[Streptococcal respiratory infection in large organized children's collectives and experience in optimizing its prevention]

Epidemiological analysis of the manifestations of respiratory streptococcal infection in the all-year-round pioneer camp "Ocean" over 1984-1990 and in similar large organized groups of children revealed some common regularities manifested as consecutively repeating morbidity rises in acute respiratory diseases, tonsillitis, scarlet fever over a year (rotations 1-3 and 9). Time course of the disease incidence over each rotation (month) had a specific pattern as well. Trials of our newly developed system of prevention and treatment with tomicid showed its high effectiveness, which manifested by a drop in the morbidity level and changes in the structure and dynamics of respiratory streptococcal infection.

Prophylactic laryngo-tracheal aerosolized lidocaine against postoperative sore throat

A randomized, double-blind study was carried out on 193 ASA I-II surgical patients to assess the effect of aerosolized lidocaine on sore throat, hoarseness and cough in connection with tracheal intubation. The study group received aerosolized lidocaine 100 mg 2 min before tracheal intubation, using a spray. The control group received no spray. The patients underwent a standardized general anaesthesia. The patients were interviewed when leaving the recovery room and the next day in the ward. Specific questions were asked regarding sore throat, cough and hoarseness. There were no significant differences between the two groups, which suggests that topical anaesthesia of the mucosa of the upper airway is ineffective as a means of ameliorating airway complaints in connection with tracheal intubation.

The relationship between preintubation lidocaine and postanesthesia sore throat

A sore throat is the most frequent adverse side effect of general anesthesia. The purpose of this study was to determine the relationship between intravenous lidocaine given during induction of general endotracheal anesthesia and postanesthesia sore throat. In addition, the study examined selected variables (bucking; gender; smoking; type of laryngoscope blade; and use of succinylcholine, condenser-humidifiers, or analgesic medication during the previous hour) in relation to the occurrence of postoperative sore throat. Variables typically associated with postoperative sore throat, including endotracheal tube lubricant, endotracheal tube cuff geometry, endotracheal tube size, local anesthetic spray to the trachea, traumatic intubation, postoperative mechanical ventilation, nasal intubation, nasogastric tubes, and nasal airways, were controlled. The researcher administered the visual analogue scale to 139 subjects at 21 to 27 hours following termination of the anesthetic in order to rate sore throat. A retrospective chart review provided data on the variables selected for study and those that were controlled. Chi-square and independent t-tests revealed that a decrease in the severity of the sore throat, as recorded on the visual analogue scale, was significantly related to use of intravenous lidocaine and condenser-humidifiers.

[Prophylactic administration of glucocorticoids prior to microlaryngoscopies?]

Intravenous glucocorticoids before direct laryngoscopy? The necessity of a preventive injection of corticoids before direct laryngoscopy was determined in a prospective, double blind study. 51 patients, who underwent direct laryngoscopy under general anaesthesia, received either 250 mg methylprednisolone in 10 ml NaCl 0.9% (corticoid group) or 10 ml NaCl (NaCl group) intravenously one hour before laryngoscopy. Oedema formation and the degree of inflammation in the pharynx and hypopharynx were examined on the day prior to surgery and three to four hours postoperatively. Complications of the airways were noted in the immediate postoperative phase and at the time of the second examination. Direct laryngoscopy did not induce any significant change in oedema formation or degree of inflammation in both groups. However, there was a correlation between the duration of surgery and the degree of increase in oedema and inflammation in the NaCl group but not in the corticoid group. No difference between the groups was noted with regard to postoperative complications of the airways. Based on the present study, routine application of corticoids to prevent oedema after direct laryngoscopy cannot be recommended.

Hyperendemic Streptococcus pyogenes infection despite prophylaxis with penicillin G benzathine

BACKGROUND

In closely confined populations, in which epidemics of Streptococcus pyogenes infection are common, penicillin G benzathine has long been used prophylactically to reduce morbidity from this pathogen. We report on our investigations of the effectiveness of penicillin G benzathine prophylaxis at a military recruit camp.

METHODS

We prospectively studied the rates of pharyngeal colonization and infection by S. pyogenes among 736 male U.S. Marine Corps recruits from January through March 1989. Throat swabs for culture, clinical data, and questionnaire data were obtained during six examinations at intervals of two weeks. Serum samples obtained before training, after training, and from acutely ill recruits were analyzed with use of an antistreptolysin O microtitration technique.

RESULTS

Although 93 percent of the recruits received prophylaxis with two intramuscular injections of 1.2 million units of penicillin G benzathine each (administered 30 to 39 days apart), 33 percent of the recruits were colonized by S. pyogenes, and 42 percent had infection (as defined by a two-dilution increase in the antistreptolysin O titer). Thirty-seven percent of 265 recruits who reported a sore throat and were infected with S. pyogenes did not seek medical attention. The recruits who were allergic to penicillin (7 percent of the total), who received no prophylaxis, were more likely to be colonized; an increased risk of colonization and infection among the nonallergic recruits was associated with the presence of a higher percentage of allergic recruits in the platoon. After the study was completed, all recruits who were allergic to penicillin were prescribed 250 mg of oral erythromycin twice daily (a total daily dose of 500 mg) for 60 days. Subsequently, the average weekly rate of clinically evident S. pyogenes pharyngitis fell by more than 75 percent.

CONCLUSIONS

If the prevention of S. pyogenes infection is to be effective in closely confined populations such as military recruits, prophylactic antibiotics must be administered to all members of the population. Exempting those who are allergic to penicillin may create a bacterial reservoir from which infection can be transmitted to nonallergic members of the population.

Peritonsillar abscess: risk of disease in the remaining tonsil after unilateral tonsillectomy à chaud

The occurrence of disease in the remaining tonsil after unilateral tonsillectomy à chaud in the treatment of peritonsillar abscess, was studied in 536 patients. No patient had a history of previous severe tonsillitis at the time of the unilateral tonsillectomy, 6.1 per cent of the patients were readmitted for surgery of the remaining tonsil during the follow-up period. Ninety-seven per cent of these patients were younger than 30 years of age. Previous investigations have shown increasing frequency by age of pharyngitis after bilateral tonsillectomy. We suggest bilateral tonsillectomy in all cases of patients younger than 30 years old who suffer from peritonsillar abscess irrespective of previous tonsillar disease. Patients older than 30 should be treated with unilateral ablation, unless there is a clear indication for bilateral tonsillectomy.

The role of day care givers in the identification and prevention of infections

The prevalence of nasopharyngeal Streptococcus pyogenes in children attending day care centers in North Jordan was studied. Nasal and throat swabs, cultured for Streptococcus pyogenes were collected from 100 children enrolled in four day care centers serving middle to high socioeconomic status portions of the population in March 1989. The identity of the streptococcal isolates was confirmed by biochemical and serological methods. Throat infection manifestations of the past 3 days, as reported and observed by the care givers, were related to culture results. The study findings showed that the prevalence of nasopharyngeal Streptococcus pyogenes was high and ranged between 10 to 23.3%. It was also noted that the care givers were able to correctly identify children with suspected throat infection, in 11 to 25% of the children who grew Streptococcus pyogenes on cultures, by mere observation of the symptoms. Due to the high prevalence of nasopharyngeal Streptococcus pyogenes in these settings, measures to control and prevent the spread of Streptococcus pyogenes must be employed. This study suggests that care givers may play an important role in achieving such a goal if they are offered proper health education programs and instructions on child hygiene.

Postoperative sore throat: topical hydrocortisone

Forty patients undergoing tracheal intubation and controlled ventilation of the lungs for elective surgical procedures were studied. They were allocated randomly into one of two groups. The tracheal tubes used for group A patients were lubricated before insertion with water-soluble 1% hydrocortisone cream. Those for group B patients were lubricated with KY jelly. The incidence of postoperative sore throat was found to be significantly greater in group A. Topical 1% hydrocortisone cream is therefore ineffective in the prevention of postoperative sore throat.

Prophylaxis of oropharyngeal candidiasis with fluconazole

A total of 112 cancer patients who could ultimately be evaluated were randomly assigned in a double-blind study to receive either fluconazole or placebo as antifungal prophylaxis during hospitalization. Thrush, defined by appropriate lesions in the oropharynx and confirmed by scrapings and cultures positive for Candida species, occurred in 2% of the 58 patients given fluconazole and in 28% of the 54 patients given placebo (P = .0003). Candida species were cultured from initial throat specimens from 29 patients given fluconazole and from 26 patients given placebo. Oropharyngeal candidiasis was detected subsequently in 3% of the former patients and 54% of the latter patients (P = .0001). Adverse reactions that were probably due to or aggravated by fluconazole occurred in only four patients and consisted of transient liver function abnormalities in three instances and nausea and vomiting in one. Oral fluconazole is an effective agent for prophylaxis of oropharyngeal candidiasis in susceptible cancer patients.

Oropharyngeal mucositis complicating bone marrow transplantation: prognostic factors and the effect of chlorhexidine mouth rinse

Oral mucosal ulceration complicating bone marrow transplantation interferes with patients' comfort, nutrition and may lead to systemic infection derived from the mouth. The mucosal injury results from epithelial damage due to the cytotoxic effects of chemotherapy and radiation conditioning as well as from superficial oropharyngeal infection. Because chlorhexidine gluconate is a broad spectrum topical antimicrobial which has been demonstrably effective in preventing oral infection and gingivitis, we performed a randomized, placebo controlled, double-blind trial of chlorhexidine as a mouth rinse in BMT recipients to study the severity of oral mucositis and both oral and systemic infectious complications. One hundred patients were randomly assigned to receive either chlorhexidine gluconate 0.12% mouth rinse or placebo three times daily from the initiation (day -8) of chemoradiotherapy conditioning until day +35 post-BMT. Chlorhexidine use resulted in a trend toward improved oral hygiene index (reduced dental plaque) (p = 0.06) but did not modify the oral mucositis. Patients using chlorhexidine developed a maximum ulceration of 18 +/- 22% of their oral mucosa, while placebo patients ulcerated 25 +/- 31% of the mouth. Ulcerative mucositis was significantly worse in adults compared with children, in individuals who received methotrexate for graft-versus-host disease prophylaxis, and was most prominent on non-keratinized epithelium. Overall, there was no clinically demonstrable additional therapeutic advantage to the use of chlorhexidine in either reducing the mucositis, controlling oral pain, facilitating oral nutrition, shortening hospital stay, or reducing oral infection with herpes simplex virus. There was a trend toward diminished oral candidiasis in chlorhexidine users (p = 0.06).(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of sore throat after nasotracheal intubation

The influence of tube size, cuff inflation, and pharyngeal packing on development of sore throat after nasotracheal intubation was studied. Pharyngeal packing was found to be the most significant factor, followed by tube size and inflation of the cuff.

Post-operative sore throat: effect of lignocaine jelly and spray with endotracheal intubation

The effects of laryngeal lignocaine spray and/or lignocaine jelly as lubricants were studied on the incidence of sore throat, hoarseness, or tracheal irritability as evidenced by either a tendency to cough or frank coughing after intubation with a Sensiv tube (Searle Medical Products). Pressure in the medium-volume, low-pressure cuff was controlled and kept below 2.5 kPa (25 cmH2O) during anaesthesia. The side-effects of 94 surgical patients were recorded in a double-blind manner in the recovery room and on the first post-operative day. The lowest number of patients (62%) with side-effects was found in the control group and the greatest (95%) after the combination of lignocaine jelly and spray (P less than 0.05). The number of side-effects after lignocaine jelly alone was 85% and after the spray alone 68%. Women were more prone to have side-effects, especially sore throat and hoarseness, than men (P less than 0.05). Induced hypotension did not increase the incidence of side-effects. Endotracheal cuff pressures were also studied in 114 patients during N2O-O2 anaesthesia and in 54 patients after the replacement of N2O with nitrogen. The minimum occluding pressure required was 1 kPa (10 cmH2O). In 42% of the patients receiving N2O a limiting value of 2.5 kPa (25 cmH2O) was reached during anesthesia in a mean time of 74 min (range 25-180 min). After the replacement of N2O with nitrogen, the cuff pressure decreased from 1.8 kPa (18 cmH2O) to 0.7 kPa (7 cmH2O) over 40 min. It is concluded that lignocaine jelly with the use of a spray significantly increases post-operative side-effects.

Management of streptococcal pharyngitis: the conundrum of acute rheumatic fever

The incidence of acute rheumatic fever in the residents of three counties in Ontario (population 507,300) from 1975 to 1986 inclusive was 0.17 hospitalized cases per 100,000 population (0.4 per 100,000 for 5- to 19-year-olds). Indigent patients (0.6 per 100,000) and North American Indians (2 per 100,000) had substantially higher rates. This experience is in marked contrast to recent outbreaks of acute rheumatic fever in areas of the United States, but is similar to experience in the United Kingdom. The implications of this data on the current management of the streptococcal sore throat is reviewed, showing the complexities of real-life prevention of acute rheumatic fever.

Premedication with meperidine and diazepam for upper gastrointestinal endoscopy precludes the need for topical anesthesia

The authors conducted a prospective study in 90 patients undergoing upper endoscopic examination under sedation to determine whether there was any beneficial effect in anesthetizing the pharynx with topical anesthesia. These patients were divided into three groups of 30 patients. Group A received 39 ml of viscous lidocaine gargle (2%) diluted with 15 ml of tap water. Group B received the placebo. Group C received neither viscous lidocaine nor placebo. All patients received intravenous meperidine and diazepam titrated to produce adequate sedation for upper endoscopy. It was demonstrated that the undesirable effects of upper endoscopy, that is, gagging, sore throat, and dysphagia, did not differ significantly in any of the three study groups as evaluated by either the patients or the endoscopist. Only two patients complained that the procedure was mildly unpleasant. The authors conclude that the practice of anesthetizing the pharynx in patients receiving sedation for upper endoscopy should be abandoned since anesthesia of the pharynx is not exempt from morbidity and mortality as well as being time-consuming and expensive.

Effects of pneumococcal vaccination on tonsillo-pharyngitis and upper respiratory tract flora

The effect of a 14-valent pneumococcal vaccine on upper respiratory tract infections and carriage of beta-haemolytic streptococci was studied in a double-blind prospective study of 405 children 0.5-5 years of age. In the children under 2 years of age at vaccination, the cases of acute tonsillitis were more frequent among the vaccinees than among the controls (p less than 0.01). In contrast, among the children over 2 years of age at vaccination, fewer episodes of acute tonsillitis were reported among the vaccinees than among the controls (p less than 0.01). In the older age group, the total rate of upper respiratory tract infections was also significantly reduced. Similarly, an increase in asymptomatic carriage of group A streptococci was registered in children vaccinated at 2-5 years of age (p less than 0.01). Inversely, the carriership of group C streptococci diminished among the vaccinated children (p less than 0.05). Some possible mechanisms underlying these unexpected findings, including non-specific mitogenic features and cross-protection due to antigenic similarities, were explored.