Streptococcus pyogenes transmission among Air Force recruits: efficacy of surveillance and prophylaxis protocols

The prevalence of Streptococcus pyogenes in Air Force recruits (n = 10,634) completing basic training at Lackland Air Force Base between November 1, 1993, and March 1, 1994, was determined. Throat cultures were obtained on the second day and the last day of training, approximately 6 weeks later. Although the prevalence on the second day was nearly identical between males (1.99%) and females (1.98%), males with positive cultures increased to 4.30%, whereas females with positive cultures increased to 2.92% at the end of training. Within flights, an increase was noted in male flights when members sought care and subsequently were positive for S. pyogenes. Within these flights, S. pyogenes prevalence significantly increased from 2.79 to 7.20% (p < 0.001) despite antibiotic therapy and prophylaxis treatment measures. Within female flights, the increase was from 2.68 to 3.35%, which was not statistically significant (p < 0.19). A total of 161 trainees were treated for S. pyogenes as a result of positive cultures; remarkably, 27.3% of these were still culture-positive on the last day of training.

Cefpodoxime: new dosage. A new, unproven, dose regimen

(1) Oral cefpodoxime, a third-generation cephalosporin, has a reduced treatment duration for recurrent pharyngitis; but this is based on a single unblinded trial. (2) At the end of the 5-day treatment during the trial, the clinical efficacy of cefpodoxime was no different from that of a 10-day course of penicillin V or the amoxicillin + clavulanate combination. (3) The relapse rate at 6 months is uninterpretable because many patients were lost to follow-up and were not included in the statistical analysis. To our knowledge the second indication granted for cefpodoxime, chronic tonsillitis, has not been validated in clinical trials. (4) Trivialising cefpodoxime may induce antibiotic resistance.

Seasonal benzathine penicillin G prophylaxis for recurrent streptococcal pharyngitis in children

BACKGROUND

To assess the efficacy of benzathine penicillin G (BPG) prophylaxis in recurrent streptococcal pharyngitis in children.

METHODS

One hundred and sixty children, aged 4-11 years, who experienced at least two episodes of group A beta-hemolytic streptococcal (GABHS) pharyngitis during a 4-month observation period between September and December 1995 were randomly divided into two groups. During the following 4-month period between January and April 1996, 80 children received BPG prophylaxis every 3 weeks as a single intramuscular injection of 1.2 million units for a body weight greater than 27 kg and a half dose for 27 kg or less. Eighty children were accepted as a control group and were not given BPG prophylaxis.

RESULTS

The children in the BPG group experienced significantly less GABHS pharyngitis than those in the control group during the second 4-month period (16 vs 244 episodes, respectively, P < 0.001). BPG prophylaxis decreased streptococcal pharyngitis by 92% in the children in the study group, while the frequency of GABHS pharyngitis was unchanged in those in the control group during the second 4-month period compared with the first 4-month period.

CONCLUSIONS

The data in the present study demonstrated that intramuscular BPG prophylaxis is very effective in preventing GABHS pharyngitis in children. It is recommended that it is used every 3 weeks in at least the fall-winter seasons in children susceptible to frequent GABHS pharyngitis.

The use of low-dose mivacurium to facilitate insertion of the laryngeal mask airway

Ninety patients were assigned randomly in a double-blind manner to receive 0.9% sodium chloride, mivacurium 0.04 mg.kg-1 or mivacurium 0.08 mg.kg-1 intravenously, followed by propofol 2.5 mg.kg-1. A laryngeal mask airway (LMA) was inserted 90 s later. The LMA was positioned correctly during the first attempt in 87% of patients and this was not significantly altered by the use of mivacurium. However, mivacurium decreased the incidence of swallowing, coughing, movement and laryngospasm (p < 0.05). LMA insertion was graded as easy in 88% of patients who had mivacurium, compared with 50% in patients who had propofol alone (p < 0.05). The conditions during LMA insertion were similar after 0.04 or 0.08 mg.kg-1 of mivacurium. Patients were apnoeic for a mean (SD) time of 0.67 (0.72) min after propofol alone, compared with 1.72 (1.06) min and 3.05 (1.36) min in patients who also received mivacurium 0.04 and 0.08 mg.kg-1, respectively (p < 0.01). Patients who received mivacurium had a lower incidence of postoperative sore throat (24-30% vs. 53%) (p < 0.05). In conclusion, low-dose mivacurium facilitates LMA insertion and decreases the incidence of postoperative sore throat.

Reducing the incidence of sore throat with the laryngeal mask airway

The incidence of sore throat after the use of the laryngeal mask was assessed with a randomized trial in 839 patients. Sore throat occurred more often in women, older patients or after multiple insertion attempts. It was found that the frequency in women, but not in men, was lowered from 11.9% to 3.9% (P = 0.012) by reducing intracuff pressure to the minimum required for an effective seal.

Recurrence rate of streptococcal pharyngitis related to hygienic measures

OBJECTIVE

To test the hypothesis that treatment failures of streptococcal pharyngotonsillitis may be caused by reinfection by the patients' own streptococci remaining on a toothbrush or in the bedclothes.

DESIGN

To elucidate the role of streptococcal contamination of the environment, hygienic measures regarding change of toothbrush and bed linen and washing of toys were given to half of the patients/families. Throat specimens were taken from all the patients before treatment with phenoxymethylpenicillin for 5 days, and the patients were followed-up for 1 month. At a home visit after 6-10 days, throat specimens were taken from the patients and all permanent residents of the home. Environmental samples were taken from pillowcases, floors, toothbrushes, dummies, and toys.

SETTING

Six health care centres.

SUBJECTS

114 patients of all ages suffering from group A streptococcal pharyngotonsillitis, and 289 family members.

MEASUREMENTS AND MAIN RESULTS

54 patients/families received hygiene instructions. The total number of recurrences was 40 (35%). There was no difference in treatment failure rate between patients/families that had taken or not taken hygienic measures.

CONCLUSIONS

Hygienic measures have no decisive influence on the risk of recurrence of streptococcal pharyngotonsillitis.

Is an alkalinized lignocaine solution a better topical anaesthetic for intratracheal application?

Topical anaesthesia of the trachea is used to avoid coughing during emergence from anaesthesia. This study was designed to compare the effects of an alkalinized lignocaine and plain lignocaine solution given intratracheally. After institutional approval and written informed consent, 30 patients were randomized into three groups and received in a double-blind fashion: lignocaine, alkalinized lignocaine and normal saline for control. After application of normal or alkalinized lignocaine the tolerance to the tube was significantly better during extubation (P = 0.001). Noradrenaline levels were significantly diminished in the lignocaine groups (P < 0.05). Plain and alkalinized lignocaine solutions for topical anaesthesia significantly improved tolerance to the tracheal tube during emergence from anaesthesia. Plain and alkalinized lignocaine given directly before intubation reduced the sympathomimetic stress response resulting in a lower noradrenaline concentration and a reduced heart rate.

Lidocaine in the endotracheal tube cuff reduces postoperative sore throat

STUDY OBJECTIVES

To test the hypothesis that continuous application of local anesthesia at the contact area between the endotracheal tube cuff and trachea would reduce both the incidence and severity of postoperative sore throat by blocking the tracheal pain receptors with local anesthetic delivered via endotracheal tube (ETT) cuff.

DESIGN

Double-blind randomized study.

SETTING

University affiliate hospital.

PATIENTS

106 ASA physical status I and II patients.

INTERVENTIONS

Patients' ETT cuffs were inflated with either air or lidocaine. The cuffs of the lidocaine group were prefilled with lidocaine for 90 minutes prior to intubation to saturate the cuff membrane. One hour and 24 hours following extubation, patients were asked about the presence and severity of postoperative sore throat.

MEASUREMENTS AND MAIN RESULTS

There was no difference between groups in demographics or anesthetic management. The incidence of sore throat was significantly different at the 24-hour evaluation (59% air vs. 32% lidocaine, p = 0.01). Severity of sore throat was significantly worse with air at both evaluation periods (1 hour = 18.7 +/- 27.0 air vs. 7.90 +/- 18.1 lidocaine, p = 0.02; 24 hours = 25.6 +/- 27.5 air vs. 14.5 +/- 24.8 lidocaine, p = 0.03).

CONCLUSIONS

Using lidocaine to inflate the ETT cuff decreases the severity of postoperative sore throat at one hour, and both the incidence and severity at 24 hours.

Can prophylactic application of immunoglobulin decrease radiotherapy-induced oral mucositis?

Therapeutic application of immunoglobulin is reported to be successful in radiation-induced oral and oropharyngeal mucositis. In this study the efficacy of prophylactic application of immunoglobulin was investigated. In 42 patients with head and neck cancer, postoperative radiation treatment or radiation combined with chemotherapy was performed. In 20 consecutive patients, prophylactic mucositis treatment consisted of panthenol (4 x 10 ml/day) and nystatin (4 x 1 ml/day). The 22 following patients received, supplementary to panthenol and nystatin, 800 mg (5 ml) human immunoglobulin intramuscularly once weekly. During the treatment time, the degree of mucositis was examined 3 times a week. The distribution of maximal mucositis degree revealed slightly more severe mucous membrane reaction in the control group compared with the immunoglobulin group (n.s.). The analysis of mean mucositis degrees in both groups demonstrated statistically significant differences (t test, p = 0.031) related to the entire group (n = 42) and to those 16 patients receiving radiation combined with chemotherapy. There was no significant immunoglobulin-induced effect on mucositis in patients treated by radiation alone. The time from the beginning of therapy to the first interruption could be prolonged 5 days in the immunoglobulin group (n.s.). In conclusion, it is demonstrated that the prophylactic application of immunoglobulin seems to lower the degree of radiation-induced mucositis. In comparison to the published data about therapeutically given immunoglobulin, the clinical efficacy of the prophylactic application of immunoglobulin as it is performed in this study is less evident.

Intranasal immunization with C5a peptidase prevents nasopharyngeal colonization of mice by the group A Streptococcus

Early inflammatory events are initiated by phased production of C5a and interleukin-8 in tissue. Most serotypes of group A streptococci express a surface-bound peptidase (SCPA) which specifically cleaves mouse and human C5a chemotaxins. This study investigates the impact of SCPA on colonization of the nasopharyngeal mucosa of mice and evaluates its potential to induce protective immunity. Two strains, serotypes M6 and M49, which contain insertion and deletion mutations in the SCPA gene (scpA) and represent the two major subdivisions of group A streptococci, were characterized and compared in a mouse intranasal infection model. In this model, SCPA mutants were more rapidly cleared from the nasopharynges of inoculated mice compared with wild-type strains. A 2,908-bp fragment of scpA49 gene, obtained by PCR, was ligated to the expression vector pGEX-4T-1 and expressed in Escherichia coli. The affinity-purified deltaSCPA49 protein proved to be highly immunogenic in mice and rabbits. Although the purified deltaSCPA49 immunogen lacked enzymatic activity, it induced high titers of rabbit antibodies which were able to neutralize peptidase activity associated with M1, M6, M12, and M49 streptococci in vitro. This result confirmed that antipeptidase antibodies lack serotype specificity. Intranasal immunization of mice with the deleted form of the SCPA49 protein stimulated significant levels of specific salivary secretory immunoglobulin A (IgA) and serum IgG antibodies and reduced the potential of wild-type M1, M2, M6, M11, and M49 streptococci to colonize. These experiments suggest a new approach to vaccine development for prevention of streptococcal pharyngitis.

Weekly fluconazole for the prevention of mucosal candidiasis in women with HIV infection. A randomized, double-blind, placebo-controlled trial. Terry Beirn Community Programs for Clinical Research on AIDS

BACKGROUND

Candidiasis is a frequent complication of infection with the human immunodeficiency virus (HIV); however, few data exist about the natural history, prevention, and treatment of mucosal candidiasis in women.

OBJECTIVE

To evaluate the safety and effectiveness of weekly fluconazole prophylaxis for mucosal candidiasis in women infected with HIV.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

14 sites participating in the Community Programs for Clinical Research on AIDS (CPCRA).

PATIENTS

323 women with HIV infection and CD4+ cell counts of 300 cells/mm3 or less.

INTERVENTION

200 mg of fluconazole per week or placebo. Open-label fluconazole for candidiasis prophylaxis was permitted after two oropharyngeal or vaginal episodes or one esophageal episode.

MEASUREMENTS

Development of mucosal candidiasis, clinical and in vitro resistance of Candida species to fluconazole, survival, and adverse events.

RESULTS

After a median follow-up of 29 months, 72 of 162 patients receiving fluconazole and 93 of 161 patients receiving placebo had at least one episode of candidiasis (relative risk [RR], 0.56 [95% Cl, 0.41 to 0.77); P < 0.001). Weekly fluconazole was effective in preventing oropharyngeal candidiasis (RR, 0.50 [Cl, 0.33 to 0.74]; P < 0.001) and vaginal candidiasis (RR, 0.64 [Cl, 0.40 to 1.00]; P = 0.05) but not esophageal candidiasis (RR, 0.91 [Cl, 0.48 to 1.72]; P > 0.2). Relative risks were similar for women who had a history of mucosal candidiasis (RR, 0.5 [Cl, 0.35 to 0.75]) and those who did not (RR, 0.69 [Cl, 0.35 to 1.34]). Absolute risk reduction for patients with a history of infection was 25.6 per 100 person-years, which is more than twice the reduction of 11.2 per 100 person-years seen in patients with no history of infection. This difference reflects the higher risk of patients who previously had an infection. Candida albicans was not usually resistant to fluconazole in vaginal specimens in clinical or in vitro settings; such resistance occurred in less than 5% of patients in each group.

CONCLUSIONS

Weekly fluconazole (200 mg) seems to be safe and effective in preventing oropharyngeal and vaginal candidiasis. This regimen has a useful role in the management of HIV-infected women who are at risk for recurrent mucosal candidiasis.

Management of healthcare workers with pharyngitis or suspected streptococcal infections

The group A streptococcus may cause pharyngitis, rheumatic fever, streptococcal toxic shock syndrome, and serious skin and soft-tissue infections. More than 50 nosocomial outbreaks have been reported since 1966. For this reason, healthcare facilities should develop policies for the diagnosis and treatment of symptomatic hospital employees, and for the recognition and management of potential outbreaks. The clinical diagnosis of streptococcal pharyngitis is unreliable. Rapid streptococcal tests may be used for initial screening, but a negative rapid test should be confirmed with a properly obtained culture. Penicillin remains the treatment of choice, but new alternatives now include a 5-day course of either azithromycin or cefpodoxime.

Dexamethasone in adenotonsillectomy

Edema contributes substantially to the postoperative discomfort and morbidity of adenotonsillectomy. In a double-blind study, 58 children undergoing adenotonsillectomy were given a single intraoperative dose of either dexamethasone or saline. The steroid markedly affected the postoperative course in the first day after surgery. According to parental reports, the percentage of patients vomiting was reduced from 48 to 4%. Severe throat pain was reported in 57% of controls and only 20% of dexamethasone patients. Twice as many steroid patients as controls tolerated some soft food on the first postoperative day. It appears that dexamethasone can greatly improve patient diet and comfort after adenotonsillectomy.

[Postoperative sore throat--a comparison of standard cuff, gas-barrier cuff and Brandt anesthesia tube cuff]

Excessive intracuff pressure due to nitrous oxide diffusion into the cuff can damage the tracheal mucosa. Several endotracheal tubes have been developed (Trachelon gas barrier type tube, Brandt Anaesthesia tube) to limit nitrous oxide-related intracuff pressure increase. We investigated whether the incidence of postoperative sore throat could be reduced by using these tubes. Endotracheal intubation was performed in 37 adult female patients with either a standard tube (group S, n = 14), a gas barrier type tube (group G, n = 11), or a Brandt tube (group B, n = 12). All patients were interviewed 16-30 h postoperatively by anesthesiologist who did not know which tube had been used. The increase of intracuff pressure was significantly lower in group G (7.6 +/- 5.1 mmHg, mean +/- SD) and in group B (3.4 +/- 1.7 mmHg) than that in group S (24.0 +/- 9.5 mmHg). The incidence of postoperative sore throat was not significantly different among the groups, 36% (5/14) in group S, 45% (5/11) in group G, and 33% (4/12) in Group B. This incidence did not correlate with intracuff pressure increase. In conclusion, specially manufactured endotracheal tubes to limit excessive intracuff pressure did not effectively attenuate the incidence of postoperative sore throat in this patient population.

Food-borne outbreak of streptococcal pharyngitis in an Israeli Airforce Base

A food-borne outbreak of group A beta hemolytic streptococcus (GAS) pharyngitis occurred in an Israeli airforce base between 15 and 18 April, 1992. An epidemiologic investigation was conducted in a random sample of the base personnel. The effectiveness of prophylactic administration of penicillin to healthy individuals during the outbreak in preventing secondary spread of the disease was evaluated. 197 patients with pharyngitis were seen at the base clinic during the outbreak. The epidemiologic investigation indicated that the outbreak was food-borne. Consumption of processed white cheese that had been prepared without using a proper hand washing technique, 24 h before lunch on 15 April 1992, and subsequently kept at room temperature for 5 h, was significantly associated with GAS infection of the epidemic strain (p < 0.05). The food handler who processed the cheese had anterior cervical lymphadenopathy and GAS T type 8/25/Imp19 (the epidemic type) was found in his throat culture. The secondary respiratory attack rate among the healthy base personnel (n > 1,000) was 1.6%. 40 base personnel were treated by penicillin prophylaxis and had a secondary attack rate of 0%. The medical personnel who were on duty during the outbreak had a secondary attack rate of 75% (p < 0.001). The use of penicillin prophylaxis did not have an advantage in preventing secondary respiratory spread of streptococcal pharyngitis. Penicillin prophylaxis might reduce the high secondary attack rate of the disease in risk groups such as the medical personnel.

Recolonization with selected alpha-streptococci for prophylaxis of recurrent streptococcal pharyngotonsillitis--a randomized placebo-controlled multicentre study

In a randomized, placebo-controlled, double-blind, multicentre study, 130 patients with recurrence of group A beta-hemolytic streptococci (GAS) and clinical signs of pharyngotonsillitis were enrolled. The patients received antibiotic treatment for 10 days, followed by 10 days of alpha-streptococci-inhibitory to GAS-or placebo spray treatment. Patients taking antibiotic treatment for at least 9 days and using the spray for at least 5 days were included in the efficacy analysis. In addition, recurrence within the first 5 days of spray treatment was classified as 'early treatment failure'. The clinical recurrences (bacteriologically verified) in the alpha- (n = 51) and placebo-treated (n = 61) patient groups were 2% (n = 1) and 23% (n = 14) respectively, in patients given spray for at least 5 days (p = 0.004). The inclusion of 'early treatment failures' reduces this difference (p = 0.064). Both treatments were equally well tolerated. Thus, alpha-streptococci given as a spray and used for at least 5 days significantly prevented recurrence of GAS pharyngotonsillitis.

The advantages of the LMA over the tracheal tube or facemask: a meta-analysis

A meta-analysis was performed on randomised prospective trials comparing the laryngeal mask airway (LMA) with other forms of airway management to determine if the LMA offered any advantages over the tracheal tube (TT) or facemask (FM). Of the 858 LMA publications identified to December 1994, 52 met the criteria for the analysis. Thirty-two different issues were tested using Fisher's method for combining the P values. The LMA has 13 advantages over the TT and four over the FM. The LMA had two disadvantages over the TT and one over the FM. There were 12 issues where neither device had an advantage. Advantages over the TT included: increased speed and ease of placement by inexperienced personnel; increased speed of placement by anaesthetists; improved haemodynamic stability at induction and during emergence; minimal increase in intraocular pressure following insertion; reduced anaesthetic requirements for airway tolerance; lower frequency of coughing during emergence; improved oxygen saturation during emergence; and lower incidence of sore throat in adults. Advantages over the FM included: easier placement by inexperienced personnel; improved oxygen saturation; less hand fatigue; and improved operating conditions during minor paediatric otological surgery. Disadvantages over the TT were lower seal pressures and a higher frequency of gastric insufflation. The only disadvantage compared with the FM was that oesophageal reflux was more likely. The importance of these findings in terms of patient outcome could not be determined from the published data.

Economic evaluation of immunoprophylaxis in children with recurrent ear, nose and throat infections

This study compares the costs of immunoprophylaxis versus no immunoprophylaxis in children with recurrent ear, nose and throat (ENT) infections (otitis media and rhinopharyngitis) using ribosomal immunotherapy ('Ribomunyl'). The per-patient cost of ribosomal immunotherapy (FF297) is offset by direct savings garnered through the prevention of many acute infectious episodes. The net 6-month per-patient savings associated with immunoprophylaxis range from FF272 to FF1704, depending on the indication and the type of treatment-cost estimate. Saved healthcare resources include physician consultations and visits, laboratory tests, medicotechnical services (audiometric tests) and antibiotic therapy. Sensitivity analysis of efficacy and treatment-cost estimates enabled threshold ranges of incremental efficacy to be identified. Cost-equivalence between the 2 treatment options was found to exist when the incremental efficacy of immunoprophylaxis lay between 7.4 and 17.5% (recurrent otitis media), and between 8.9 and 26.1% (recurrent rhinopharyngitis). Thus, even when clearly lower incremental efficacy rates than those reported in controlled clinical trials (approximately 40 to 60%) are assumed, ribosomal immunotherapy can still be expected to be cost effective. An analysis of the perspectives of the various payers in the French healthcare system demonstrated that net savings occurred for all payers involved. However, social security insurance would gain most from an immunoprophylaxis programme. Based on the evidence presented here for France, physicians and payers should give increased attention to this treatment option.

[Control of recurrent ENT infections in children]

Recurrent ENT infections are extremely frequent in children. Actually, early childhood is a period of adaptation to the environment, with low immunologic defences. The hypertrophy of the lymphoid tissue in the Waldeyer ring, which is normal in early childhood, gives a particular picture to these problems. The repercussions of such recurrent ENT infections on the status of the lower respiratory tract, on the stature and weight as on the general well-being of the child, and their potential complications, are sufficient reasons for eradicating them. The various therapeutical means to reach this goal, are described.

Midazolam pretreatment does not ameliorate myoglobinemia or the clinical side effects of succinylcholine

STUDY OBJECTIVE

To determine whether the levels of serum myoglobin and the occurrence of fasciculations and postoperative symptoms following a single dose of succinylcholine are modified by the prior administration of midazolam.

DESIGN

Randomized, double-blind, placebo-controlled study.

SETTING

Outpatient surgical service of a university hospital.

PATIENTS

69 ASA physical status I and II healthy, adult female outpatients undergoing laparoscopy (for diagnosis or tubal ligation) with general anesthesia that included succinylcholine.

INTERVENTIONS

Patients received pretreatment of either a saline placebo (Group 1, n = 31) or intravenous midazolam 0.03 mg/kg (Group 2, n = 38) 5 minutes before succinylcholine.

MEASUREMENTS AND MAIN RESULTS

Serum myoglobin prior to pretreatment and at 5 (t5) and 30 (t30) minutes after succinylcholine was determined by radioimmunoassay. Pain was assessed by telephone interview 24 to 36 hours postoperatively. Baseline myoglobin levels ranged from 14 to 69 ng/ml; the 5- and 30-minute samples varied widely (range, 16 to 900 ng/ml). The rise was 3 or more SDs above the baseline mean in 23% and 42% of Group 1 at t5 and t30, respectively, and in 21% and 35% of Group 2 at t5 and t30, respectively. The differences between groups were not significant. The frequency of fasciculations (77% in Group 1, 87% in Group 2), postoperative sore throat (64% in Group 1, 57% in Group 2), and myalgias (44% in Group 1, 51% in Group 2) also was not significantly different between groups.

CONCLUSIONS

Midazolam had no effect on myoglobin level or postoperative symptoms following succinylcholine.

Beclomethasone prevents postoperative sore throat

The effects of a dose of beclomethasone inhaler (50 micrograms) or lidocaine 10% spray on postoperative sore throat were studied in 120 patients undergoing tracheal intubation for elective surgical procedures. Fifty-four patients (90%) in the beclomethasone group scored no postoperative sore throat compared with 27 (45%) in the lidocaine group (P < 0.001). Beclomethasone inhaler seems to be highly effective in the prevention of postoperative sore throat and is therefore to be recommended before tracheal intubation for general anaesthesia.