol into breast milk: results from CRADLE, a prospective, postmarketing, multicentre, pharmacokinetic study

Background

Women with chronic inflammatory diseases face uncertainty regarding the safety of biologics during breast feeding. CRADLE was the first industry-sponsored study to evaluate certolizumab pegol (CZP) concentrations in human breast milk and estimate average daily infant dose (ADID) of maternal CZP.

Methods

CRADLE (NCT02154425) was a pharmacokinetic study of lactating mothers receiving CZP. After ≥3 CZP doses, breast milk samples were collected across one dosing period (14 days for 200 mg every 2 weeks [Q2W]; 28 days for 400 mg every 4 weeks [Q4W]). Optimal analytical methods were developed to determine CZP and polyethylene glycol (PEG) levels in breast milk. ADID and relative infant dose (RID) were estimated. Safety events in mothers and infants were assessed.

Results

19 CZP-treated mothers were screened; 17 entered the sampling period: 16 on 200 mg Q2W, 1 on 400 mg Q4W. 77/137 (56%) breast milk samples had no measurable CZP. For 4/17 mothers, all samples were below the lower limit of quantification (LLOQ). Estimated ADID was 0–0.0104 mg/kg/day; median RID: 0.15%. PEG was undetectable in 134/137 samples (results could not be determined in three samples). Infants of CZP-exposed mothers had a safety profile consistent with that of unexposed similar-age infants.

Conclusion

When quantifiable, CZP concentrations were <3× LLOQ (<1% plasma concentration observed with therapeutic dose), indicating no/minimal CZP transfer from plasma to breast milk. RID was 0.15% of maternal dose; <10% is considered unlikely to be of clinical concern. No PEG transfer was observed. CZP absorption by infants via breast milk is unlikely due to its low oral bioavailability and Fc-­free molecular structure. These findings are reassuring and support continuation of CZP treatment during breast feeding.

Trial registration number

NCT02154425; Results.

Are the Saudi parents aware of antibiotic role in upper respiratory tract infections in children?

Upper respiratory tract infection (URTI) is considered to be the most common reason for children's visits to emergency departments or outpatient clinics. The misuse and overuse of antibiotics are currently major public health problems worldwide. This study aimed to assess Saudi parents' knowledge, attitude, and practice (KAP) regarding the use of antibiotics in URTIs in children. This cross-sectional study was conducted in Saudi Arabia using a previously validated questionnaire, which was distributed using Twitter. A total of 385 individuals completed the questionnaire. For the majority of the participants (77%), physicians were the primary source of information regarding the use of antibiotics. Forty-four percent of parents agreed that most URTIs are caused by viruses, and 81% were aware that inappropriate use of antibiotics leads to the development of antibiotic resistance. Fever was the primary symptom (27%) that led parents to ask for prescriptions for antibiotics. Although women had a higher attitude score (p=0.01), there was no difference between genders regarding knowledge and practice. Older participants (41 years or more) had a lower attitude score (p=0.02). Furthermore, participants with five children or more had lower attitude and practice scores (p=0.006, 0.04, respectively). Participants who lived in large cities had greater knowledge compared to the inhabitants of small cities (p=0.01). In conclusion, the findings of this study demonstrated that most of the participants were educated but lacked knowledge regarding antibiotic use in URTIs in children. This lack of knowledge led to inappropriate attitude and practice. Thus, launching public educational campaigns and encouraging physicians to educate parents regarding the proper use of antibiotics are recommended.

Misconceptions and Malpractices Toward Antibiotic Use in Childhood Upper Respiratory Tract Infections Among a Cohort of Lebanese Parents

Antimicrobial resistance is an emerging global health threat. Misuse and abuse of antibiotics are of particular concern in the pediatric population. Since management of childhood illnesses depends considerably on parents' perceptions, the objectives of this study were to report parents' perspectives and assess their practices toward antibiotics used for upper respiratory tract infections (URTIs) in children. Using a cross-sectional design, anonymous structured questionnaires were completed by 1,037 parents in public and private schools across Lebanon's largest governorate. Descriptive statistics were used to report participants' responses. A multivariate analysis was performed to identify factors affecting knowledge and malpractice related to antibiotic use. Significant misconceptions and malpractices were identified among parents. For instance, 33.9% of parents considered that antibiotics are helpful in treating common cold among children and 36.2% believed antibiotics expedite the recovery of their child with common cold infection. Moreover, there was a lack of knowledge concerning antibiotic coverage, since 37.9% of the respondents believed that antibiotics treat viral infections and 21.5% were neutral toward this question. Around 20% of the participants believed they can reduce the dose of antibiotics if the child gets better. Significant factors associated with poor knowledge and misuses were parents' lower educational and socioeconomic levels. Despite extensive evidence on the limited role of antibiotics in URTIs, parents in Lebanon continue to misuse them. More concerted efforts are needed to improve parents' knowledge and practices with regard to the rational use of antibiotics.

Respiratory infections of the human bocavirus

The human bocavirus is one of the most common respiratory viruses and occurs in all age groups. It is associated with upper and lower respiratory tract infections, and causes clinical symptoms from the mild common cold to life threatening respiratory diseases. Besides its ability to persist the virus appears to trigger chronic lung disease and increase the clinical symptoms, while being a putative trigger for fibrotic lung diseases.

Laboratory diagnostics should include serological diagnostics in order to rule out a viremia because due to prolonged viral shedding acute and chronic infections cannot be differentiated on the detection of viral nucleic acids in respiratory specimen alone.

Although Koch’s postulates cannot be formally fulfilled due to the lack of an animal model and the chance for clinical trials with volunteers are limited due to the long term effects of HBoV infections, there is no doubt that the virus is a serious pathogen and requires attention.

The aim of the chapter is to present an overview of our current knowledge on respiratory infections with the human bocavirus, and to provide basic and essential information on clinical features, molecular diagnostics, and epidemiologic challenges arising with this pathogen.

Practical use of povidone-iodine antiseptic in the maintenance of oral health and in the prevention and treatment of common oropharyngeal infections

AIMS

To better inform medical practitioners on the role of antiseptics in oropharyngeal health and disease, this article focuses on povidone-iodine (PVP-I), an established and widely-available antiseptic agent.

METHODOLOGY

Review of the anti-infective profile, efficacy and safety of PVP-I in managing common upper respiratory tract infections such as the common cold, influenza and tonsillo-pharyngitis, as well as oral complications resulting from cancer treatment (oral mucositis), and dental conditions (periodontitis, caries).

RESULTS

Antiseptics with broad-spectrum anti-infective activity and low resistance potential offer an attractive option in both infection control and prevention. While there is some evidence of benefit of antiseptics in a variety of clinical settings that include dental and oral hygiene, dermatology, oncology, and pulmonology, there appears to be discordance between the evidence-base and practice. This is especially apparent in the management and prevention of oropharyngeal infections, for which the use of antiseptics varies considerably between clinical practices, and is in marked contrast to their dermal application, where they are extensively used as both a prophylaxis and a treatment of skin and wound infections, thus minimising the use of antibiotics.

CONCLUSION

The link between oral and oropharyngeal health status and susceptibility to infection has long been recognised. The high rates of antibiotic misuse and subsequent development of bacterial resistance (e.g. increasing vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA)) in large parts of the world, especially across Asia Pacific, highlight the need for identifying alternative antimicrobials that would minimise the use of these medications. This, together with recent large-scale outbreaks of, for example, avian and swine influenza virus, further underline the importance of an increasing armamentarium for infection prevention and control.

Antimicrobial properties of honey

Honey has been widely accepted as food and medicine by all generations, traditions, and civilizations, both ancient and modern. For at least 2700 years, honey has been used by humans to treat a variety of ailments through topical application, but only recently have the antiseptic and antimicrobial properties of honey been discovered. Honey has been reported to be effective in a number of human pathologies. Clinical studies have demonstrated that application of honey to severely infected cutaneous wounds rapidly clears infection from the wound and improves tissue healing. A large number of in vitro and limited clinical studies have confirmed the broad-spectrum antimicrobial (antibacterial, antifungal, antiviral, and antimycobacterial) properties of honey, which may be attributed to the acidity (low pH), osmotic effect, high sugar concentration, presence of bacteriostatic and bactericidal factors (hydrogen peroxide, antioxidants, lysozyme, polyphenols, phenolic acids, flavonoids, methylglyoxal, and bee peptides), and increase in cytokine release, and to immune modulating and anti-inflammatory properties of honey; the antimicrobial action involves several mechanisms. Despite a large amount of data confirming the antimicrobial activity of honey, there are no studies that support the systemic use of honey as an antibacterial agent.

Effectiveness of internal quality assurance programmes in improving clinical practice and reducing costs

RATIONALE, AIMS AND OBJECTIVES

To assess the effectiveness of internal initiatives to improve quality as compared with external feedback, and as compared with a control group.

METHOD

Ten primary health centres were randomly selected from the centres in the Murcia's Region and were randomly assigned into three groups: G1 committed themselves to the improvement; G2 composed by two subgroups: with and without quality improvement (QI) activities - received external feedback; G3 received no intervention. Quality of common cold management was measured in a random sample of 50 patients per centre before and after interventions. Effect was assessed comparing criteria compliance and the cost of treatments for common cold in the three groups.

RESULTS

G1 and G2 subgroup with internal QI improved significantly in all criteria, and in G1 average treatment cost decreased by 60% (P < 0.01). G3 improved only in one criterion. Estimated yearly savings in treatment costs for common cold, for a centre with internal QI, were euro 12,193.83 and it would be euro 1,817 004.65 for the 30 centres in the Region.

CONCLUSIONS

Internally assumed QI activities were significantly more effective than external feedback. Besides, the high cost of deficient quality provides a wide margin to invest with benefits in the promotion of internal QI programmes.