Excessive antibiotic use for acute respiratory infections in the United States

Increased Virulence of an Encapsulated Streptococcus pneumoniae Upon Expression of Pneumococcal Surface Protein K

Background

Current Streptococcus pneumoniae vaccines selectively target capsular polysaccharide of specific serotypes, leading to an increase in nonencapsulated S. pneumoniae (NESp). Cocolonization by encapsulated pneumococci and NESp increases the opportunity for intraspecies genetic exchange. Acquisition of NESp genes by encapsulated pneumococci could alter virulence and help vaccine-targeted serotypes persist in the host.

Methods

Adhesion and invasion assays were performed using immortalized human pharyngeal or lung epithelial cells. In vivo models assessing murine nasopharyngeal colonization and pneumonia, as well as chinchilla otitis media (OM), were also used.

Results

Pneumococcal surface protein K (PspK) expression increased encapsulated pneumococcal adhesion and invasion of lung cells and enhanced virulence during pneumonia and OM. Additionally, PspK increased nasopharyngeal colonization, persistence in the lungs, and persistence in the middle ear when expressed in a capsule deletion mutant. Competition experiments demonstrated encapsulated pneumococci expressing PspK also had a selective advantage in both the lungs and nasopharynx.

Conclusions

PspK increases pneumococcal virulence during pneumonia and OM. PspK also partially compensates for loss of virulence in the absence of capsule. Additionally, PspK provides a selective advantage in a competitive environment. Therefore, acquisition of PspK increases encapsulated virulence in a condition-dependent manner. Together, these studies demonstrate risks associated with pneumococcal intraspecies genetic exchange.

Impact of Education and Peer Comparison on Antibiotic Prescribing for Pediatric Respiratory Tract Infections

Supplemental Digital Content is available in the text.

Introduction:

Inappropriate prescribing of broad-spectrum antibiotics is a significant modifiable risk factor for the development of antibiotic resistance. The objective was to improve guideline-concordant care for 3 common acute respiratory tract infections (ARTIs) and to reduce broad-spectrum antibiotic prescribing in ambulatory pediatric patients.

Methods:

Quality measures were developed for 3 ARTIs: viral upper respiratory infection (URI), acute bacterial sinusitis (ABS), and acute otitis media (AOM). Among 22 pediatric clinics, a collaborative of 10 was identified for intervention using baseline data for each ARTI, and 3 plan-do-study-act cycles were planned and completed. Outcomes included guideline-concordant antibiotic utilization and broad-spectrum antibiotic prescribing percentage (BSAP%). Comparison in number of diagnoses for the ARTI measures and total antibiotic prescribing over time served as balancing measures.

Results:

Collaborative clinics had baseline medians for appropriate or first-line treatment of 70% for URI, 53% for ABS, and 36% for AOM. To reach targets for URI, ABS, and AOM required 6, 14, and 18 months, respectively. At 42 months, performance for all 3 ARTIs remained ≥90%. BSAP% decreased from a baseline of 57% to 34% at 24 months. There was a limited effect from financial incentives but a significant decrease was noted in total antibiotic utilization. Diagnosis shifting may have occurred for URI and ABS while the rates for diagnoses for AOM declined over time.

Conclusions:

Through education and peer comparison feedback, guideline-concordant care for 3 ARTIs in collaborative clinics improved and remained beyond above targets and was accompanied by reductions in BSAP% and total antibiotic prescribing.

Use of antibiotics for common illnesses among children aged under 5 years in a rural community in Indonesia: a cross-sectional study

Background

The incidence of antimicrobial resistance has been increasing worldwide in the past decades, which includes resistance to bacteria that cause common childhood illnesses, such as acute respiratory infections and diarrhea. Numerous children with those common illnesses are treated with antibiotics. However, in such cases, antibiotic treatment is not required. Community-based studies focusing on antibiotic use among children are still limited. This study aimed to identify the prevalence of antibiotic use for common childhood illnesses and to investigate factors associated with antibiotic use in children under 5 years old as well as female caregivers in a rural community in Indonesia.

Methods

A cross-sectional study of 334 children in three villages of Banten Province, located in the western part of Java Island, was conducted in May 2018. Female caregivers who were responsible for providing medications to children were interviewed. We obtained information such as demographic data, any common clinical illness within the last 30 days, and antibiotic usage during an episode of illness. We excluded children with underlying disease that require a regular follow-up and children who were hospitalized in the last 30 days in the analysis. Antibiotic use answered by female caregivers was verified by checking its package or showing photos of various antibiotics to the female caregivers. Crushed antibiotics were confirmed with health professionals.

Results

A total of 203 children had clinical symptoms, and the most common symptom was fever and respiratory symptoms. In total, 49.3% received antibiotics, and 66% of them were prescribed by private health professionals. Only two children received antibiotics without a prescription. The most common antibiotic used among children was amoxicillin.

Conclusions

The high prevalence of antibiotic use was observed in children under 5 years of age, and the major source to obtain antibiotics was to consult health professionals. Training on appropriate antibiotic use must be conducted for health professionals in not only public but also private sectors.

Communication interventions to promote the public's awareness of antibiotics: a systematic review

Background

Inappropriate antibiotic use is implicated in antibiotic resistance and resultant morbidity and mortality. Overuse is particularly prevalent for outpatient respiratory infections, and perceived patient expectations likely contribute. Thus, various educational programs have been implemented to educate the public.

Methods

We systematically identified public-directed interventions to promote antibiotic awareness in the United States. PubMed, Google Scholar, Embase, CINAHL, and Scopus were queried for articles published from January 1996 through January 2016. Two investigators independently assessed titles and abstracts of retrieved articles for subsequent full-text review. References of selected articles and three review articles were likewise screened for inclusion. Identified educational interventions were coded for target audience, content, distribution site, communication method, and major outcomes.

Results

Our search yielded 1,106 articles; 34 met inclusion criteria. Due to overlap in interventions studied, 29 distinct educational interventions were identified. Messages were primarily delivered in outpatient clinics (N = 24, 83%) and community sites (N = 12, 41%). The majority included clinician education. Antibiotic prescription rates were assessed for 22 interventions (76%). Patient knowledge, attitudes, and beliefs (KAB) were assessed for 10 interventions (34%). Similar rates of success between antibiotic prescription rates and patient KAB were reported (73 and 70%, respectively). Patient interventions that did not include clinician education were successful to increase KAB but were not shown to decrease antibiotic prescribing. Three interventions targeted reductions in Streptococcus pneumoniae resistance; none were successful.

Conclusions

Messaging programs varied in their designs, and many were multifaceted in their approach. These interventions can change patient perspectives regarding antibiotic use, though it is unclear if clinician education is also necessary to reduce antibiotic prescribing. Further investigations are needed to determine the relative influence of interventions focusing on patients and physicians and to determine whether these changes can influence rates of antibiotic resistance long-term.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7258-3) contains supplementary material, which is available to authorized users.

Antibacterial and Cytotoxic Activity of Nepeta Cataria L., N. Cataria Var. Citriodora (Beck.) Balb. and Melissa Officinalis L. Essential Oils

The aim of the present study was to investigate the susceptibility of bacteria that play a role in respiratory tract and skin infections to the essential oils of catnip (Nepeta cataria), lemon catnip (N. cataria var. citriodora) and lemon balm (Melissa officinalis) with regard to their chemical composition. In addition, we wanted to assess whether antibiotic-resistant and -sensitive strains differ in their susceptibility to the oils and if there are cross resistances between standard antibiotics and essential oils. To evaluate the safety of topical application, cytotoxicity of the oils was studied in human keratinocyte and bronchial epithelial cell lines and irritation threshold concentrations were determined in ovo using the HET-CAM-test. The composition of the essential oils was analyzed by GC and GC-MS. Their MICs and MBCs were determined by a broth microdilution method against both reference strains from culture collections and clinical isolates with different susceptibility to standard antibiotics. Cytotoxicity was assessed by the MTT assay. Except for P. aeruginosa (MIC ≥2%), all reference strains tested were susceptible to catnip and lemon balm oils with MIC values ranging from 0.016 % to 0.25% (v/v). The clinical isolates were as susceptible to the oils (± 1 serial dilution) as the corresponding reference strains, regardless of their origin and resistance to standard antibiotics. The oils were cytotoxic to both keratinocytes and bronchial epithelial cells at CC50 values from 0.0012% to 0.015% (v/v). Lemon balm oil, whose main components were monoterpene aldehydes, exhibited the highest antibacterial and cytotoxic activity, followed by lemon catnip oil, which contained mainly monoterpene alcohols, and catnip oil, which was characterized by nepetalactones. Our results provide a rationale for the use of catnip, lemon catnip and lemon balm oils in the complementary topical treatment of respiratory tract infections, as the oils show a high antibacterial activity against respiratory tract pathogens, including clinical isolates with reduced susceptibility to standard antibiotics. However, cytotoxicity must be considered in topical therapy.

Dental Infection and Resistance-Global Health Consequences

Antibiotics are widely used in dental caries and another dental related issues, both for therapeutic and prophylactic reasons. Unfortunately, in recent years the use of antibiotics has been accompanied by the rapid emergence antimicrobial resistance. Dental caries and periodontal diseases are historically known as the top oral health burden in both developing and developed nations affecting around 20⁻50% of the population of this planet and the uppermost reason for tooth loss. Dental surgeons and family practitioners frequently prescribed antimicrobials for their patients as outpatient care. Several studies reported that antibiotics are often irrationally- and overprescribed in dental diseases which is the basis of antimicrobial resistance. The aim of this review is to evaluate the use of antibiotics in dental diseases. Almost certainly the promotion of primary oral health care (POHC) in primary health care program especially among the least and middle-income countries (LMIC) may be the answer to ensure and promote rational dental care.

Knowledge and Practices of Family and Emergency Physicians in Managing Nontraumatic Dental Conditions: A Case-based Survey

INTRODUCTION

Physicians are often patients' first point of contact for management of nontraumatic dental conditions (NTDCs). This study's aim was to evaluate the knowledge and practices of Ontario physicians in managing NTDCs, with a specific focus on antibiotic usage.

METHODS

A Web-based survey featured 4 NTDC clinical scenarios: irreversible pulpitis, localized acute apical abscess with or without systemic involvement, and chronic apical abscess. The survey link was distributed to active Ontario family and emergency physicians. The sample group was asked questions about their management of and experience with NTDCs, and demographic and practice characteristics were collected. Descriptive and multivariate logistic regression analyses were undertaken (P ≤ .05).

RESULTS

Sampled Ontario physicians tend to manage NTDCs in a manner that is not consistent with evidence-based care. For irreversible pulpitis and for localized acute apical abscess with or without systemic involvement, most physicians would prescribe an antibiotic (57.4%, 84.8%, and 96.3%, respectively), and 23.5% would prescribe an antibiotic for chronic apical abscess. Approximately half the sample (52.9%) felt discomfort in managing NTDCs, and 85.3% felt they were inadequately trained to manage NTDCs.

CONCLUSION

Areas that present opportunities for improvement in the physician management of NTDCs were identified, including the incorporation of further NTDC training in medical curricula and continuing medical education courses, and development and dissemination of guidelines for physicians in managing NTDCs.

Principles and Practice of Antibiotic Stewardship in the ICU

In the face of emerging drug-resistant pathogens and a decrease in the development of new antimicrobial agents, antibiotic stewardship should be practiced in all critical care units. Antibiotic stewardship should be a core competency of all critical care practitioners in conjunction with a formal antibiotic stewardship program (ASP). Prospective audit and feedback, and antibiotic time-outs, are effective components of an ASP in the ICU. As rapid diagnostics are introduced in the ICU, assessment of performance and effect on outcomes will clearly be needed. Disease-specific stewardship for community-acquired pneumonia that relies on clinical pathways may be particularly high-yield. Computerized decision support has the potential to individualize stewardship for specific patients. Finally, infection control and prevention is the cornerstone of every ASP.

Role of Dentists in Prescribing Opioid Analgesics and Antibiotics: An Overview

Opioid analgesics and antibiotics prescribed by dentists is a useful and cost-effective measure when prescribed appropriately. Common dental conditions are best managed by extracting the offending tooth, restoring the tooth with an appropriate filling material, performing root canal therapy, and/or fabricating a prosthesis for the edentulous space. Unnecessary prescription of opioid analgesics and antibiotics to treat dental pain and bacterial infection is a growing public health concern. This article highlights the state of the literature on opioid analgesic and antibiotic prescribing practices in dentistry, the impact of opioid analgesic overdose, and prevention strategies to reduce opioid analgesics and antibiotic overprescription.

Prevention and Treatment of Multidrug-Resistant Organisms in End-Stage Renal Disease

Chronic kidney disease patients are at high risk for infections because of multidrug-resistant organisms. Infections are the second most common cause of death in patients with ESRD. Patients with ESRD are prone to infections given alterations in immunity, increased rates of colonization with multidrug-resistant organisms, increased hospitalizations, and interactions with health care systems. Infections range from urinary tract infections, pneumonia, skin and soft tissue infections, central line-associated bloodstream infections to sepsis. A coordinated collaborative effort using a multipronged approach must be stressed to reduce the burden of infections. Preventive measures such as hand hygiene, antibiotic stewardship, immunizations, and minimizing central venous catheters are critical to curtail infections with multidrug-resistant organisms. Empirical and targeted treatment for multidrug-resistant organisms may require collaboration with infectious disease providers to improve outcomes in these serious infections. It is imperative to address multidrug-resistant organisms in ESRD patients at this juncture to improve medical outcomes now and for the future.

Practical and Conceptual Considerations for the Primary Prevention of Asthma

Asthma is among the most common chronic diseases worldwide and is a significant contributor to the global health burden, highlighting the urgent need for primary prevention. This article outlines several practical and conceptual challenges that accompany primary prevention efforts. It advocates for improved predictive modeling to identify those at high-risk of developing asthma using automated algorithms within electronic medical records systems and explanatory modeling to refine understanding of causal pathways. Understanding the many issues that are likely to affect the success of primary prevention efforts helps the community of individuals invested in asthma prevention organize efforts and maximize their impact.

Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults

BACKGROUND

Dental pain can have a detrimental effect on quality of life. Symptomatic apical periodontitis and acute apical abscess are common causes of dental pain and arise from an inflamed or necrotic dental pulp, or infection of the pulpless root canal system. Clinical guidelines recommend that the first-line treatment for teeth with these conditions should be removal of the source of inflammation or infection by local, operative measures, and that systemic antibiotics are currently only recommended for situations where there is evidence of spreading infection (cellulitis, lymph node involvement, diffuse swelling) or systemic involvement (fever, malaise). Despite this, there is evidence that dentists frequently prescribe antibiotics in the absence of these signs. There is concern that this could contribute to the development of antibiotic-resistant bacterial colonies within both the individual and the community. This review is an update of the original version that was published in 2014.

OBJECTIVES

To evaluate the effects of systemic antibiotics provided with or without surgical intervention (such as extraction, incision and drainage of a swelling, or endodontic treatment), with or without analgesics, for symptomatic apical periodontitis and acute apical abscess in adults.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 26 February 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1) in the Cochrane Library (searched 26 February 2018), MEDLINE Ovid (1946 to 26 February 2018), Embase Ovid (1980 to 26 February 2018), and CINAHL EBSCO (1937 to 26 February 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. A grey literature search was conducted using OpenGrey (to 26 February 2018) and ZETOC Conference Proceedings (1993 to 26 February 2018). No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials of systemic antibiotics in adults with a clinical diagnosis of symptomatic apical periodontitis or acute apical abscess, with or without surgical intervention (considered in this situation to be extraction, incision and drainage or endodontic treatment) and with or without analgesics.

DATA COLLECTION AND ANALYSIS

Two authors screened the results of the searches against inclusion criteria, extracted data and assessed risk of bias independently and in duplicate. We calculated mean differences (MD) (standardised mean difference (SMD) when different scales were reported) and 95% confidence intervals (CI) for continuous data. A fixed-effect model was used in the meta-analysis as there were fewer than four studies. We contacted study authors to obtain missing information.

MAIN RESULTS

We included two trials in this review, with 62 participants included in the analyses. Both trials were conducted in university dental schools in the USA and compared the effects of oral penicillin V potassium (penicillin VK) versus a matched placebo when provided in conjunction with a surgical intervention (total or partial pulpectomy) and analgesics to adults with acute apical abscess or symptomatic necrotic tooth. The patients included in these trials had no signs of spreading infection or systemic involvement (fever, malaise). We assessed one study as having a high risk of bias and the other study as having unclear risk of bias.The primary outcome variables reported in both studies were participant-reported pain and swelling (one trial also reported participant-reported percussion pain). One study reported the type and number of analgesics taken by participants. One study recorded the incidence of postoperative endodontic flare-ups (people who returned with symptoms that necessitated further treatment). Adverse effects, as reported in one study, were diarrhoea (one participant, placebo group) and fatigue and reduced energy postoperatively (one participant, antibiotic group). Neither study reported quality of life measurements.Objective 1: systemic antibiotics versus placebo with surgical intervention and analgesics for symptomatic apical periodontitis or acute apical abscessTwo studies provided data for the comparison between systemic antibiotics (penicillin VK) and a matched placebo for adults with acute apical abscess or a symptomatic necrotic tooth when provided in conjunction with a surgical intervention. Participants in one study all underwent a total pulpectomy of the affected tooth, while participants in the other study had their tooth treated by either partial or total pulpectomy. Participants in both trials received oral analgesics. There were no statistically significant differences in participant-reported measures of pain or swelling at any of the time points assessed within the review. The MD for pain (short ordinal numerical scale 0 to 3) was -0.03 (95% CI -0.53 to 0.47) at 24 hours; 0.32 (95% CI -0.22 to 0.86) at 48 hours; and 0.08 (95% CI -0.38 to 0.54) at 72 hours. The SMD for swelling was 0.27 (95% CI -0.23 to 0.78) at 24 hours; 0.04 (95% CI -0.47 to 0.55) at 48 hours; and 0.02 (95% CI -0.49 to 0.52) at 72 hours. The body of evidence was assessed as at very low quality.Objective 2: systemic antibiotics without surgical intervention for adults with symptomatic apical periodontitis or acute apical abscessWe found no studies that compared the effects of systemic antibiotics with a matched placebo delivered without a surgical intervention for symptomatic apical periodontitis or acute apical abscess in adults.

AUTHORS' CONCLUSIONS

There is very low-quality evidence that is insufficient to determine the effects of systemic antibiotics on adults with symptomatic apical periodontitis or acute apical abscess.

Pneumococcal Vaccines: Host Interactions, Population Dynamics, and Design Principles

Streptococcus pneumoniae (the pneumococcus) is a nasopharyngeal commensal and respiratory pathogen. Most isolates express a capsule, the species-wide diversity of which has been immunologically classified into ∼100 serotypes. Capsule polysaccharides have been combined into multivalent vaccines widely used in adults, but the T cell independence of the antibody response means they are not protective in infants. Polysaccharide conjugate vaccines (PCVs) trigger a T cell–dependent response through attaching a carrier protein to capsular polysaccharides. The immune response stimulated by PCVs in infants inhibits carriage of vaccine serotypes (VTs), resulting in population-wide herd immunity. These were replaced in carriage by non-VTs. Nevertheless, PCVs drove reductions in infant pneumococcal disease, due to the lower mean invasiveness of the postvaccination bacterial population; age-varying serotype invasiveness resulted in a smaller reduction in adult disease. Alternative vaccines being tested in trials are designed to provide species-wide protection through stimulating innate and cellular immune responses, alongside antibodies to conserved antigens.

Provider Variation in Antibiotic Prescribing and Outcomes of Respiratory Tract Infections

OBJECTIVES

Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes.

METHODS

This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic.

RESULTS

Of 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt.

CONCLUSIONS

Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.

Changes in Antimicrobial Usage Patterns in Korea: 12-Year Analysis Based on Database of the National Health Insurance Service-National Sample Cohort

National antimicrobial usage and prescription patterns during the 12 years from 2002 to 2013 were analyzed using the National Health Insurance Service-National Sample Cohort. Antimicrobial usage was analyzed by major illness, sex, age, area of residence, income rank, diagnosis, and type of medical institution for each year. Total antimicrobial prescriptions increased from 15.943 daily defined dose (DDD)/1,000 inhabitants/day in 2002 to 24.219 in 2013. In 2013, 72% of total prescriptions were administered in clinics. Antimicrobials were most frequently prescribed to children younger than 10 years, followed by adults aged 70 years or older and those aged 60-69 years. Penicillins and cephems were the most popular classes of antimicrobial used. In 2013, 48% of total antibiotic usage (11.683 DDD/1,000 inhabitants/day) was due to respiratory diseases. After the Korean government has implemented a series of healthcare policies, antibiotic prescription decreased for the treatment of upper respiratory infection, the causative agents are mostly viruses.

HaCaT epithelial cells as an innovative novel model of rhinovirus infection and impact of clarithromycin treatment on infection kinetics

The in vitro propagation of human rhinoviruses (RVs) is difficult because only few continuous human cell lines are permissive to these agents. We propose an innovative model of epithelial cell infection using a non-transformed continuous keratinocyte line from human origin (HaCaT cells). After infection with RV-A13, RV-A16 or RV-A19, HaCaT cells produced infectious particles without showing any observable cytopathic effect and overexpressed ICAM-1 (intercellular adhesion molecule 1), the major entry receptor of RVs. Furthermore, the treatment of HaCaT cells with 10 µM clarithromycin reduced the viral titer by 93% and 60% during the first and second days following viral infection, respectively, probably by down-regulating ICAM-1 expression. This original model of epithelial cell infection by RV could be useful to study chronic viral infection and bacterium-virus interactions at the cell level. These results also suggest that clarithromycin may be evaluated for treating in vivo infections associating RV to a susceptible bacterium.

Trends in outpatient antibiotic use and prescribing practice among US older adults, 2011-15: observational study

OBJECTIVE

To identify temporal trends in outpatient antibiotic use and antibiotic prescribing practice among older adults in a high income country.

DESIGN

Observational study using United States Medicare administrative claims in 2011-15.

SETTING

Medicare, a US national healthcare program for which 98% of older adults are eligible.

PARTICIPANTS

4.5 million fee-for-service Medicare beneficiaries aged 65 years old and older.

MAIN OUTCOME MEASUREMENTS

Overall rates of antibiotic prescription claims, rates of potentially appropriate and inappropriate prescribing, rates for each of the most frequently prescribed antibiotics, and rates of antibiotic claims associated with specific diagnoses. Trends in antibiotic use were estimated by multivariable regression adjusting for beneficiaries' demographic and clinical covariates.

RESULTS

The number of antibiotic claims fell from 1364.7 to 1309.3 claims per 1000 beneficiaries per year in 2011-14 (adjusted reduction of 2.1% (95% confidence interval 2.0% to 2.2%)), but then rose to 1364.3 claims per 1000 beneficiaries per year in 2015 (adjusted reduction of 0.20% over 2011-15 (0.09% to 0.30%)). Potentially inappropriate antibiotic claims fell from 552.7 to 522.1 per 1000 beneficiaries over 2011-14, an adjusted reduction of 3.9% (3.7% to 4.1%). Individual antibiotics had heterogeneous changes in use. For example, azithromycin claims per beneficiary decreased by 18.5% (18.2% to 18.8%) while levofloxacin claims increased by 27.7% (27.2% to 28.3%). Azithromycin use associated with each of the potentially appropriate and inappropriate respiratory diagnoses decreased, while levofloxacin use associated with each of those diagnoses increased.

CONCLUSION

Among US Medicare beneficiaries, overall antibiotic use and potentially inappropriate use in 2011-15 remained steady or fell modestly, but individual drugs had divergent changes in use. Trends in drug use across indications were stronger than trends in use for individual indications, suggesting that guidelines and concerns about antibiotic resistance were not major drivers of change in antibiotic use.

Global burden of hearing impairment and ear disease

Background

Hearing loss can present at birth or be acquired as a result of illness, middle-ear disease, injury, age, overuse of certain medications, and/or induced by exposure to damaging noise levels. There are serious short-term consequences for people living with hearing impairment, including the effects on language acquisition, education, employment and overall wellbeing. There are also complex long-term implications.

Objectives

This review aimed to present some of the leading causes of ear disease and hearing loss globally, and to identify their impact at both an individual and societal level.

National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults-United States, 2011-2015

BACKGROUND

Detailed, nationally representative data describing high-risk populations and circumstances involved in antibiotic adverse events (AEs) can inform approaches to prevention.

OBJECTIVE

Describe US burden, rates, and characteristics of emergency department (ED) visits by adults for antibiotic AEs.

DESIGN

Nationally representative, public health surveillance of adverse drug events (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance [NEISS-CADES]) and a nationally projected database of dispensed prescriptions (QuintilesIMS), 2011-2015.

PATIENTS

Antibiotic-treated adults (≥ 20 years) seeking ED care.

MAIN MEASURES

Estimated annual numbers and rates of ED visits for antibiotic AEs among outpatients treated with systemically administered antibiotics.

KEY RESULTS

Based on 10,225 cases, US adults aged ≥ 20 years made an estimated 145,490 (95% confidence interval, 115,279-175,701) ED visits for antibiotic AEs each year in 2011-2015. Antibiotics were implicated in 13.7% (12.3-15.2%) of all estimated adult ED visits for adverse drug events. Most (56.6%; 54.8-58.4%) antibiotic AE visits involved adults aged < 50 years, and 71.8% (70.4-73.1%) involved females. Accounting for prescriptions dispensed from retail and long-term care pharmacies, adults aged 20-34 years had twice the estimated rate of ED visits for oral antibiotic AEs compared with those aged ≥ 65 years (9.7 [7.6-11.8] versus 4.6 [3.6-5.7] visits per 10,000 dispensed prescriptions, respectively). Allergic reactions accounted for three quarters (74.3%; 70.0-78.6%) of estimated ED visits for antibiotic AEs. The three most frequently implicated antibiotic classes in ED visits for antibiotic AEs were oral sulfonamides (23.2%; 20.6-25.8%), penicillins (20.8%; 19.3-22.4%), and quinolones (15.7%; 14.2-17.1%). Per-prescription rates declined with increasing age group.

CONCLUSIONS

Antibiotics are a common cause of ED visits by adults for adverse drug events and represent an important safety issue. Quantifying risks of AEs from specific antibiotics for specific patient populations, such as younger adults, provides additional information to help clinicians assess risks versus benefits when making the decision to prescribe or not prescribe an antibiotic. AE rates may also facilitate communication with patients about antibiotic risks.

Differential Diagnosis of the Etiologies of Bacterial and Viral Infections Using Infrared Microscopy of Peripheral Human Blood Samples and Multivariate Analysis

Human viral and bacterial infections are responsible for a variety of diseases that are still the main causes of death and economic burden for society across the globe. Despite the different responses of the immune system to these infections, some of them have similar symptoms, such as fever, sneezing, inflammation, vomiting, diarrhea, and fatigue. Thus, physicians usually encounter difficulties in distinguishing between viral and bacterial infections on the basis of these symptoms. Rapid identification of the etiology of infection is highly important for effective treatment and can save lives in some cases. The current methods used for the identification of the nature of the infection are mainly based on growing the infective agent in culture, which is a time-consuming (over 24 h) and usually expensive process. The main objective of this study was to evaluate the potential of the mid-infrared spectroscopic method for rapid and reliable identification of bacterial and viral infections based on simple peripheral blood samples. For this purpose, white blood cells (WBCs) and plasma were isolated from the peripheral blood samples of patients with confirmed viral or bacterial infections. The obtained spectra were analyzed by multivariate analysis: principle component analysis (PCA) followed by linear discriminant analysis (LDA), to identify the infectious agent type as bacterial or viral in a time span of about 1 h after the collection of the blood sample. Our preliminary results showed that it is possible to determine the infectious agent with high success rates of 82% for sensitivity and 80% for specificity, based on the WBC data.

Comparison of serum PCT and CRP levels in patients infected by different pathogenic microorganisms: a systematic review and meta-analysis

To avoid the abuse and misuse of antibiotics, procalcitonin (PCT) and C-reactive protein (CRP) have been used as new approaches to identify different types of infection. Multiple databases were adopted to search relevant studies, and the articles that satisfied the inclusion criteria were included. Meta-analyses were conducted with Review Manager 5.0, and to estimate the quality of each article, risk of bias was assessed. Eight articles satisfied the inclusion criteria. The concentrations of both PCT and CRP in patients with bacterial infection were higher than those with non-bacterial infection. Both PCT and CRP levels in patients with G− bacterial infection were higher than in those with G+ bacterial infection and fungus infection. In the G+ bacterial infection group, a higher concentration of CRP was observed compared with fungus infection group, while the difference of PCT between G+ bacterial infection and fungus infection was not significant. Our study suggested that both PCT and CRP are helpful to a certain extent in detecting pneumonia caused by different types of infection.

The Cost-Effectiveness of the Management of Acute Sinusitis

Background

Sinusitis is a common medical disease with a tremendous economic impact on health care. Our objective was to determine the most cost-effective strategy for the management of acute sinusitis from the societal and payers’ perspectives.

Methods

A Markov disease simulation model was used for comparing four treatment strategies: (1) no antibiotic (Abx), (2) empiric Abx, (3) CT-based Abx, and (4) clinical guideline-based Abx.

Results

Empiric Abx treatment was the most cost-effective from the societal perspective. Clinical guideline-based treatment was the most cost-effective strategy from the payers’ perspective ($38,515/quality-adjusted life year). Cost and effectiveness of Abx, time lost from work, and prevalence of acute bacterial sinusitis are influential variables.

Conclusion

Empiric Abx treatment is a cost-effective strategy from the short-term societal perspective. However, Abx resistance will lead to increased costs and reduced efficacy of this strategy in the long-term. Clinical guidelines provide a low-cost method of targeting therapy.

Homeopathy Use in the United States and Implications for Public Health: A Review

Homeopathy is used by just over 2% of the U.S. population, predominantly for respiratory, otorhinolaryngology, and musculoskeletal complaints. Individual users who see a homeopathic provider for care are more likely to perceive the therapy as helpful than those who do not; however, only 19% of users in the United States see a provider. The rest presumably rely upon over-the-counter products. Recent clinical trials highlight several areas in which homeopathy may play a role in improving public health, including infectious diseases, pain management, mental health, and cancer care. This review examines recent studies in these fields, studies assessing costs associated with homeopathic care, safety, and regulations in the United States. Data suggest the potential for public health benefit from homeopathy, especially for conditions such as upper respiratory infections and fibromyalgia.

Antibiotic Prescribing for Patients with Upper Respiratory Tract Infections by Emergency Physicians in a Singapore Tertiary Hospital

Objective

Despite the paucity of supporting evidence, the use of antibiotics in the management of upper respiratory tract infections (URTI) remains a persistent and worrying trend worldwide. This survey study set out to examine the antibiotic prescribing profile of emergency physicians for patients diagnosed with URTI at a local tertiary hospital.

Methods

Patients seeking treatment for URTI at the emergency department in the year 2001 were identified by their ICD-9 code. The electronic medical records of a random sample of these patients were reviewed. Patients with the following documented findings were excluded: (a) a duration of more than 7 days between disease onset and date of consultation, (b) prior antibiotic usage or medical consultation, (c) presentation of purulent sputum and/or purulent nasal discharge, and (d) existing medical conditions requiring antibiotic treatment/prophylaxis. Chi-square and multivariate analyses were performed to assess the association of patient-related factors with antibiotic prescribing.

Results

Of a random sample of 488 cases of URTI, inappropriate antibiotic prescribing was observed in 24% of cases (95% CI 20%, 28%). Significant associations were observed between antibiotic prescribing and month of consultation, patients' temperature and symptom of rhinorrhoea.

Conclusion

A substantial proportion of emergency department patients with URTI received antibiotics despite the lack of evidence supporting the drugs' effectiveness. Appropriate interventions to promote evidence-based prescribing amongst emergency physicians are required to reduce the extent of inappropriate antibiotic prescribing as well as to ensure the longevity of antibiotic effectiveness.

Multiplex PCR system for the rapid diagnosis of respiratory virus infection: systematic review and meta-analysis

OBJECTIVES

To provide a summary of evidence for the diagnostic accuracies of three multiplex PCR systems (mPCRs)-BioFire FilmArray RP (FilmArray), Nanosphere Verigene RV+ test (Verigene RV+) and Hologic Gen-Probe Prodesse assays-on the detection of viral respiratory infections.

METHODS

A comprehensive search up to 1 July 2017 was conducted on Medline and Embase for studies that utilized FilmArray, Verigene RV+ and Prodesse for diagnosis of viral respiratory infections. A summary of diagnostic accuracies for the following five viruses were calculated: influenza A virus (FluA), influenza B virus, respiratory syncytial virus, human metapneumovirus and adenovirus. Hierarchical summary receiver operating curves were used for estimating the viral detection performance per assay.

RESULTS

Twenty studies of 5510 patient samples were eligible for analysis. Multiplex PCRs demonstrated high diagnostic accuracy, with area under the receiver operating characteristic curve (AUROC) equal to or more than 0.98 for all the above viruses except for adenovirus (AUROC 0.89). FilmArray, Verigene RV+ and ProFlu+ (the only Prodesse assay with enough data) demonstrated a summary sensitivity for FluA of 0.911 (95% confidence interval, 0.848-0.949), 0.949 (95% confidence interval, 0.882-0.979) and 0.954 (95% confidence interval, 0.871-0.985), respectively. The three mPCRs were comparable in terms of detection of FluA.

CONCLUSIONS

Point estimates calculated from eligible studies showed that the three mPCRs (FilmArray, Verigene RV+ and ProFlu+) are highly accurate and may provide important diagnostic information for early identification of respiratory virus infections. In patients with low pretest probability for FluA, these three mPCRs can predict a low possibility of infection and may justify withholding empirical antiviral treatments.

First-year results of an antibiotic stewardship program in a Greek tertiary care hospital

The aim of this study was to investigate the effect of the implementation of an antibiotic stewardship program (ASP) on antibiotic consumption in our 428-bed hospital. The Infection Control Committee implemented an ASP beginning in January 2016, aiming to reduce inappropriate antibiotic use through improved prescribing practices. The ASP included both pre-authorization and prospective audit and feedback strategies. We collected pharmacy and hospital data for the years 2015 (pre-intervention) and 2016 (post-intervention). Consumption data were expressed as daily defined doses (DDDs) per 100 patient-days (PD) and the significance of the differences between 2015 and 2016 was assessed by paired t-test. Antibiotic resistance rates for the most important hospital pathogens were monitored for 2015-2016. The ASP effectively reduced consumption of most antimicrobials; total antibiotic use decreased by 16.7% (from 104.3 in 2015 to 86.9 DDDs/100 patient-days in 2016, p < 0.001) owing to reduction of 19.1% for non-restricted and 13.8% for restricted antibiotics. Important restricted antimicrobials, such as colistin, carbapenems, quinolones and tigecycline showed significantly decreased usage post-intervention. Significant changes in the resistance rates were not observed, except a decreasing trend for colistin and tigecycline (Acinetobacter baumannii and Klebsiella pneumoniae) and also vancomycin (enterococci). The ASP was successful in terms of reducing the antibiotic consumption for the first year of its implementation. Interestingly, antimicrobials requiring pre-authorization exhibited a lower reduction than other antibiotics. Potential effects of the ASP in reducing resistance rates remain to be shown.

Implementation of Alere i Influenza A & B point of care test for the diagnosis of influenza in an ED

STUDY OBJECTIVE

This study aimed to evaluate the impact of implementing rapid point-of-care testing (POCT) with the Alere i Influenza A & B in an emergency department (ED) during an influenza epidemic.

METHODS

Direct nasal swabs were prospectively collected following the physical examination of patients aged >18years who presented to the ED of a tertiary hospital in France with influenza-like illness (ILI) symptoms (N=301) between February 1st and March 31st, 2016, which coincided with an influenza epidemic. Laboratory-based testing (standard of care) was used to obtain a diagnosis in February 2016 (pre-POCT cohort) and positive results were confirmed using polymerase chain reaction. The primary endpoint was patient time in the ED.

RESULTS

A total of 169 and 132 patients participated in the pre-POCT phase and POCT phase respectively. A significantly higher proportion of patients received a positive diagnosis in the POCT cohort compared with the pre-POCT cohort (31% versus 5.3%, P<0.01). Mean time spent in the ED and hospitalization rate were significantly lower in the POCT cohort (6.06h versus 4.15h, P=0.03, and 44.4% versus 9.7%, P=0.02, respectively). Despite similar rates in the prescription of antibiotics and antiviral therapies, the proportion of patients who were referred for additional tests was significantly lower in the POCT cohort (78.1% versus 62.1%, P=0.003, and 80.5% versus 63.6%, P=0.01, respectively).

CONCLUSIONS

The Alere i Influenza A & B POCT reduced the length of stay in ED, the hospitalization rates, and the number of additional diagnostic tests compared with standard of care testing.

Virulence determinants of Moraxella catarrhalis: distribution and considerations for vaccine development

Moraxella catarrhalis is a human-restricted opportunistic bacterial pathogen of the respiratory mucosa. It frequently colonizes the nasopharynx asymptomatically, but is also an important causative agent of otitis media (OM) in children, and plays a significant role in acute exacerbations of chronic obstructive pulmonary disease (COPD) in adults. As the current treatment options for M. catarrhalis infection in OM and exacerbations of COPD are often ineffective, the development of an efficacious vaccine is warranted. However, no vaccine candidates for M. catarrhalis have progressed to clinical trials, and information regarding the distribution of M. catarrhalis virulence factors and vaccine candidates is inconsistent in the literature. It is largely unknown if virulence is associated with particular strains or subpopulations of M. catarrhalis, or if differences in clinical manifestation can be attributed to the heterogeneous expression of specific M. catarrhalis virulence factors in the circulating population. Further investigation of the distribution of M. catarrhalis virulence factors in the context of carriage and disease is required so that vaccine development may be targeted at relevant antigens that are conserved among disease-causing strains. The challenge of determining which of the proposed M. catarrhalis virulence factors are relevant to human disease is amplified by the lack of a standardized M. catarrhalis typing system to facilitate direct comparisons of worldwide isolates. Here we summarize and evaluate proposed relationships between M. catarrhalis subpopulations and specific virulence factors in the context of colonization and disease, as well as the current methods used to infer these associations.

Trends in Antibiotic Use by Birth Season and Birth Year

OBJECTIVES

We examined 2 birth cohort effects on antibiotic prescribing during the first year of life (henceforth, infancy) in Denmark: (1) the birth season effect on timing and overall occurrence of antibiotic prescribing, and (2) the birth year effect amid emerging nationwide pneumococcal vaccination programs and changing prescribing guidelines.

METHODS

We linked data for all live births in Denmark from 2004 to 2012 (N = 561 729) across the National Health Service Prescription Database, Medical Birth Registry, and Civil Registration System. Across birth season and birth year cohorts, we estimated 1-year risk, rate, and burden of redeemed antibiotic prescriptions during infancy. We used interrupted time series methods to assess prescribing trends across birth year cohorts. Graphical displays of all birth cohort effect data are included.

RESULTS

The 1-year risk of having at least 1 redeemed antibiotic prescription during infancy was 39.5% (99% confidence interval [CI]: 39.3% to 39.6%). The hazard of a first prescription increased with age throughout infancy and varied by season; subsequently, Kaplan-Meier-derived risk functions varied by birth season cohort. After rollout of a first vaccination program and new antibiotic prescribing guidelines, 1-year risk decreased by 4.4% over 14 months (99% CI: 3.4% to 5.5%); it decreased again after rollout of a second vaccination program by 6.9% over 3 years (99% CI: 4.4% to 9.3%).

CONCLUSIONS

In Denmark, birth season and birth year cohort effects influenced timing and risk of antibiotic prescribing during infancy. Future studies of antibiotic stewardship, effectiveness, and safety in children should consider these cohort effects, which may render some children inherently more susceptible than others to downstream antibiotic effects.

Effect of Oral Prednisolone on Symptom Duration and Severity in Nonasthmatic Adults With Acute Lower Respiratory Tract Infection: A Randomized Clinical Trial

IMPORTANCE

Acute lower respiratory tract infection is common and often treated inappropriately in primary care with antibiotics. Corticosteroids are increasingly used but without sufficient evidence.

OBJECTIVE

To assess the effects of oral corticosteroids for acute lower respiratory tract infection in adults without asthma.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, placebo-controlled, randomized trial (July 2013 to final follow-up October 2014) conducted in 54 family practices in England among 401 adults with acute cough and at least 1 lower respiratory tract symptom not requiring immediate antibiotic treatment and with no history of chronic pulmonary disease or use of asthma medication in the past 5 years.

INTERVENTIONS

Two 20-mg prednisolone tablets (n = 199) or matched placebo (n = 202) once daily for 5 days.

MAIN OUTCOMES AND MEASURES

The primary outcomes were duration of moderately bad or worse cough (0 to 28 days; minimal clinically important difference, 3.79 days) and mean severity of symptoms on days 2 to 4 (scored from 0 [not affected] to 6 [as bad as it could be]; minimal clinically important difference, 1.66 units). Secondary outcomes were duration and severity of acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, and adverse events.

RESULTS

Among 401 randomized patients, 2 withdrew immediately after randomization, and 1 duplicate patient was identified. Among the 398 patients with baseline data (mean age, 47 [SD, 16.0] years; 63% women; 17% smokers; 77% phlegm; 70% shortness of breath; 47% wheezing; 46% chest pain; 42% abnormal peak flow), 334 (84%) provided cough duration and 369 (93%) symptom severity data. Median cough duration was 5 days (interquartile range [IQR], 3-8 days) in the prednisolone group and 5 days (IQR, 3-10 days) in the placebo group (adjusted hazard ratio, 1.11; 95% CI, 0.89-1.39; P = .36 at an α = .05). Mean symptom severity was 1.99 points in the prednisolone group and 2.16 points in the placebo group (adjusted difference, -0.20; 95% CI, -0.40 to 0.00; P = .05 at an α = .001). No significant treatment effects were observed for duration or severity of other acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, or nonserious adverse events. There were no serious adverse events.

CONCLUSIONS AND RELEVANCE

Oral corticosteroids should not be used for acute lower respiratory tract infection symptoms in adults without asthma because they do not reduce symptom duration or severity.

TRIAL REGISTRATION

ISRCTN.com Identifier: ISRCTN57309858.

Andrographis paniculata (Chuān Xīn Lián) for symptomatic relief of acute respiratory tract infections in adults and children: A systematic review and meta-analysis

INTRODUCTION

Antimicrobial resistance (AMR) is a substantial threat to public health. Safe and effective alternatives are required to reduce unnecessary antibiotic prescribing. Andrographis Paniculata (A. Paniculata, Chuān Xīn Lián) has traditionally been used in Indian and Chinese herbal medicine for cough, cold and influenza, suggesting a role in respiratory tract infections (RTIs). This systematic review aimed to evaluate the clinical effectiveness and safety of A. Paniculata for symptoms of acute RTIs (ARTIs).

MATERIALS AND METHODS

English and Chinese databases were searched from their inception to March 2016 for randomised controlled trials (RCTs) evaluating oral A. Paniculata without language barriers (Protocol ID: CRD42016035679). The primary outcomes were improvement in ARTI symptoms and adverse events (AEs). A random effects model was used to pool the mean differences and risk ratio with 95% CI reported. Methodological quality was evaluated using the Cochrane risk of bias tool; two reviewers independently screened eligibility and extracted data.

RESULTS

Thirty-three RCTs (7175 patients) were included. Most trials evaluated A. Paniculata (as a monotherapy and as a herbal mixture) provided commercially but seldom reported manufacturing or quality control details. A. Paniculata improved cough (n = 596, standardised mean difference SMD: -0.39, 95% confidence interval CI [-0.67, -0.10]) and sore throat (n = 314, SMD: -1.13, 95% CI [-1.37, -0.89]) when compared with placebo. A. Paniculata (alone or plus usual care) has a statistically significant effect in improving overall symptoms of ARTIs when compared to placebo, usual care, and other herbal therapies. Evidence also suggested that A. Paniculata (alone or plus usual care) shortened the duration of cough, sore throat and sick leave/time to resolution when compared versus usual care. No major AEs were reported and minor AEs were mainly gastrointestinal. The methodological quality of included trials was overall poor.

CONCLUSIONS

A. Paniculata appears beneficial and safe for relieving ARTI symptoms and shortening time to symptom resolution. However, these findings should be interpreted cautiously owing to poor study quality and heterogeneity. Well-designed trials evaluating the effectiveness and potential to reduce antibiotic use of A. Paniculata are warranted.

The Role of Breastfeeding in Childhood Otitis Media

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent literature, both systematic reviews and recently published original studies not included within those reviews, on the relationship between breastfeeding and childhood otitis media (OM).

RECENT FINDINGS

There is clear evidence that breastfeeding is associated with a reduced risk of OM in childhood with sound biological plausibility to support that the association is likely causal. Any breastfeeding reduces OM risk in early childhood by 40-50 %. Systematic reviews also support a further reduced risk for continued breastfeeding. Recent studies have estimated burden of disease savings if breastfeeding within countries and globally approached WHO guidelines. Cost savings per year for reduced cases of OM by increasing ever and exclusive breastfeeding rates are estimated to be millions of pounds or dollars for UK and Mexico. Breastfeeding reduces OM in children. The burden of disease and economic impact of increasing breastfeeding rates and duration would be substantial.

Clinical profile of respiratory viral infections: A study from tertiary care centre of South India

Background

Aim

Materials and methods

Results

Conclusion

Polyamine transporter potABCD is required for virulence of encapsulated but not nonencapsulated Streptococcus pneumoniae

Streptococcus pneumoniae is commonly found in the human nasopharynx and is the causative agent of multiple diseases. Since invasive pneumococcal infections are associated with encapsulated pneumococci, the capsular polysaccharide is the target of licensed pneumococcal vaccines. However, there is an increasing distribution of non-vaccine serotypes, as well as nonencapsulated S. pneumoniae (NESp). Both encapsulated and nonencapsulated pneumococci possess the polyamine oligo-transport operon (potABCD). Previous research has shown inactivation of the pot operon in encapsulated pneumococci alters protein expression and leads to a significant reduction in pneumococcal murine colonization, but the role of the pot operon in NESp is unknown. Here, we demonstrate deletion of potD from the NESp NCC1 strain MNZ67 does impact expression of the key proteins pneumolysin and PspK, but it does not inhibit murine colonization. Additionally, we show the absence of potD significantly increases biofilm production, both in vitro and in vivo. In a chinchilla model of otitis media (OM), the absence of potD does not significantly affect MNZ67 virulence, but it does significantly reduce the pathogenesis of the virulent encapsulated strain TIGR4 (serotype 4). Deletion of potD also significantly reduced persistence of TIGR4 in the lungs but increased persistence of PIP01 in the lungs. We conclude the pot operon is important for the regulation of protein expression and biofilm formation in both encapsulated and NCC1 nonencapsulated Streptococcus pneumoniae. However, in contrast to encapsulated pneumococcal strains, polyamine acquisition via the pot operon is not required for MNZ67 murine colonization, persistence in the lungs, or full virulence in a model of OM. Therefore, NESp virulence regulation needs to be further established to identify potential NESp therapeutic targets.

Vaccines for the common cold

BACKGROUND

The common cold is a spontaneously remitting infection of the upper respiratory tract, characterised by a runny nose, nasal congestion, sneezing, cough, malaise, sore throat, and fever (usually < 37.8º C). The widespread morbidity caused by the common cold worldwide is related to its ubiquitousness rather than its severity. The development of vaccines for the common cold has been difficult because of antigenic variability of the common cold virus and the indistinguishable multiple other viruses and even bacteria acting as infective agents. There is uncertainty regarding the efficacy and safety of interventions for preventing the common cold in healthy people. This is an update of a Cochrane review first published in 2011 and previously updated in 2013.

OBJECTIVES

To assess the clinical effectiveness and safety of vaccines for preventing the common cold in healthy people.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (September 2016), MEDLINE (1948 to September 2016), Embase (1974 to September 2016), CINAHL (1981 to September 2016), and LILACS (1982 to September 2016). We also searched three trials registers for ongoing studies and four websites for additional trials (February 2017). We included no language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of any virus vaccines compared with placebo to prevent the common cold in healthy people.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated methodological quality and extracted trial data. We resolved disagreements by discussion or by consulting a third review author.

MAIN RESULTS

We found no additional RCTs for inclusion in this update. This review includes one RCT dating from the 1960s with an overall high risk of bias. The RCT included 2307 healthy participants, all of whom were included in analyses. This trial compared the effect of an adenovirus vaccine against placebo. No statistically significant difference in common cold incidence was found: there were 13 (1.14%) events in 1139 participants in the vaccines group and 14 (1.19%) events in 1168 participants in the placebo group (risk ratio 0.95, 95% confidence interval 0.45 to 2.02; P = 0.90). No adverse events related to the live vaccine were reported. The quality of the evidence was low due to limitations in methodological quality and a wide 95% confidence interval.

AUTHORS' CONCLUSIONS

This Cochrane Review was based on one study with low-quality evidence. We found no conclusive results to support the use of vaccines for preventing the common cold in healthy people compared with placebo. We identified a need for well-designed, adequately powered RCTs to investigate vaccines for the common cold in healthy people. Any future trials on medical treatments for preventing the common cold should assess a variety of virus vaccines for this condition. Outcome measures should include common cold incidence, vaccine safety, and mortality related to the vaccine.

Incidence of respiratory viral infections and associated factors among children attending a public kindergarten in Taipei City

BACKGROUND

Kindergarteners frequently encounter various infectious diseases, so surveillance of viral infectious diseases would provide information for their health promotion.

METHODS

We enrolled kindergarten attendees, age 2-5 years, during the academic years of 2006 and 2007 in a Taipei City kindergarten. Daily monitoring of illness and regular biweekly physical examinations were undertaken. Multiple infections were defined as one child having two or more laboratory-confirmed viral infections with different viruses or different serotypes during one academic year.

RESULTS

The overall laboratory-confirmed incidence rate of respiratory viral infection was 239 per 100 person-years in the 2006 academic year and 136 per 100 person-years in the 2007 academic year. The attack rate for seasonal influenza was 17% in the 2006 academic year and 27% in the 2007 academic year. Boys and children with allergies had significantly higher risks to get multiple viral infections [odds ratio (OR) 1.81, 95% confidence interval (CI) 1.20-2.75; OR 1.56, 95% CI 1.00-2.39, respectively]. Boys also tended to get enterovirus infections (OR 1.56, 95% CI 1.02-2.38) while children with allergies tended to acquire adenovirus infections (OR 1.71, 95% CI 1.12-2.66).

CONCLUSION

Boys and children with allergies were more susceptible to multiple viral infections, so they should be more cautious about viral infections.

Prevalence of inappropriate antibiotic prescriptions after the great east Japan earthquake, 2011

Few studies have investigated the appropriateness of antibiotic use in postdisaster settings. We retrospectively evaluated clinical databases on health care delivered at clinics near shelters set up after the Great East Japan Earthquake, 2011. We defined appropriate, acceptable, and inappropriate antibiotic use for each diagnostic category, by applying and adopting precedent studies and clinical guidelines. From March to July, 2011, a total of 23,704 clinic visits occurred at 98 shelters with 7934 residents. Oral antibiotics were prescribed a total of 2253 times. The median age of the patients was 48.5 years old (range 0-97), and 43.7% were male. Of 2253 antibiotic prescriptions, 1944 were judged to be inappropriate (86.3% 95% CI 84.8%-87.7%). The most prescribed antibiotic was clarithromycin (646 times, 28.7%), followed by cefcapene pivoxil (644 times, 28.6%), levofloxacin (380, 16.9%), cefdinir (194, 8.6%), and cefditren pivoxil (98, 4.4%). The most frequent diagnosis for which antibiotics were prescribed was upper respiratory infection (URI, 1040 visits, 46.2%), followed by acute bronchitis (369, 16.4%), pharyngitis (298, 13.2%), traumatic injuries (194, 8.6%), acute gastroenteritis (136, 6.0%), urinary tract infections (UTIs, 123, 5.5%), and allergic rhinitis (5.1%). The majority of antibiotics prescribed at clinics after the Great East Japan Earthquake was inappropriate. Significant improvement of the use of antibiotics in postdisaster settings should be sought immediately in Japan.

Advances in Rapid Identification and Susceptibility Testing of Bacteria in the Clinical Microbiology Laboratory: Implications for Patient Care and Antimicrobial Stewardship Programs

Early availability of information on bacterial pathogens and their antimicrobial susceptibility is of key importance for the management of infectious diseases patients. Currently, using traditional approaches, it usually takes at least 48 hours for identification and susceptibility testing of bacterial pathogens. Therefore, the slowness of diagnostic procedures drives prolongation of empiric, potentially inappropriate, antibacterial therapies. Over the last couple of years, the improvement of available techniques (e.g. for susceptibility testing, DNA amplification assays), and introduction of novel technologies (e.g. MALDI-TOF) has fundamentally changed approaches towards pathogen identification and characterization. Importantly, these techniques offer increased diagnostic resolution while at the same time shorten the time-to-result, and are thus of obvious importance for antimicrobial stewardship. In this review, we will discuss recent advances in medical microbiology with special emphasis on the impact of novel techniques on antimicrobial stewardship programs.

Risk Factors for Outpatient Use of Antibiotics in Children with Acute Respiratory Illnesses

OBJECTIVES

Antibiotics for acute respiratory illness (ARI) constitute most pediatric medication use and contribute to the emergence of antimicrobial resistance. We investigated antibiotic prescription risk factors for ARI in pediatric clinics and clinical follow-up in individuals prescribed and not prescribed antibiotics.

METHODS

In this observational study, we enrolled children ages 2 to 17 years old presenting with ARI with fever to two academic pediatric primary care outpatient clinics during influenza season 2013-2014. We collected information on demographics, initial symptoms, medical conditions, laboratory tests, discharge diagnoses, treatments, and 30 days of follow-up medical encounters. Factors associated with antibiotic prescription receipt were evaluated using logistic regression.

RESULTS

Of 206 consented and enrolled children, 59 (29%) were prescribed antibiotics, 51 of 59 (86%) for indicated diagnoses: 34 for streptococcal pharyngitis, 15 for acute otitis media (AOM), and 2 for pneumonia. Discharge diagnoses were the only factors independently associated with an antibiotic prescription. Of children prescribed/not prescribed an antibiotic, 17%/17% received follow-up telephone calls and 27%/17% had follow-up visits related to ARI within 30 days. Two children with AOM were prescribed a second antibiotic during follow-up, and one developed Clostridium difficile colitis. Eighteen of 206 (9%) additional children were prescribed antibiotics within 30 days for ARI symptoms, 17 for streptococcal pharyngitis, AOM, pneumonia, or sinusitis; one was prescribed antibiotics for influenza-like illness.

CONCLUSIONS

Among study children 2 to 17 years old with outpatient ARI, 29% were prescribed antibiotics at the initial visit and another 9% were prescribed antibiotics during the 30-day follow-up (most were for appropriate indications). Further decreasing antibiotic use in similar settings will likely require wider implementation of watchful waiting for AOM, a change in guidelines for pharyngitis management, and/or reductions in these diseases.

Medical and psychosocial factors associated with antibiotic prescribing in primary care: survey questionnaire and factor analysis

BACKGROUND

Acute upper respiratory infections (AURI) are the leading causes of antibiotic prescribing in primary care although antibiotics are often not indicated.

AIM

To gain an understanding of the knowledge, attitudes, and practices (KAP) of GPs in Singapore and the associated latent factors to guide the implementation of an effective programme to reduce antibiotic use in primary care.

DESIGN AND SETTING

An anonymous survey on the KAP of antibiotic use in AURI of GPs in Singapore.

METHOD

KAP survey questionnaires were posted to all GPs from a database. To ascertain the latent factors affecting prescribing patterns, exploratory factor analysis was performed.

RESULTS

Among 427 responses, 351 (82.2%) were from GPs working in private practice. It was found that 58.4% of GPs in the private versus 72.4% of those in the public sector recognised that >80% of AURIs were caused by viruses (P = 0.02). The majority of GPs (353/427; 82.7%) felt that antibiotics were overprescribed in primary care. Significant factors associated with low antibiotic prescribing were good medical knowledge and clinical competency (adjusted odds ratio [aOR] 3.2, 95% confidence interval [CI] = 2.4 to 4.3), good clinical practice (aOR 2.7 [95% CI = 2.0 to 3.6]), availability of diagnostic tests (aOR 1.4 [95% CI = 1.1 to 1.8]), and desire to improve clinical practice (aOR 1.5 [95% CI = 1.2 to 1.9]). The conservative practice of giving antibiotics 'to be on the safe side' is significantly less likely to be associated with low antibiotic prescribing (aOR 0.7 [95% CI = 0.5 to 0.9]).

CONCLUSION

This is the first KAP survey on antibiotic prescribing for AURI among GPs in Singapore. With the latent factors identified, future interventions should be directed at addressing these factors to reduce inappropriate antibiotic prescribing.

Efficacy and tolerability of a polysaccharide-resin-honey based cough syrup as compared to carbocysteine syrup for children with colds: a randomized, single-blinded, multicenter study

BACKGROUND

Available pediatric treatments for acute cough are limited by lack of demonstrated efficacy. The objective of this trial is to compare the effects of a polysaccharide-resin-honey based cough syrup, and carbocysteine syrups on nocturnal and daytime cough associated with childhood upper respiratory tract infections (URIs).

METHODS

Using a single-blind randomization design, the study recruited children from 4 general pediatric community clinics. Participants included 150 children aged 2 to 5 years with an URI, nocturnal and daytime cough and illness duration of ≤7 days. To be eligible, children had to be free of medication on the day before presentation. A survey was administered to parents on 4 consecutive days beginning from the day of presentation in clinic. Children received the study preparation on the first evening and then 3 times per day for 3 further days. Main outcome measures were cough frequency, cough severity, bothersome nature of cough, and quality of sleep for both child and parent.

RESULTS

Both preparations were well tolerated and cough improved over the study period. After one night and on all survey days, there was a significantly better result for polysaccharide-resin-honey (P<0.05) for all the main outcome measures. The trend of improvement over the 4 days was steeper for polysaccharide-resin-honey (P<0.05) with regards to all cough parameters.

CONCLUSIONS

Both polysaccharide-resin-honey and carbocysteine cough syrups were well tolerated in children over 2 years of age. The polysaccharide-resin-honey syrup was associated with a more rapid and greater improvement in all clinical cough symptoms measured, beginning from the first night of therapy. Both nocturnal and daytime cough improved, as did sleep quality for both children and parents.

Teaching Shared Decision Making to Family Medicine Residents: A Descriptive Study of a Web-Based Tutorial

BACKGROUND

DECISION+2, a Web-based tutorial, was designed to train family physicians in shared decision making (SDM) regarding the use of antibiotics for acute respiratory infections (ARIs). It is currently mandatory for second-year family medicine residents at Université Laval, Quebec, Canada. However, little is known about how such tutorials are used, their effect on knowledge scores, or how best to assess resident participation.

OBJECTIVE

The objective of our study was to describe the usage of this Web-based training platform by family medicine residents over time, evaluate its effect on their knowledge scores, and identify what kinds of data are needed for a more comprehensive analysis of usage and knowledge acquisition.

METHODS

We identified, collected, and analyzed all available data about participation in and current usage of the tutorial and its before-and-after 10-item knowledge test. Residents were separated into 3 log-in periods (2012-2013, 2013-2014, and 2014-2015) depending on the day of their first connection. We compared residents' participation rates between entry periods (Cochran-Armitage test), assessed the mean rank of the difference in total scores and category scores between pre- and posttest (Wilcoxon signed-rank test), and compared frequencies of each. Subsequent to analyses, we identified types of data that would have provided a more complete picture of the usage of the program and its effect on knowledge scores.

RESULTS

The tutorial addresses 3 knowledge categories: diagnosing ARIs, treating ARIs, and SDM regarding the use of antibiotics for treating ARIs. From July 2012 to July 2015, all 387 second-year family medicine residents were eligible to take the Web-based tutorial. Out of the 387 eligible residents, 247 (63.8%) logged in at least once. Their participation rates varied between entry periods, most significantly between the 2012-2013 and 2013-2014 cohorts (P=.006). For the 109 out of 387 (28.2%) residents who completed the tutorial and both tests, total and category scores significantly improved between pre- and posttest (all P values <.001). However, the frequencies of those answering correctly on 2 of the 3 SDM questions did not increase significantly (P>.99, P=.25). Distribution of pre- or posttest total and category scores did not increase between entry periods (all P values >.1). Available data were inadequate for evaluating the associations between the tutorial and its impact on the residents' scores and therefore could tell us little about its effect on increasing their knowledge.

CONCLUSION

Residents' use of this Web-based tutorial appeared to increase between entry periods following the changes to the SDM program, and the tutorial seemed less effective for increasing SDM knowledge scores than for diagnosis or treatment scores. However, our results also highlight the need to improve data availability before participation in Web-based SDM tutorials can be properly evaluated or knowledge scores improved.

Patterns of medication use and factors associated with antibiotic use among adult fever patients at Singapore primary care clinics

Background

Antimicrobial resistance is a public health problem of global importance. In Singapore, much focus has been given to antibiotic usage patterns in hospital settings. Data on antibiotic use in primary care is lacking. We describe antibiotic usage patterns and assess factors contributing to antibiotic usage among adults presenting with acute febrile illness (AFI) in primary care settings in Singapore.

Methods

We analyzed data from the Early Dengue infection and outcome study. Adults with AFI presenting at 5 Singapore polyclinics were included. We used multivariable logistic regression to assess demographic, clinical and laboratory factors associated with antibiotic usage among adults with AFI.

Results

Between December 2007 and February 2013, 1884 adult AFI patients were enrolled. Overall, 16% of adult AFI patients reported antibiotic use. We observed a rise in the use of over-the-counter medications in late 2009 and a decrease in antibiotic use during 2010, possibly related to the outbreak of pandemic influenza A H1N1 virus. After adjusting for age, gender, polyclinic and year of enrolment, the following factors were associated with higher odds of antibiotic use: living in landed property (compared to public housing) (OR = 1.73; 95% CI: 1.06–2.80); body mass index (BMI) <18.5 (OR = 1.87; 95% CI: 1.19–2.93); elevated white blood cell (WBC) count (OR = 1.98; 95% CI: 1.42–2.78); and persistence of initial symptoms at 2–3 days follow-up with OR (95% CI) for categories of 1, 2, 3, and ≥4 persisting symptoms being 2.00 (1.38–2.92), 2.67 (1.80–3.97), 4.26 (2.73–6.64), and 2.79 (1.84–4.24) respectively.

Conclusions

Our study provides insights on antibiotic usage among adult patients presenting to primary care clinics with febrile illness, and suggests that high socio-economic status, and risk factors of a severe illness, that is, low BMI and persistence of initial symptoms, are associated with higher antibiotic use. Further work to understand trends of antibiotic usage in both private and public primary care clinics, and factors that influence patient expectation and physician prescribing of antibiotics is important.

Evidence of Inefficiencies in Practice Patterns: Regional Variation in Medicare Medical and Drug Spending

Several studies have explored the causes and magnitude of geographic variation in Medicare spending and service use, but most of these studies have not taken into account that pharmaceuticals may substitute for medical service use. We address this issue using Medicare medical and pharmaceutical administrative claims data to explore the correlation between medical and pharmaceutical spending and utilization; we also examine medical and pharmaceutical use for subsets of the Medicare population with certain chronic conditions often treated with drugs. Beneficiary-level regressions with controls for health status and demographics were used to construct standardized medical spending and pharmaceutical spending and utilization measures for each region and patient cohort. Areas with higher medical spending tend to have higher pharmaceutical spending in general. However, areas with higher medical spending also tend to have lower pharmaceutical spending for conditions for which prescription drugs may substitute for additional medical care. Both of these patterns are consistent with less efficient medical practices in higher-spending areas. Likewise, more expensive drugs and more broad-spectrum antibiotics, which are often considered discretionary and overused, are more likely to be prescribed in higher-spending areas. Our results suggest that care may be provided more efficiently in some regions than in others. However, additional research is needed to investigate relationships between spending and health care outcomes, and what types of policies may create incentives for higher-spending regions to reduce spending without a loss in quality.