Meta-analysis of randomized controlled trials on the comparative efficacy and safety of azithromycin against other antibiotics for upper respiratory tract infections

WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections

The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.

Short- vs. Long-Course Antibiotic Treatment for Acute Streptococcal Pharyngitis: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

To evaluate the effectiveness of short courses of antibiotic therapy for patients with acute streptococcal pharyngitis.

METHODS

Randomized controlled trials comparing short-course antibiotic therapy (≤5 days) with long-course antibiotic therapy (≥7 days) for patients with streptococcal pharyngitis were included. Two primary outcomes: early clinical cure and early bacterial eradication.

RESULTS

Fifty randomized clinical trials were included. Overall, short-course antibiotic treatment was as effective as long-course antibiotic treatment for early clinical cure (odds ratio (OR) 0.85; 95% confidence interval (CI) 0.79 to 1.15). Subgroup analysis showed that short-course penicillin was less effective for early clinical cure (OR 0.43; 95% CI, 0.23 to 0.82) and bacteriological eradication (OR 0.34; 95% CI, 0.19 to 0.61) in comparison to long-course penicillin. Short-course macrolides were equally effective, compared to long-course penicillin. Finally, short-course cephalosporin was more effective for early clinical cure (OR 1.48; 95% CI, 1.11 to 1.96) and early microbiological cure (OR 1.60; 95% CI, 1.13 to 2.27) in comparison to long-course penicillin. In total, 1211 (17.7%) participants assigned to short-course antibiotic therapy, and 893 (12.3%) cases assigned to long-course, developed adverse events (OR 1.35; 95% CI, 1.08 to 1.68).

CONCLUSIONS

Macrolides and cephalosporins belong to the list of "Highest Priority Critically Important Antimicrobials"; hence, long-course penicillin V should remain as the first line antibiotic for the management of patients with streptococcal pharyngitis as far as the benefits of using these two types of antibiotics do not outweigh the harms of their unnecessary use.

Sinus Fluid Penetration of Oral Clarithromycin and Azithromycin in Patients with Acute Rhinosinusitis

Background

The aim of this study was to investigate the extracellular concentration and the degree of sinus fluid penetration of newer macrolides, within the first 24–48 hours of treatment in patients with acute bacterial rhinosinusitis (ABRS), choosing clarithromycin and azithromycin as model antibiotics. An open, noninterventional pharmacokinetic study was performed at a tertiary teaching hospital.

Methods

In 36 outpatients with ABRS, sinus fluid aspirates and serum samples were collected 2, 4, 6, 8, and 12 hours or 2, 6, 12, and 24 hours after the administration of three doses of oral clarithromycin, 500 mg, twice daily or two doses of oral azithromycin, 500 mg, once daily, respectively. Drug concentrations were determined in both matrices by high-performance liquid chromatography with fluorometric detection, and the pH was estimated for all sinus fluid samples.

Results

The average clarithromycin sinus fluid concentration was found to be significantly higher than the corresponding azithromycin concentration (2.47 mg/L versus 0.65 mg/L), while the extent of the average sinus fluid penetration, expressed by the ratio of drug concentration in tissue versus serum, was similar for both drugs (115 and 120%, respectively).

Conclusion

In patients with ABRS, clarithromycin and azithromycin present adequate penetration into sinus fluid to eradicate erythromycin-sensitive strains of Streptococcus pneumoniae. Considering their comparative in vitro activity, the sinus fluid pH effect, and their sinus fluid penetration profile, we may conclude that among the erythromycin-resistant S. pneumoniae strains, clarithromycin might be advantageous over azithromycin in eradicating some of the low-level resistant strains.

WITHDRAWN: Antibiotics for acute maxillary sinusitis in adults

Currently, two separate Cochrane reviews, ‘Antibiotics for acute maxillary sinusitis in adults ’ and ‘Antibiotics for clinically diagnosed acute rhinosinusitis in adults ’ describe the effect of antibiotics for acute rhinosinusitis. Although both Cochrane reviews study the same condition, they look at different populations (patients in which the diagnosis was based on clinical signs and symptoms and patients in which the diagnosis was confirmed by imaging). Because of this, the conclusions are different in these Cochrane reviews. This was confusing for clinicians who needed to read both Cochrane reviews to know which conclusions are most applicable to their patients.
 
 This review is being withdrawn and will be incorporated into the updated publication of ‘Antibiotics for clinically diagnosed acute rhinosinusitis in adults ’. This ‘merged’ review will still maintain the relevant distinction between the two populations. However, information on the effectiveness of antibiotics for rhinosinusitis will be published in the ‘merged’ Cochrane review. We will omit the comparison between antibiotics (as published in this Cochrane review) because the choice for certain antibiotics and/or doses differs according to the local antibiotic resistance patterns and therefore this comparison is less relevant.

The editorial group responsible for this previously published document have withdrawn it from publication.

Antibiotics for acute maxillary sinusitis in adults

BACKGROUND

Sinusitis is one of the most common diagnoses among adults in ambulatory care, accounting for 15% to 21% of all adult outpatient antibiotic prescriptions. However, the role of antibiotics for sinusitis is controversial.

OBJECTIVES

To assess the effects of antibiotics in adults with acute maxillary sinusitis by comparing antibiotics with placebo, antibiotics from different classes and the side effects of different treatments.

SEARCH METHODS

We searched CENTRAL 2013, Issue 2, MEDLINE (1946 to March week 3, 2013), EMBASE (1974 to March 2013), SIGLE (OpenSIGLE, later OpenGrey (accessed 15 January 2013)), reference lists of the identified trials and systematic reviews of placebo-controlled studies. We also searched for ongoing trials via ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). We imposed no language or publication restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotics with placebo or antibiotics from different classes for acute maxillary sinusitis in adults. We included trials with clinically diagnosed acute sinusitis, confirmed or not by imaging or bacterial culture.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed trial quality. We calculated risk ratios (RRs) for differences between intervention and control groups in whether the treatment failed or not. All measures are presented with 95% confidence intervals (CIs). We conducted the meta-analyses using either the fixed-effect or random-effects model. In meta-analyses of the placebo-controlled studies, we combined data across antibiotic classes. Primary outcomes were clinical failure rates at 7 to 15 days and 16 to 60 days follow-up. We used GRADEpro to assess the quality of the evidence.

MAIN RESULTS

We included 63 studies in this updated review; nine placebo-controlled studies involving 1915 participants (seven of the studies clearly conducted in primary care settings) and 54 studies comparing different classes of antibiotics (10 different comparisons). Five studies at low risk of bias comparing penicillin or amoxicillin to placebo provided information on the main outcome: clinical failure rate at 7 to 15 days follow-up, defined as a lack of full recovery or improvement, for participants with symptoms lasting at least seven days. In these studies antibiotics decreased the risk of clinical failure (pooled RR of 0.66, 95% CI 0.47 to 0.94, 1084 participants randomised, 1058 evaluated, moderate quality evidence). However, the clinical benefit was small. Cure or improvement rates were high in both the placebo group (86%) and the antibiotic group (91%) in these five studies. When clinical failure was defined as a lack of full recovery (n = five studies), results were similar: antibiotics decreased the risk of failure (pooled RR of 0.73, 95% CI 0.63 to 0.85, high quality evidence) at 7 to 15 days follow-up.Adverse effects in seven of the nine placebo-controlled studies (comparing penicillin, amoxicillin, azithromycin or moxicillin to placebo) were more common in antibiotic than in placebo groups (median of difference between groups 10.5%, range 2% to 23%). However, drop-outs due to adverse effects were rare in both groups: 1.5% in antibiotic groups and 1% in control groups.In the 10 head-to-head comparisons, none of the antibiotic preparations were superior to another. However, amoxicillin-clavulanate had significantly more drop-outs due to adverse effects than cephalosporins and macrolides.

AUTHORS' CONCLUSIONS

There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, about 80% of participants treated without antibiotics improved within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population levels.

Use of azithromycin and death from cardiovascular causes

BACKGROUND

Azithromycin use is associated with an increased risk of death from cardiovascular causes among patients at high baseline risk. Whether azithromycin confers a similar risk in the unselected general population is unknown.

METHODS

We conducted a nationwide historical cohort study involving Danish adults (18 to 64 years of age), linking registry data on filled prescriptions, causes of death, and patient characteristics for the period from 1997 through 2010. We estimated rate ratios for death from cardiovascular causes, comparing 1,102,050 episodes of azithromycin use with no use of antibiotic agents (matched in a 1:1 ratio according to propensity score, for a total of 2,204,100 episodes) and comparing 1,102,419 episodes of azithromycin use with 7,364,292 episodes of penicillin V use (an antibiotic with similar indications; analysis was conducted with adjustment for propensity score).

RESULTS

The risk of death from cardiovascular causes was significantly increased with current use of azithromycin (defined as a 5-day treatment episode), as compared with no use of antibiotics (rate ratio, 2.85; 95% confidence interval [CI], 1.13 to 7.24). The analysis relative to an antibiotic comparator included 17 deaths from cardiovascular causes during current azithromycin use (crude rate, 1.1 per 1000 person-years) and 146 during current penicillin V use (crude rate, 1.5 per 1000 person-years). With adjustment for propensity scores, current azithromycin use was not associated with an increased risk of cardiovascular death, as compared with penicillin V (rate ratio, 0.93; 95% CI, 0.56 to 1.55). The adjusted absolute risk difference for current use of azithromycin, as compared with penicillin V, was -1 cardiovascular death (95% CI, -9 to 11) per 1 million treatment episodes.

CONCLUSIONS

Azithromycin use was not associated with an increased risk of death from cardiovascular causes in a general population of young and middle-aged adults. (Funded by the Danish Medical Research Council.).

Guideline for the management of acute sore throat

The European Society for Clinical Microbiology and Infectious Diseases established the Sore Throat Guideline Group to write an updated guideline to diagnose and treat patients with acute sore throat. In diagnosis, Centor clinical scoring system or rapid antigen test can be helpful in targeting antibiotic use. The Centor scoring system can help to identify those patients who have higher likelihood of group A streptococcal infection. In patients with high likelihood of streptococcal infections (e.g. 3-4 Centor criteria) physicians can consider the use of rapid antigen test (RAT). If RAT is performed, throat culture is not necessary after a negative RAT for the diagnosis of group A streptococci. To treat sore throat, either ibuprofen or paracetamol are recommended for relief of acute sore throat symptoms. Zinc gluconate is not recommended to be used in sore throat. There is inconsistent evidence of herbal treatments and acupuncture as treatments for sore throat. Antibiotics should not be used in patients with less severe presentation of sore throat, e.g. 0-2 Centor criteria to relieve symptoms. Modest benefits of antibiotics, which have been observed in patients with 3-4 Centor criteria, have to be weighed against side effects, the effect of antibiotics on microbiota, increased antibacterial resistance, medicalisation and costs. The prevention of suppurative complications is not a specific indication for antibiotic therapy in sore throat. If antibiotics are indicated, penicillin V, twice or three times daily for 10 days is recommended. At the present, there is no evidence enough that indicates shorter treatment length.

Azithromycin in acute bacterial upper respiratory tract infections: an Indian non-interventional study

To assess the effectiveness, safety and tolerability of azithromycin in acute bacterial upper respiratory tract infections (URTIs). In this open-label, prospective, multi-center, non-interventional study in bacterial URTI, the decision to prescribe azithromycin was independent of enrolment. Follow up was 1 week after treatment and if possible, at Week 2. Investigators' assessment of clinical outcome (Success/Failure) at the end of study was the primary endpoint for efficacy analysis. Clinical outcome of 'Success' was defined as the global response of Cure or Improvement. A pharmacoeconomic analysis of management of URTIs was also attempted. Of the 410 patients recruited, all were evaluated for safety and 278 for efficacy. The median treatment duration was 3 days. Following treatment with azithromycin, overall success rate was 98.92% (95% CI 96.88-99.78%; Clopper-Pearson method). The success rate was similar across the sub-groups of acute otitis media-100%, bacterial sinusitis-95.83%, and pharyngotonsillitis-99.38%. The success rate was 100% among children and adolescents (age ≤18 years) and 98.6% among adults (age >18 years). Most of the common signs and symptoms of URTI reported during baseline, significantly improved at the end of the study. Sixteen (3.90%) patients reported treatment emergent adverse events, the most common being diarrhea-5 (1.2%) and flatulence-2 (0.5%). The average cost of treating bacterial URTI was INR 716 per patient. Azithromycin is effective and well tolerated in Indian patients with bacterial URTIs.

Review of macrolides (azithromycin, clarithromycin), ketolids (telithromycin) and glycylcyclines (tigecycline)

The advanced macrolides, azithromycin and clarithromycin, and the ketolide, telithromycin, are structural analogs of erythromycin. They have several distinct advantages when compared with erythromycin, including enhanced spectrum of activity, more favorable pharmacokinetics and pharmacodynamics, once-daily administration, and improved tolerability. Clarithromycin and azithromycin are used extensively for the treatment of respiratory tract infections, sexually transmitted diseases, and Helicobacter pylori-associated peptic ulcer disease. Telithromycin is approved for the treatment of community-acquired pneumonia. Severe hepatotoxicity has been reported with the use of telithromycin.

Canadian clinical practice guidelines for acute and chronic rhinosinusitis

This document provides healthcare practitioners with information regarding the management of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) to enable them to better meet the needs of this patient population. These guidelines describe controversies in the management of acute bacterial rhinosinusitis (ABRS) and include recommendations that take into account changes in the bacteriologic landscape. Recent guidelines in ABRS have been released by American and European groups as recently as 2007, but these are either limited in their coverage of the subject of CRS, do not follow an evidence-based strategy, or omit relevant stakeholders in guidelines development, and do not address the particulars of the Canadian healthcare environment.

Advances in understanding the pathophysiology of CRS, along with the development of appropriate therapeutic strategies, have improved outcomes for patients with CRS. CRS now affects large numbers of patients globally and primary care practitioners are confronted by this disease on a daily basis. Although initially considered a chronic bacterial infection, CRS is now recognized as having multiple distinct components (eg, infection, inflammation), which have led to changes in therapeutic approaches (eg, increased use of corticosteroids). The role of bacteria in the persistence of chronic infections, and the roles of surgical and medical management are evolving. Although evidence is limited, guidance for managing patients with CRS would help practitioners less experienced in this area offer rational care. It is no longer reasonable to manage CRS as a prolonged version of ARS, but rather, specific therapeutic strategies adapted to pathogenesis must be developed and diffused.

Guidelines must take into account all available evidence and incorporate these in an unbiased fashion into management recommendations based on the quality of evidence, therapeutic benefit, and risks incurred. This document is focused on readability rather than completeness, yet covers relevant information, offers summaries of areas where considerable evidence exists, and provides recommendations with an assessment of strength of the evidence base and degree of endorsement by the multidisciplinary expert group preparing the document.

These guidelines have been copublished in both Allergy, Asthma & Clinical Immunology and the Journal of Otolaryngology-Head and Neck Surgery.

Macrolides, ketolides, and glycylcyclines: azithromycin, clarithromycin, telithromycin, tigecycline

The advanced macrolides, azithromycin and clarithromycin, and the ketolide, telithromycin, are structural analogs of erythromycin. They have several distinct advantages when compared with erythromycin, including enhanced spectrum of activity, more favorable pharmacokinetics and pharmacodynamics, once-daily administration, and improved tolerability. Clarithromycin and azithromycin are used extensively for the treatment of respiratory tract infections, sexually transmitted diseases, and Helicobacter pylori-associated peptic ulcer disease. Telithromycin is approved for the treatment of community-acquired pneumonia. Severe hepatotoxicity has been reported with the use of telithromycin.

Increased clinical failures when treating acute otitis media with macrolides: a meta-analysis

BACKGROUND

Macrolide antibiotics are often used to treat children with acute otitis media (AOM); however, the 2004 American Academy of Pediatrics (AAP) and American Academy of Family Physicians guidelines recommend against their use in patients without history of a type I allergic reaction to penicillins.

OBJECTIVE

To evaluate via meta-analysis the comparative efficacy of amoxicillin or amoxicillin/clavulanate to that of macrolide antibiotics in the treatment of children with AOM.

METHODS

A systematic literature search of MEDLINE, EMBASE, and International Pharmaceutical Abstracts was conducted from the earliest available date through September 2008. We used the following MeSH and key words: amoxicillin, amoxicillin/clavulanate, Augmentin, azithromycin, ceftriaxone, clarithromycin, macrolides, AND media, otitis media, and effusion. Included studies were randomized, blinded, and controlled trials evaluating guideline-recommended antibiotics (amoxicillin or amoxicillin/clavulanate) compared to macrolide antibiotics (azithromycin or clarithromycin) in AOM in children. The primary outcome assessed was clinical failure measured between days 10 and 16 after starting antibiotic therapy. Results are reported as relative risks (RRs) with 95% confidence intervals and were calculated using a random-effects model.

RESULTS

A total of 10 trials (N = 2766) evaluating children 6 months-15 years old were included in the meta-analysis. Upon meta-analysis, the use of macrolide antibiotics was associated with an increased risk of clinical failure (RR 1.31 [95% CI 1.07 to 1.60]; p = 0.008) corresponding to a number needed to harm of 32. Upon safety analysis, rates of any adverse reaction (RR 0.74 [95% CI 0.60 to 0.90]; p = 0.003) and diarrhea (RR 0.41 [95% CI 0.32 to 0.52]; p < 0.0001) were significantly lower in the macrolide group.

CONCLUSIONS

The meta-analysis suggests that patients treated with macrolides for AOM may be more likely to have clinical failures. As such, it supports the current AAP AOM recommendation that macrolides be reserved for patients who can not receive amoxicillin or amoxicillin/clavulanate.

Amoxicillin and amoxicillin plus clavulanate: a safety review

Despite the considerable number of newer antibacterials made available over the past decades, amoxicillin, alone or in combination with clavulanic acid, still accounts among the most widely used antibacterial agents. Although they are often considered 'twin drugs', they are different both in terms of antibacterial activities and of safety profile. It is well documented that the clavulanate component may cause adverse reactions by itself, thus exposing patients to further, and sometimes undue, risks. Although amoxicillin/clavulanate should be considered as an alternative agent only for the treatment of resistant bacteria, evidence shows that it is often used also when a narrow-spectrum antibiotic would have been just as effective. This prescription habit may have serious consequences in terms of patients' safety, as well as in terms of the development of bacterial resistance.

TLR4 as a risk factor for periodontal disease: a reappraisal

AIM

To determine whether genetic variants of the TLR4 gene are associated with either chronic or aggressive periodontitis.

METHODS

A systematic electronic search of literature was conducted to identify all published studies without any language restriction on the association between TLR4 and periodontal diseases, including chronic periodontitis and aggressive periodontitis. All case-control studies evaluating the TLR4 Asp299Gly and Thr399Ile polymorphisms in chronic or aggressive periodontitis were identified. A meta-analysis of the studies that fulfilled the inclusion criteria was performed.

RESULTS

Seven studies comprising 744 chronic periodontitis cases and 855 controls and four studies consisting of a total of 295 aggressive periodontitis cases and 456 controls were included in the meta-analysis. In the pooled analysis, the TLR4 299Gly allele (TLR4+896 A>G) appeared to be a genetic risk factor for susceptibility to chronic periodontitis with a random effects and fixed effects odds ratio (OR) of 1.43 [95% confidence interval (CI):1.04-1.97; p=0.03]. On the other hand, the TLR4 399Ile polymorphism (TLR4+1196 C>T) showed a protective effect against aggressive periodontitis with a random effects OR of 0.29 (95% CI: 0.13-0.61; p=0.001).

CONCLUSION

Our results suggest that the alleles 299Gly and 399Ile in TLR4 can be a potential genetic marker for periodontal disease.

Antibiotics for acute maxillary sinusitis

BACKGROUND

Expert opinions vary on the appropriate role of antibiotics for sinusitis, one of the most commonly diagnosed conditions among adults in ambulatory care.

OBJECTIVES

We examined whether antibiotics are effective in treating acute sinusitis, and if so, which antibiotic classes are the most effective.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2007, Issue 3); MEDLINE (1950 to May 2007) and EMBASE (1974 to June 2007).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing antibiotics with placebo or antibiotics from different classes for acute maxillary sinusitis in adults. We included trials with clinically diagnosed acute sinusitis, whether or not confirmed by radiography or bacterial culture.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened search results, extracted data and quality assessed trials. Risk ratios (RR) were calculated for differences in the intervention and control groups to see whether or not the treatment was a failure. In meta-analysing the placebo-controlled studies, the data across antibiotic classes were combined. Primary outcomes were the clinical failure rates at 7 to 15 days and 16 to 60 days follow up.

MAIN RESULTS

Fifty-seven studies were included in the review; six placebo-controlled studies and 51 studies comparing different classes of antibiotics. Five studies involving 631 participants provided data for comparison of antibiotics to placebo, when clinical failure was defined as a lack of cure or improvement at 7 to 15 days follow up. These studies found a slight statistical difference in favor of antibiotics, compared to placebo, with a pooled RR of 0.66 (95% confidence interval (CI) 0.44 to 0.98). However, the clinical significance of the result is equivocal, also considering that cure or improvement rate was high in both the placebo group (80%) and the antibiotic group (90%). Based on six studies, when clinical failure was defined as a lack of total cure, there was significant difference in favor of antibiotics compared to placebo with a pooled RR of 0.74 (95% CI 0.65 to 0.84) at 7 to 15 days follow up. None of the antibiotic preparations was superior to each other.

AUTHORS' CONCLUSIONS

Antibiotics have a small treatment effect in patients with uncomplicated acute sinusitis in a primary care setting with symptoms for more than seven days. However, 80% of participants treated without antibiotics improve within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population level.

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.

Acute otitis media-diagnosis and treatment in the era of antibiotic resistant organisms: updated clinical practice guidelines

The treatment of children with AOM has to rely on an accurate diagnosis and a clear discrimination between AOM and serous otitis media. The last decade has seen major changes in the epidemiology of AOM with an earlier onset of disease and a greater proportion of children with recurrent/complicated AOM. The processes of changing susceptibility of bacterial pathogens added a major problem in treatment selection. Tastier, more efficient, safe and conveniently-dosing as well as cost effective drugs are required to achieve adherence to therapy. The recent published guidelines for the treatment of AOM in the present era of pneumoccocal resistance represent a major step forward in the approach to the management of this disease by establishing a clear hierarchy among the various therapeutic agents. A 48-72 h observation option without use of antibacterial therapy in selected children with uncomplicated AOM should be promoted. Immunization against S. pneumoniae with the heptavalent pneumococcal conjugated vaccines was showed to result in a decrease in the frequency of AOM caused by this pathogen, including AOM caused by antibiotic-resistant S. pneumoniae.

Macrolides and ketolides: azithromycin, clarithromycin, telithromycin

The advanced macrolides, azithromycin and clarithromycin, and the ketolide telithromycin are structural analogues of erythromycin. They have several distinct advantages when compared with erythromycin including enhanced spectrum of activity, more favorable pharmacokinetics and pharmacodynamics, once daily administration, and improved tolerability. This article reviews the pharmacokinetics, antimicrobial activity, clinical use, and adverse effects of these antimicrobial agents.

[Short treatment of donovanosis with azithromycin]

INTRODUCTION

Azithromycine is recommended in the treatment of donovanosis with a 7-day treatment cycle. We report the efficacy of a single cure of 1 gram in two patients.

OBSERVATIONS

Four patients, presenting with donovanosis, were treated with azithromycine according to 2 regimens. The first used 500 mg/d the molecule during 1 week, the second used azithromycine in single cure of 1 gram. The latter led to the complete cure of 2 patients.

DISCUSSION

Many antibiotics are used in the treatment of donovanosis. Since 1996, Australian authors have used azithromycine in this indication. A single dose of this molecule appears effective in recent and confined donovanosis.

Treatment outcomes after highly active antiretroviral therapy: a meta-analysis of randomised controlled trials

This systematic review summarises the evidence for treatment efficacy and tolerability of highly active antiretroviral therapies containing two nucleoside reverse transcriptase inhibitors (NRTI) with a protease inhibitor (PI), compared with two NRTIs alone for the treatment of HIV-1 infection in randomised controlled trials. Three electronic databases (Medline, Embase, and the Cochrane Library) were searched up to December 2003. 16 randomised controlled trials met the inclusion criteria and were included in the analysis from 328 articles screened. The pooled analysis indicated that treatment with two NRTIs with a PI is more effective in achieving viral suppression than two NRTIs alone (relative risk [RR] 3.44, 95% confidence interval [CI] 2.43-4.87). However, the RR for discontinuation of treatment due to adverse events of treatment with two NRTIs with a PI compared with two NRTIs alone was 1.81 (95% CI 1.17-2.79). The benefits of treatment with two NRTIs and a PI are substantial among those who can tolerate the regimen in comparison with treatment with two NRTIs alone.

Safety and tolerability of azithromycin in pediatric infectious diseases: 2003 update

Oral azithromycin suspension has been prescribed to >80 million patients. Children find the color and taste of the oral suspension of azithromycin agreeable, and the drug is well-tolerated. On average 9% of patients have treatment-related adverse events, which are most frequently gastrointestinal complaints. The side effects are mild to moderate and very seldom necessitate withdrawal of the treatment. In addition to the conventional 3-day 10-mg/kg/day regimen and the 10 mg/kg on Day 1 followed by 5 mg/kg on Days 2 to 5 regimens, single dose 30 mg/kg and 3-day 20-mg/kg/day regimens are well-tolerated, although these new dosages are associated with more adverse effects.

Acute rhinosinusitis : a pharmacoeconomic review of antibacterial use

Acute rhinosinusitis is a common disease, in both children and adult patients, and happens most often in the setting of a viral infection with or without bacterial superinfection. Although spontaneous resolution is common, antibacterials are often prescribed and have a tremendous impact on costs, either directly or through the emergence of resistance in causative or colonising micro-organisms. The purpose of this work was to review published literature from 1989 to 2002 on antibacterial treatment in acute rhinosinusitis from a clinical and economical perspective. A relatively small number of studies have compared antibacterials with placebo and few have suggested that antibacterials are superior to placebo, except when a bacterial cause is established or in the presence of specific CT-scan findings. On the other hand, 58 randomised controlled trials were published between 1989 and 2002, that compared the relative efficacy of various antibacterials. Most of these studies had serious methodological flaws, and no single antibacterial proved superior to its comparators. Economic data are scarce and indicate cost of disease is high. Of the different treatment strategies assessed symptomatic treatment (patients being treated with antibacterials only if they failed to improve after 7 days) was the most cost-effective approach, compared with treating patients on the basis of specific clinical criteria, empirical treatment (all patients initially treated with antibacterials), or radiology-guided treatment. Cost effectiveness varied with disease prevalence. In conclusion, this pharmacoeconomic review of antibacterial use in acute rhinosinusitis shows the need for improvement in the quality of the studies feeding economic analyses, but suggests that huge financial interests are at stake. Savings achievable, by better targeting patients needing antibacterial treatment, could be substantial, and more practical and precise diagnostic procedures are clearly needed. Acute rhinosinusitis is a typical example of a clinical dilemma in which good clinical practice must be balanced against imperfect information and patients' individual interests balanced against society's interest.

Meta-Analysis

Systematic reviews use explicit and reproducible criteria to assemble, appraise, and combine articles with a minimum of bias. Meta-analysis is a form of systematic review that uses statistical techniques to derive quantitative estimates of the magnitude of treatment effects and their associated precision. Valid meta-analyses address focused questions, use appropriate criteria to select articles, assess the quality and combinability of articles, provide graphic and numeric summaries, consider potential biases, and can be generalized to a meaningful target population. The rate difference, or absolute risk reduction, is the preferred measure of clinical effect size; the reciprocal tells the number needed to treat for one additional favorable outcome. The benefits of meta-analysis over individual trials include greater precision, increased statistical power, and the ability to identify and explore diversity among studies. Threats to validity include heterogeneity, citation bias, publication bias, language bias, and variations in study quality. Because meta-analysis defines rational treatment expectations at a population level, it is an adjunct to, not a substitute for, clinical judgment in the care of individual patients.

Acute sinusitis in children: current treatment strategies

Acute sinusitis is a very common infection in childhood, but its management remains a controversial issue. Antibacterials may be effective in selected children, but direct evidence is limited. One randomized, placebo-controlled trial has shown that amoxicillin or amoxicillin/clavulanate are better than placebo for children with symptoms of nasal discharge and cough that are persistent (over 10 days) and not improving. However, another placebo-controlled trial of the same agents did not demonstrate any benefit from antibacterials in a patient population selected with a clinical diagnosis of sinusitis of moderate severity, based on a composite clinical symptom score. A systematic assessment of cure rates with various antibacterials shows no consistent differences between classes. Evidence on the use of ancillary measures and nasal corticosteroids is also limited. The only randomized, placebo-controlled trial of antihistamines and decongestants has shown no incremental benefit when given in addition to amoxicillin. Another placebo-controlled randomized trial showed some transient symptomatic improvement with the use of nasal corticosteroids. No randomized trials exist on the use of antral lavage in children with acute sinusitis. The current rates of antimicrobial resistance among commonly implicated pathogens should be considered in therapeutic decisions. However, there is no evidence from well-designed trials on specifically how to manage children at high risk of carrying resistant organisms. The inaccuracy of clinical signs and symptoms in documenting the diagnosis further complicates therapeutic decisions. Nevertheless, radiographic assessment does not meaningfully improve the accuracy of the diagnosis for uncomplicated cases, and it is not cost effective. In the absence of definitive evidence, treatment with amoxicillin 45 mg/kg/day in two divided doses may be used in selected patients with symptoms that are persistent and not improving. High doses (90 mg/kg in two divided doses) may also be considered, and amoxicillin/clavulanate may be a more appropriate choice when there is high risk of resistant pathogens, e.g. in a child attending a childcare center, or recent use of antibacterials. However, a considerable proportion of children, especially those with mild or improving symptoms, may not have to be treated at all.

Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care

CONTEXT

Broad-spectrum antibiotics are commonly prescribed, but little is known about the physicians who prescribe and the patients who take these agents.

OBJECTIVE

To identify factors associated with prescribing of broad-spectrum antibiotics by physicians caring for patients with nonpneumonic acute respiratory tract infections (ARTIs).

DESIGN, SETTING, AND PATIENTS

Cross-sectional study using data from the National Ambulatory Medical Care Survey between 1997 and 1999. Information was collected on a national sample of 1981 adults seen by physicians for the common cold and nonspecific upper respiratory tract infections (URTIs) (24%), acute sinusitis (24%), acute bronchitis (23%), otitis media (5%), pharyngitis, laryngitis, and tracheitis (11%), or more than 1 of the above diagnoses (13%).

MAIN OUTCOME MEASURE

Prescription of broad-spectrum antibiotics, defined for this study as quinolones, amoxicillin/clavulanate, second- and third-generation cephalosporins, and azithromycin and clarithromycin.

RESULTS

Antibiotics were prescribed to 63% of patients with an ARTI, ranging from 46% of patients with the common cold or nonspecific URTIs to 69% of patients with acute sinusitis. Broad-spectrum agents were chosen in 54% of patients prescribed an antibiotic, including 51% of patients with the common cold and nonspecific URTIs, 53% with acute sinusitis, 62% with acute bronchitis, and 65% with otitis media. Multivariable analysis identified several clinical and nonclinical factors associated with choice of a broad-spectrum agent. After adjusting for diagnosis and chronic comorbid illnesses, the strongest independent predictors of broad-spectrum antibiotic prescribing were physician specialty (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.5 for internal medicine physicians compared with general and family physicians) and geographic region (OR, 2.6; 95% CI, 1.4-4.8 for Northeast and OR, 2.4; 95% CI, 1.4-4.2 for South [both compared with West]). Other independent predictors of choosing a broad-spectrum agent included black race, lack of health insurance, and health maintenance organization membership, each of which was associated with lower rates of broad-spectrum prescribing. Patient age, sex, and urban vs rural location were not significantly associated with prescribing choice.

CONCLUSIONS

Broad-spectrum antibiotics are commonly prescribed for the treatment of ARTIs, especially by internists and physicians in the Northeast and South. These high rates of prescribing, wide variations in practice patterns, and the strong association of nonclinical factors with antibiotic choice suggest opportunities to improve prescribing patterns.