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Turk K, Jacobson Vann J, Oppewal S. Antibiotic prescribing patterns and guideline-concordant management of acute respiratory tract infections in virtual urgent care settings. J Am Assoc Nurse Pract 2022; 34:813-824. [PMID: 35472013 DOI: 10.1097/jxx.0000000000000705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/02/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antibiotic overprescribing for acute respiratory tract infections (ARTIs) commonly occurs and can lead to higher medical costs, antibiotic resistance, and health complications. Inappropriate prescribing of antibiotics for ARTIs has been shown to occur more frequently in urgent care than other outpatient settings. It is not clear whether antibiotic overprescribing varies between virtual and in-person urgent care. OBJECTIVES Summarize published primary scientific literature on antibiotic prescribing patterns for ARTIs among adults in virtual urgent care settings. DATA SOURCES We conducted a systematic review to compare antibiotic prescribing for ARTIs between virtual and in-person urgent care. Our review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. We assessed risk of bias using the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) assessment tool. We summarized study results from seven included retrospective cohort studies. CONCLUSIONS Antibiotic prescribing frequency may be similar between virtual urgent care and in-person care for adult patients treated for ARTIs. However, variability existed in intervention characteristics, settings, and outcome measures. Additional studies are needed to better understand the conditions in which virtual care may be most effective. IMPLICATIONS FOR PRACTICE Evidence suggests that giving providers direct access to evidence-based guidelines and electronic health records within the virtual visit may support diagnosis and management. Furthermore, practices that use telemedicine platforms for virtual urgent care visits should consider how to potentially improve diagnosis and management of conditions through the use of home-based point-of-care testing or accessory "e-tools."
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Butler AM, Brown DS, Durkin MJ, Sahrmann JM, Nickel KB, O’Neil CA, Olsen MA, Hyun DY, Zetts RM, Newland JG. Association of Inappropriate Outpatient Pediatric Antibiotic Prescriptions With Adverse Drug Events and Health Care Expenditures. JAMA Netw Open 2022; 5:e2214153. [PMID: 35616940 PMCID: PMC9136626 DOI: 10.1001/jamanetworkopen.2022.14153] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Nonguideline antibiotic prescribing for the treatment of pediatric infections is common, but the consequences of inappropriate antibiotics are not well described. OBJECTIVE To evaluate the comparative safety and health care expenditures of inappropriate vs appropriate oral antibiotic prescriptions for common outpatient pediatric infections. DESIGN, SETTING, AND PARTICIPANTS This cohort study included children aged 6 months to 17 years diagnosed with a bacterial infection (suppurative otitis media [OM], pharyngitis, sinusitis) or viral infection (influenza, viral upper respiratory infection [URI], bronchiolitis, bronchitis, nonsuppurative OM) as an outpatient from April 1, 2016, to September 30, 2018, in the IBM MarketScan Commercial Database. Data were analyzed from August to November 2021. EXPOSURES Inappropriate (ie, non-guideline-recommended) vs appropriate (ie, guideline-recommended) oral antibiotic agents dispensed from an outpatient pharmacy on the date of infection. MAIN OUTCOMES AND MEASURES Propensity score-weighted Cox proportional hazards models were used to estimate hazards ratios (HRs) and 95% CIs for the association between inappropriate antibiotic prescriptions and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable health care expenditures by infection type. National-level annual attributable expenditures were calculated by scaling attributable expenditures in the study cohort to the national employer-sponsored insurance population. RESULTS The cohort included 2 804 245 eligible children (52% male; median [IQR] age, 8 [4-12] years). Overall, 31% to 36% received inappropriate antibiotics for bacterial infections and 4% to 70% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and severe allergic reaction among children treated with a nonrecommended antibiotic agent for a bacterial infection (among patients with suppurative OM, C. difficile infection: HR, 6.23; 95% CI, 2.24-17.32; allergic reaction: HR, 4.14; 95% CI, 2.48-6.92). Thirty-day attributable health care expenditures were generally higher among children who received inappropriate antibiotics, ranging from $21 to $56 for bacterial infections and from -$96 to $97 for viral infections. National annual attributable expenditure estimates were highest for suppurative OM ($25.3 million), pharyngitis ($21.3 million), and viral URI ($19.1 million). CONCLUSIONS AND RELEVANCE In this cohort study of children with common infections treated in an outpatient setting, inappropriate antibiotic prescriptions were common and associated with increased risks of adverse drug events and higher attributable health care expenditures. These findings highlight the individual- and national-level consequences of inappropriate antibiotic prescribing and further support implementation of outpatient antibiotic stewardship programs.
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Affiliation(s)
- Anne M. Butler
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | | | - Michael J. Durkin
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - John M. Sahrmann
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Katelin B. Nickel
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Caroline A. O’Neil
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Margaret A. Olsen
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | | | | | - Jason G. Newland
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
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Venditto VJ, Feola DJ. Delivering macrolide antibiotics to heal a broken heart - And other inflammatory conditions. Adv Drug Deliv Rev 2022; 184:114252. [PMID: 35367307 PMCID: PMC9063468 DOI: 10.1016/j.addr.2022.114252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/07/2022] [Accepted: 03/28/2022] [Indexed: 12/17/2022]
Abstract
Drug carriers to deliver macrolide antibiotics, such as azithromycin, show promise as antibacterial agents. Macrolide drug carriers have largely focused on improving the drug stability and pharmacokinetics, while reducing adverse reactions and improving antibacterial activity. Recently, macrolides have shown promise in treating inflammatory conditions by promoting a reparative effect and limiting detrimental pro-inflammatory responses, which shifts the immunologic setpoint from suppression to balance. While macrolide drug carriers have only recently been investigated for their ability to modulate immune responses, the previous strategies that deliver macrolides for antibacterial therapy provide a roadmap for repurposing the macrolide drug carriers for therapeutic interventions targeting inflammatory conditions. This review describes the antibacterial and immunomodulatory activity of macrolides, while assessing the past in vivo evaluation of drug carriers used to deliver macrolides with the intention of presenting a case for increased effort to translate macrolide drug carriers into the clinic.
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Gunnarsson R, Orda U, Elliott B, Heal C, Del Mar C. What is the optimal strategy for managing primary care patients with an uncomplicated acute sore throat? Comparing the consequences of nine different strategies using a compilation of previous studies. BMJ Open 2022; 12:e059069. [PMID: 35487741 PMCID: PMC9058799 DOI: 10.1136/bmjopen-2021-059069] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Identifying optimal strategies for managing patients of any age with varying risk of acute rheumatic fever (ARF) attending for an apparently uncomplicated acute sore throat, also clarifying the role of point-of-care testing (POCT) for presence of group A beta-haemolytic Streptococcus (GABHS) in these settings. DESIGN We compared outcomes of adhering to nine different strategies for managing these patients in primary healthcare. SETTING AND PARTICIPANTS The nine strategies, similar to guidelines from several countries, were tested against two validation data sets being constructs from seven prior studies. MAIN OUTCOME MEASURES The proportion of patients requiring a POCT, prescribed antibiotics, prescribed antibiotics having GABHS and finally having GABHS not prescribed antibiotics, if different strategies had been adhered to. RESULTS In a scenario with high risk of ARF, adhering to existing guidelines would risk many patients ill from GABHS left without antibiotics. Hence, using a POCT on all of these patients minimised their risk. For low-risk patients, it is reasonable to only consider antibiotics if the patient has more than low pain levels despite adequate analgesia, 3-4 Centor scores (or 2-3 FeverPAIN scores or 3-4 McIsaac scores) and a POCT confirming the presence of GABHS. This would require testing only 10%-15% of patients and prescribing antibiotics to only 3.5%-6.6%. CONCLUSIONS Patients with high or low risk for ARF needs to be managed very differently. POCT can play an important role in safely targeting the use of antibiotics for patients with an apparently uncomplicated acute sore throat.
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Affiliation(s)
- Ronny Gunnarsson
- School of Public Health and Community Medicine - General Practice/Family Medicine, Göteborgs universitet Institutionen för medicin, Goteborg, Sweden
- Research, Development, Education and Innovation, Primary Health Care, Västra Götalandsregionen, Göteborg, Sweden
- Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Göteborg, Sweden
- The primary health care clinic for homeless people, Närhälsan, Region Västra Götaland, Göteborg, Sweden
| | - Ulrich Orda
- Mount Isa Hospital, North West Hospital and Health Service, Mount Isa, Queensland, Australia
| | | | - Clare Heal
- School of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
| | - Chris Del Mar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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Barth DD, Mullane MJ, Sampson C, Chou C, Pickering J, Nicol MP, Davies MR, Carapetis J, Bowen AC. Missing Piece Study protocol: prospective surveillance to determine the epidemiology of group A streptococcal pharyngitis and impetigo in remote Western Australia. BMJ Open 2022; 12:e057296. [PMID: 35387825 PMCID: PMC8987764 DOI: 10.1136/bmjopen-2021-057296] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/17/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Group A β-haemolytic Streptococcus (GAS), a Gram-positive bacterium, causes skin, mucosal and systemic infections. Repeated GAS infections can lead to autoimmune diseases acute rheumatic fever (ARF) and rheumatic heart disease (RHD). Aboriginal and Torres Strait Islander peoples in Australia have the highest rates of ARF and RHD in the world. Despite this, the contemporaneous prevalence and incidence of GAS pharyngitis and impetigo in remote Australia remains unknown. To address this, we have designed a prospective surveillance study of GAS pharyngitis and impetigo to collect coincident contemporary evidence to inform and enhance primary prevention strategies for ARF. METHODS AND ANALYSIS The Missing Piece Study aims to document the epidemiology of GAS pharyngitis and impetigo through collection of clinical, serological, microbiological and bacterial genomic data among remote-living Australian children. The study comprises two components: (1) screening of all children at school for GAS pharyngitis and impetigo up to three times a year and (2) weekly active surveillance visits to detect new cases of pharyngitis and impetigo. Environmental swabbing in remote schools will be included, to inform environmental health interventions. In addition, the application of new diagnostic technologies, microbiome analysis and bacterial genomic evaluations will enhance primary prevention strategies, having direct bearing on clinical care, vaccine development and surveillance for vaccine clinical trials. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Western Australian Aboriginal Health Ethics Committee (Ref: 892) and Human Research Ethics Committee of the University of Western Australia (Ref: RA/4/20/5101). Study findings will be shared with community members, teachers and children at participating schools, together with academic and medical services. Sharing findings in an appropriate manner is important and will be done in a suitable way which includes plain language summaries and presentations. Finally, findings and updates will also be disseminated to collaborators, researchers and health planners through peer-reviewed journal publications.
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Affiliation(s)
- Dylan D Barth
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Marianne J Mullane
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Claudia Sampson
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Coco Chou
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Janessa Pickering
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Mark P Nicol
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Mark R Davies
- Department of Microbiology and Immunology, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Jonathan Carapetis
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Asha C Bowen
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Institute for Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
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Xiao Y, Leung EKY. Over-the-Counter and Direct-to-Consumer Testing for Group A Streptococcus. Clin Biochem 2022; 117:34-38. [DOI: 10.1016/j.clinbiochem.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/03/2022] [Accepted: 04/06/2022] [Indexed: 11/03/2022]
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Sarangarm P, Huerena TA, Norii T, Walraven CJ. Antibiotic Prescribing in Adults Presenting with Pharyngitis Pre- and Post-Implementation of a Rapid Group A Streptococcus Test. Hosp Pharm 2022; 57:309-314. [PMID: 35601722 PMCID: PMC9117770 DOI: 10.1177/00185787211032365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Group A Streptococcus (GAS) pharyngitis is the most common bacterial cause of acute pharyngitis and is often over treated with unnecessary antibiotics. The purpose was to evaluate if implementation of a rapid antigen detection test (RADT) for GAS would reduce the number of inappropriately prescribed antibiotics for adult patients presenting with symptoms of pharyngitis. Methods: This was a retrospective cohort study of adult urgent care clinic patients pre- and post-implementation of a GAS RADT. We included patients who had a diagnosis of GAS identified via ICD-10 codes and either a throat culture, GAS RADT, or antibiotic prescribed for GAS. Antibiotic prescribing was assessed as appropriate or inappropriate based on testing and IDSA guideline recommendations. Thirty-day follow-up visits related to pharyngitis or the prescribed antibiotics was also evaluated. Results: A total of 1734 patients were included; 912 and 822 in the pre- and post-implementation groups, respectively. Following implementation of the GAS RADT, there was an increase in the number of antibiotics prescribed for GAS (43.4% vs 59.1%, P < .001) as well as an increase in appropriate prescribing (67.6% vs 77.5%, P < .001). More 30-day pharyngitis-related follow-up visits were seen in the pre-intervention group (12.5% vs 9.3%, P = .03). Conclusion: Implementation of a RADT for GAS pharyngitis was associated with an increase in both the overall number of antibiotic prescriptions for GAS and the proportion of appropriately prescribed antibiotics. There was also a reduction in follow up visits related to GAS pharyngitis, however educational efforts to further increase appropriate prescribing is needed.
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58
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Eisenberg P, Albert L, Teuffel J, Zitzow E, Michaelis C, Jarick J, Sehlke C, Große L, Bader N, Nunes-Alves A, Kreikemeyer B, Schindelin H, Wade RC, Fiedler T. The Non-phosphorylating Glyceraldehyde-3-Phosphate Dehydrogenase GapN Is a Potential New Drug Target in Streptococcus pyogenes. Front Microbiol 2022; 13:802427. [PMID: 35242116 PMCID: PMC8886048 DOI: 10.3389/fmicb.2022.802427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/14/2022] [Indexed: 01/01/2023] Open
Abstract
The strict human pathogen Streptococcus pyogenes causes infections of varying severity, ranging from self-limiting suppurative infections to life-threatening diseases like necrotizing fasciitis or streptococcal toxic shock syndrome. Here, we show that the non-phosphorylating glyceraldehyde-3-phosphate dehydrogenase GapN is an essential enzyme for S. pyogenes. GapN converts glyceraldehyde 3-phosphate into 3-phosphoglycerate coupled to the reduction of NADP to NADPH. The knock-down of gapN by antisense peptide nucleic acids (asPNA) significantly reduces viable bacterial counts of S. pyogenes laboratory and macrolide-resistant clinical strains in vitro. As S. pyogenes lacks the oxidative part of the pentose phosphate pathway, GapN appears to be the major NADPH source for the bacterium. Accordingly, other streptococci that carry a complete pentose phosphate pathway are not prone to asPNA-based gapN knock-down. Determination of the crystal structure of the S. pyogenes GapN apo-enzyme revealed an unusual cis-peptide in proximity to the catalytic binding site. Furthermore, using a structural modeling approach, we correctly predicted competitive inhibition of S. pyogenes GapN by erythrose 4-phosphate, indicating that our structural model can be used for in silico screening of specific GapN inhibitors. In conclusion, the data provided here reveal that GapN is a potential target for antimicrobial substances that selectively kill S. pyogenes and other streptococci that lack the oxidative part of the pentose phosphate pathway.
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Affiliation(s)
- Philip Eisenberg
- Institute of Medical Microbiology, Virology, and Hygiene, Rostock University Medical Centre, Rostock, Germany
| | - Leon Albert
- Rudolf Virchow Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany
| | - Jonathan Teuffel
- Molecular and Cellular Modeling Group, Heidelberg Institute for Theoretical Studies, Heidelberg, Germany
| | - Eric Zitzow
- Institute of Medical Microbiology, Virology, and Hygiene, Rostock University Medical Centre, Rostock, Germany
| | - Claudia Michaelis
- Institute of Medical Microbiology, Virology, and Hygiene, Rostock University Medical Centre, Rostock, Germany
| | - Jane Jarick
- Institute of Medical Microbiology, Virology, and Hygiene, Rostock University Medical Centre, Rostock, Germany
| | - Clemens Sehlke
- Institute of Medical Microbiology, Virology, and Hygiene, Rostock University Medical Centre, Rostock, Germany
| | - Lisa Große
- Institute of Medical Microbiology, Virology, and Hygiene, Rostock University Medical Centre, Rostock, Germany
| | - Nicole Bader
- Rudolf Virchow Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany
| | - Ariane Nunes-Alves
- Molecular and Cellular Modeling Group, Heidelberg Institute for Theoretical Studies, Heidelberg, Germany.,Center for Molecular Biology (ZMBH), DKFZ-ZMBH Alliance, Heidelberg University, Heidelberg, Germany
| | - Bernd Kreikemeyer
- Institute of Medical Microbiology, Virology, and Hygiene, Rostock University Medical Centre, Rostock, Germany
| | - Hermann Schindelin
- Rudolf Virchow Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany
| | - Rebecca C Wade
- Molecular and Cellular Modeling Group, Heidelberg Institute for Theoretical Studies, Heidelberg, Germany.,Center for Molecular Biology (ZMBH), DKFZ-ZMBH Alliance, Heidelberg University, Heidelberg, Germany.,Interdisciplinary Center for Scientific Computing (IWR), Heidelberg University, Heidelberg, Germany
| | - Tomas Fiedler
- Institute of Medical Microbiology, Virology, and Hygiene, Rostock University Medical Centre, Rostock, Germany
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Poole NM, Frost H. Targets and Methods to Improve Outpatient Antibiotic Prescribing for Pediatric Patients. Infect Dis Clin North Am 2022; 36:187-202. [DOI: 10.1016/j.idc.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Thompson JM, Zagel AL, Spaulding AB, Krause EA, Arms JL. Streptococcal Pharyngitis: Compliance With National Testing Guidelines in a Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e519-e523. [PMID: 34417790 DOI: 10.1097/pec.0000000000002512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The Infectious Diseases Society of America (IDSA) guidelines regarding group A streptococcal (GAS) pharyngitis advise against routine testing for patients younger than 3 years, patients without pharyngitis, and patients with symptoms suggesting a viral infection. Group A streptococcal testing may be overused in some clinical settings; thus, we conducted this study to evaluate compliance with the IDSA guidelines in a pediatric emergency department (ED) setting. METHODS This retrospective cohort study describes patients younger than 18 years presenting to 2 urban pediatric EDs in 2016 who underwent rapid antigen detection testing for GAS pharyngitis. Testing was classified as noncompliant with the IDSA guidelines if the chief complaint was not indicative of GAS infection and/or the patient age was younger than 3 years. Appropriate nonparametric tests compared groups by IDSA testing compliance status. RESULTS A total of 13,585 patient encounters met inclusion criteria; 5255 (39%) were noncompliant with the IDSA testing guidelines, the majority due to a chief complaint inconsistent with GAS pharyngitis (67%) and secondarily due to the age of younger than 3 years (48%). Among the patients with noncompliant testing, 51% were prescribed an antibiotic, and return encounters were more likely to occur (13% vs 10%, P < 0.001). Return encounters more commonly resulted in respiratory diagnoses in those with noncompliant GAS testing (60% vs 45%, P < 0.001). CONCLUSIONS Nearly 40% of all pediatric ED encounters with GAS testing were noncompliant with the IDSA guidelines and were associated with greater return encounter rates. Potential negative outcomes from noncompliant GAS testing include misdiagnosis, inappropriate use of antibiotics, allergic reactions, and loss of school days. Informed interventions to reduce unnecessary GAS testing are warranted.
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Affiliation(s)
| | - Alicia L Zagel
- Children's Minnesota Research Institute, Minneapolis, MN
| | | | | | - Joseph L Arms
- From the Children's Minnesota Department of Pediatric Emergency Medicine
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Muhaj FF, George SJ, Tyring SK. Bacterial resistance and dermatological ramifications. Br J Dermatol 2022; 187:12-20. [PMID: 35083740 DOI: 10.1111/bjd.21033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 01/18/2022] [Accepted: 01/18/2022] [Indexed: 11/28/2022]
Abstract
The spread of COVID-19 serves as a reminder of the might of microbes in the era of modern medicine. For years, another threat has preoccupied infectious disease experts and public health officials alike: rising antimicrobial resistance (AMR). Resistance is exceeding stewardship efforts and the rates of new drug development and approval in the market. A dry antimicrobial pipeline is threatening our regression to a pre-antibiotic era. While the consequences of resistance may seem far removed from daily clinical practices, awareness of AMR is significant to dermatological care given that dermatologists prescribe more antibiotics per physician than other providers. Antibiotics in dermatology are often used for prolonged courses, with a significant potential for microbiome alteration and antibiotic-related adverse effects. Through this review we hope to contribute to efforts of bringing the crisis of AMR to the forefront of daily dermatological practice.
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Affiliation(s)
- F F Muhaj
- Department of Dermatology, MD Anderson Cancer Center, Houston, Texas, USA
| | - S J George
- Department of Dermatology, MD Anderson Cancer Center, Houston, Texas, USA
| | - S K Tyring
- Department of Dermatology, University of Texas McGovern Medical School at Houston, Houston, Texas, USA.,Center for Clinical Studies, Houston, Texas, USA
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Covino M, Buonsenso D, Gatto A, Morello R, Curatole A, Simeoni B, Franceschi F, Chiaretti A. Determinants of antibiotic prescriptions in a large cohort of children discharged from a pediatric emergency department. Eur J Pediatr 2022; 181:2017-2030. [PMID: 35118518 PMCID: PMC8813572 DOI: 10.1007/s00431-022-04386-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/03/2022] [Accepted: 01/21/2022] [Indexed: 01/26/2023]
Abstract
While there is evidence of high use of wide-spectrum antibiotics in children evaluated in the pediatric emergency departments, determinants of this behavior are still unclear. This study was aimed at defining the demographic, social, clinical, and laboratory factors that affect antibiotic prescriptions in children discharged from the emergency department. We performed a retrospective observational study of children aged younger than 18 years discharged from a pediatric university hospital between Jan. 1, 2015 and Dec. 31, 2020. We determined the proportion and type of antibiotic prescription according to demographic, social, clinical, laboratory, and imaging data, as well as doctor's expertise. Fifty-one thousand six hundred thirty-three children were included, and 13,167 (25.5%) received an antibiotic prescription. Amoxicilline/clavulanate (Am/Cl) was the most prescribed antibiotic (8453, 64.2% of all prescriptions). Factors independently associated with an antibiotic prescription were older age (OR = 1.62 [1.53-1.73] for age 2-5 years, OR = 1.77 [1.64-1.91] for age 6-10 years, OR = 1.36 [1.25-1.49] for age 11-18 years, p < 0.001 for all groups); being evaluated by a physician with > 3 years of pediatric expertise (OR = 1.22 [1.13-1.31], p < 0.001); fever peak higher than 40 °C (OR = 1.37 [1.21-1.54], p < 0.001); abnormal findings on auscultation (OR = 1.95 [1.75-2.17], p < 0.001), CRP values (OR = 1.63 [1.26-2.10] for CRP < 50 mg/L, and OR = 3.78 (2.75-5.21) for CRP ≥ 50 mg/L with respect to CRP not requested; p < 0.01); CXR results whatever positive (OR = 4.47 [3.62-5.52], p < 0.001) or negative (1.82 [1.62-2.04], p < 0.001); being diagnosed with upper respiratory tract infections (OR = 4.27 [4.04-4.51], p < 0.001), lower respiratory tract infections (OR = 5.35 [4.88-5.85]; p < 0.001), and UTI (OR = 9.33 [8.14-10.71], p < 0.001). Conclusions: Overprescription of antibiotics, including Am/Cl, is relevant in pediatric emergency departments. Factors associated with overprescription are not limited to the clinical characteristics of the treated patients. These findings highlight the need for a new and comprehensive approach to ensure successful antibiotic stewardship initiatives in the emergency departments. What is Known: • Antibiotic resistance is a growing problem in medical practice, including in pediatrics. • Antibiotics are overprescribed in children assessed in the emergency department, but comprehensive and large studies are lacking. What is New: • Factors associated with overprescription are not limited to the clinical characteristics of the patients. • Non-clinical factors such as environmental variables, doctor's expertise, and attitudes to laboratory and radiological examinations affect prescription.
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Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Danilo Buonsenso
- Dipartimento Di Scienze Di Laboratorio E Infettivologiche, Fondazione Policlinico Universitario A. 8 Gemelli, IRCCS, Rome, Italy
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario 10 A. Gemelli, IRCCS, Rome, Italy
- Global Health Research Institute, Istituto Di Igiene, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Gatto
- Dipartimento Di Scienze Di Laboratorio E Infettivologiche, Fondazione Policlinico Universitario A. 8 Gemelli, IRCCS, Rome, Italy
| | - Rosa Morello
- Dipartimento Di Scienze Di Laboratorio E Infettivologiche, Fondazione Policlinico Universitario A. 8 Gemelli, IRCCS, Rome, Italy
| | - Antonietta Curatole
- Dipartimento Di Scienze Di Laboratorio E Infettivologiche, Fondazione Policlinico Universitario A. 8 Gemelli, IRCCS, Rome, Italy
| | - Benedetta Simeoni
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Chiaretti
- Dipartimento Di Scienze Di Laboratorio E Infettivologiche, Fondazione Policlinico Universitario A. 8 Gemelli, IRCCS, Rome, Italy
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63
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Palchun VT, Kryukov AI, Gurov AV, Kelemetov AA, Ermolaev AG, Muratov DL. [Modern approaches to the surgical treatment of chronic tonsillitis]. Vestn Otorinolaringol 2022; 87:72-77. [PMID: 35818949 DOI: 10.17116/otorino20228703172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
At the moment, all over the world there are a large number of various methods of surgical treatment of chronic tonsillitis. In particular: classical tonsillectomy, cryosurgical method for removing the palatine tonsils, shaver tonsillectomy, monopolar and bipolar tonsillectomy, tonsillectomy with an ultrasonic scalpel, bipolar dissection using cutting instruments, laser tonsillectomy, coldablation. This article analyzes the existing methods, describes the fundamental technique for their implementation, as well as their advantages and disadvantages. Given the abundance of various surgical approaches to the treatment of chronic tonsillitis, there is a need for studies aimed at comparative study of their clinical and microbiological efficacy, including the postoperative period.
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Affiliation(s)
- V T Palchun
- Pirogov Russian National Research Medical University, Moscow, Russia
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - A I Kryukov
- Pirogov Russian National Research Medical University, Moscow, Russia
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - A V Gurov
- Pirogov Russian National Research Medical University, Moscow, Russia
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - A A Kelemetov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A G Ermolaev
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - D L Muratov
- Pirogov Russian National Research Medical University, Moscow, Russia
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
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64
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Sinusitis, Tonsillitis, and Pharyngitis. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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65
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Linafelter A, Burns A, Lee BR, Myers A, Burris A, Jones H, Dusin J, El Feghaly RE. Group A Streptococcal Pharyngitis Testing Appropriateness in Pediatric Acute Care Settings. Pediatr Emerg Care 2022; 38:e231-e233. [PMID: 32898124 DOI: 10.1097/pec.0000000000002223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Acute pharyngitis is one of the most common causes of ambulatory clinic visits; however, group A Streptococcus accounts for less than a third. National guidelines recommend against streptococcal testing in patients with viral features. This study aims to assess the rate of inappropriate streptococcal rapid antigen detection tests (RADT)s in children evaluated in urgent care clinics (UCC)s and emergency department (ED)s at a children's hospital. METHODS We retrospectively reviewed charts of 10% of children 3 years or older with RADTs ordered between April and September 2018 at EDs and UCCs. The test was determined to be inappropriate if the patient had no sore throat and/or had 2 or more viral symptoms: rhinorrhea/congestion, cough, diarrhea, hoarseness, conjunctivitis, or viral exanthem. RESULTS Over the study period, 7678 RADTs were performed, of which 7024 (91.2%) were in children 3 years or older. We evaluated 708 charts and found 44% of RADTs were inappropriate. The predicted probability of inappropriate RADT was highest among patients with a triaged reason for visit for respiratory complaints (70.5%), viral upper respiratory tract infection (69.7%), and rash (61.3%). Of the inappropriate RADTs, 20.1% were positive, whereas 32.2% of the appropriate RADTs were positive. CONCLUSION Quality improvement initiatives are needed to decrease the rate of inappropriate RADTs in pediatric UCC and ED settings.
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Affiliation(s)
| | - Alaina Burns
- From the Division of Pharmacy, University of Missouri
| | | | | | | | | | - Jarrod Dusin
- Department of Evidence-Based Practice, Children's Mercy Kansas City, Kansas City, MO
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Herdman MT, Cordery R, Karo B, Purba AK, Begum L, Lamagni T, Kee C, Balasegaram S, Sriskandan S. Clinical management and impact of scarlet fever in the modern era: findings from a cross-sectional study of cases in London, 2018-2019. BMJ Open 2021; 11:e057772. [PMID: 34952887 PMCID: PMC9066343 DOI: 10.1136/bmjopen-2021-057772] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/25/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES In response to increasing incidence of scarlet fever and wider outbreaks of group A streptococcal infections in London, we aimed to characterise the epidemiology, symptoms, management and consequences of scarlet fever, and to identify factors associated with delayed diagnosis. DESIGN AND SETTING Cross-sectional community-based study of children with scarlet fever notified to London's three Health Protection Teams, 2018-2019. PARTICIPANTS From 2575 directly invited notified cases plus invitations via parental networks at 410 schools/nurseries with notified outbreaks of confirmed/probable scarlet fever, we received 477 responses (19% of those directly invited), of which 412 met the case definition. Median age was 4 years (range <1 to 16), 48% were female, and 70% were of white ethnicity. OUTCOME MEASURES Preplanned measures included quantitative description of case demographics, symptoms, care-seeking, and clinical, social, and economic impact on cases and households. After survey completion, secondary analyses of factors associated with delayed diagnosis (by logistic regression) and consequences of delayed diagnosis (by Cox's regression), and qualitative analysis of free text comments were added. RESULTS Rash was reported for 89% of cases, but followed onset of other symptoms for 71%, with a median 1-day delay. Pattern of onset varied with age: sore throat was more common at onset among children 5 years and older (OR3.1, 95% CI 1.9 to 5.0). At first consultation, for 28%, scarlet fever was not considered: in these cases, symptoms were frequently attributed to viral infection (60%, 64/106). Delay in diagnosis beyond first consultation occurred more frequently among children aged 5+ who presented with sore throat (OR 2.8 vs 5+without sore throat; 95% CI 1.3 to 5.8). Cases with delayed diagnosis took, on average, 1 day longer to return to baseline activities. CONCLUSIONS Scarlet fever may be initially overlooked, especially among older children presenting with sore throat. Raising awareness among carers and practitioners may aid identification and timely treatment.
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Affiliation(s)
- Michael Trent Herdman
- National Infection Service, Public Health England (now UK Health Security Agency), London, UK
- UK Field Epidemiology Training Programme, Public Health England (now UK Health Security Agency), London, UK
| | - Rebecca Cordery
- South London Health Protection Team, Public Health England (now UK Health Security Agency), London, UK
| | - Basel Karo
- National Infection Service, Public Health England (now UK Health Security Agency), London, UK
| | - Amrit Kaur Purba
- South London Health Protection Team, Public Health England (now UK Health Security Agency), London, UK
| | - Lipi Begum
- South London Health Protection Team, Public Health England (now UK Health Security Agency), London, UK
| | - Theresa Lamagni
- National Infection Service, Public Health England (now UK Health Security Agency), London, UK
| | - Chuin Kee
- Oak Lodge Medical Centre, Barnet, North Central London CCG, London, UK
| | - Sooria Balasegaram
- National Infection Service, Public Health England (now UK Health Security Agency), London, UK
| | - Shiranee Sriskandan
- Department of Infectious Disease, Imperial College London, London, UK
- NIHR Health Protection Research Unit in Healthcare-associated infection and AMR, Imperial College London, London, UK
- MRC Centre for Molecular Bacteriology and Infection, Imperial College London, London, UK
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67
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Oliver J, Bennett J, Thomas S, Zhang J, Pierse N, Moreland NJ, Williamson DA, Jack S, Baker M. Preceding group A streptococcus skin and throat infections are individually associated with acute rheumatic fever: evidence from New Zealand. BMJ Glob Health 2021; 6:bmjgh-2021-007038. [PMID: 34887304 PMCID: PMC8663084 DOI: 10.1136/bmjgh-2021-007038] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/17/2021] [Indexed: 01/23/2023] Open
Abstract
Introduction Acute rheumatic fever (ARF) is usually considered a consequence of group A streptococcus (GAS) pharyngitis, with GAS skin infections not considered a major trigger. The aim was to quantify the risk of ARF following a GAS-positive skin or throat swab. Methods This retrospective analysis used pre-existing administrative data. Throat and skin swab data (1 866 981 swabs) from the Auckland region, New Zealand and antibiotic dispensing data were used (2010–2017). Incident ARF cases were identified using hospitalisation data (2010–2018). The risk ratio (RR) of ARF following swab collection was estimated across selected features and timeframes. Antibiotic dispensing data were linked to investigate whether this altered ARF risk following GAS detection. Results ARF risk increased following GAS detection in a throat or skin swab. Māori and Pacific Peoples had the highest ARF risk 8–90 days following a GAS-positive throat or skin swab, compared with a GAS-negative swab. During this period, the RR for Māori and Pacific Peoples following a GAS-positive throat swab was 4.8 (95% CI 3.6 to 6.4) and following a GAS-positive skin swab, the RR was 5.1 (95% CI 1.8 to 15.0). Antibiotic dispensing was not associated with a reduction in ARF risk following GAS detection in a throat swab (antibiotics not dispensed (RR: 4.1, 95% CI 2.7 to 6.2), antibiotics dispensed (RR: 4.3, 95% CI 2.5 to 7.4) or in a skin swab (antibiotics not dispensed (RR: 3.5, 95% CI 0.9 to 13.9), antibiotics dispensed (RR: 2.0, 95% CI 0.3 to 12.1). Conclusions A GAS-positive throat or skin swab is strongly associated with subsequent ARF, particularly for Māori and Pacific Peoples. This study provides the first population-level evidence that GAS skin infection can trigger ARF.
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Affiliation(s)
- Jane Oliver
- The Peter Doherty Institute for Infection and Immunity, Department of Infectious Diseases, University of Melbourne, Melbourne, Victoria, Australia
| | - Julie Bennett
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Sally Thomas
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Jane Zhang
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Nevil Pierse
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Nicole J Moreland
- Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand
| | - Deborah A Williamson
- The Peter Doherty Institute for Infection and Immunity, Department of Infectious Diseases, University of Melbourne, Melbourne, Victoria, Australia
| | - Susan Jack
- Southern District Health Board, Dunedin, Otago, New Zealand
| | - Michael Baker
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
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68
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Taylor A, Morpeth S, Webb R, Taylor S. The Utility of Rapid Group A Streptococcus Molecular Testing Compared with Throat Culture for the Diagnosis of Group A Streptococcal Pharyngitis in a High-Incidence Rheumatic Fever Population. J Clin Microbiol 2021; 59:e0097821. [PMID: 34550808 PMCID: PMC8601248 DOI: 10.1128/jcm.00978-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/27/2021] [Indexed: 11/20/2022] Open
Abstract
Group A streptococcus (GAS) causes significant morbidity and mortality in New Zealand and is responsible for invasive disease and immune sequelae, including acute rheumatic fever (ARF). Early treatment of GAS pharyngitis reduces the risk of ARF. In settings with a high burden of GAS disease, a rapid GAS pharyngitis diagnostic test with a strong negative predictive value is needed to enable prompt and accurate treatment. This prospective study compares the Xpert Xpress Strep A molecular test (Cepheid) to throat culture and a second molecular method, the BioGX group A streptococcus-open system reagent (OSR) for BD Max for the diagnosis of GAS pharyngitis. Throat swabs were collected from the emergency department and wards of Middlemore Hospital, New Zealand. The BioGX group A streptococcus OSR for BD Max contributes to the composite gold standard of throat culture or both molecular methods positive. Basic demographic, clinical, and laboratory data were collected. Two hundred five out of two hundred fourteen swabs were suitable for analysis. Of those, 28/205 (13.7%) were GAS culture positive, 45/205 (22%) Xpert Xpress Strep A positive, and 38/205 (18.5%) BioGX positive. Compared to culture, the sensitivity, specificity, and positive and negative predictive values of the Xpert Xpress Strep A molecular test were 100%, 90.4%, 62.2%, and 100%, respectively. Compared to the composite gold standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 100%, 95.8%, 84.4%, and 100%, respectively. Seventeen samples were Xpert Xpress positive but culture negative; 6 of these 17 swabs represent true positives with evidence of recent GAS infection. Ten samples were culture negative but both Xpert Xpress and BioGX positive. The Xpert Xpress Strep A molecular test is highly sensitive with a strong negative predictive value and rapid turnaround time. It can be safely introduced as a first-line test for throat swabs in a high-incidence ARF population.
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Affiliation(s)
- Amanda Taylor
- Department of Microbiology, Middlemore Hospital, Auckland, New Zealand
| | - Susan Morpeth
- Department of Microbiology, Middlemore Hospital, Auckland, New Zealand
| | - Rachel Webb
- Kidz First Hospital, Counties Manukau, Auckland, New Zealand
- Starship Children’s Hospital, Auckland, New Zealand
- University of Auckland, Auckland, New Zealand
| | - Susan Taylor
- Department of Microbiology, Middlemore Hospital, Auckland, New Zealand
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69
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Miron VD, Bar G, Filimon C, Gaidamut VA, Craiu M. Streptococcal Pharyngitis in Children: A Tertiary Pediatric Hospital in Bucharest, Romania. J Glob Infect Dis 2021; 13:154-155. [PMID: 34703159 PMCID: PMC8491814 DOI: 10.4103/jgid.jgid_59_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Victor Daniel Miron
- Department of Pediatrics, National Institute for Mother and Child Health "Alessandrescu-Rusescu", Bucharest, Romania.,Faculty of Medicine, Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Gabriela Bar
- Department of Pediatrics, National Institute for Mother and Child Health "Alessandrescu-Rusescu", Bucharest, Romania
| | - Claudiu Filimon
- Faculty of Medicine, General Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Vlad Alexandru Gaidamut
- Faculty of Medicine, General Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mihai Craiu
- Department of Pediatrics, National Institute for Mother and Child Health "Alessandrescu-Rusescu", Bucharest, Romania.,Faculty of Medicine, Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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70
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Bennett J, Moreland NJ, Williamson DA, Carapetis J, Crane J, Whitcombe AL, Jack S, Harwood M, Baker MG. Comparison of group A streptococcal titres in healthy children and those with pharyngitis and skin infections. J Infect 2021; 84:24-30. [PMID: 34710392 DOI: 10.1016/j.jinf.2021.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/04/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Rates of acute rheumatic fever, a sequelae of group A Streptococcal (GAS) infection, remain unacceptably high in Indigenous Māori and Pacific children in New Zealand. This prospective study aimed to describe GAS antibody titres in healthy children (5-14 years) by ethnicity, and to determine how paired titres vary with GAS culture positive and negative pharyngitis, and GAS skin infections. METHODS Analysis included 887 children (32% Māori, 36% Pacific, 33% European/Other) from Auckland, New Zealand. Cases comprise 772 children who had a sore throat or skin infection, which resulted in a swab taken for culture. Healthy controls were asymptomatic (N = 154) and matched by age, ethnicity and region. All participants had a serum sample, with a second sample collected from cases only. Sera were analysed for anti-streptolysin O (ASO) and anti-DNase-B (ADB) antibodies. RESULTS Healthy Māori and Pacific children had higher GAS antibody titres than healthy European/Other children. Children with GAS-positive sore throat had the highest mean ASO titres and children with GAS-positive skin infection had the highest mean ADB titres. When a two-fold increase or an upper limit of normal cut-off (ASO 450 IU/ml, ADB 400 U/ml) was applied to titres from children with GAS-positive sore throat, 62.1% were classified as having serologically confirmed GAS pharyngitis and 37.9% had GAS detected without serological response. CONCLUSIONS Elevated ASO titres were associated with GAS pharyngitis and elevated ADB titres were associated with GAS skin infections in New Zealand children. Higher ASO/ADB titres in healthy Māori and Pacific children could indicate a greater prior exposure to GAS infections.
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Affiliation(s)
- Julie Bennett
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand.
| | - Nicole J Moreland
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
| | - Deborah A Williamson
- Peter Doherty Institute for Infection and Immunity, University of Melbourne, Victoria, Australia
| | - Jonathan Carapetis
- Telethon Kids Institute and Perth Children's Hospital, University of Western Australia, Perth 6009, Australia
| | - Julian Crane
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Alana L Whitcombe
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
| | - Susan Jack
- Public Health South, Southern District Health Board, Dunedin, New Zealand
| | - Matire Harwood
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand; Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
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71
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Lakkis NA, Alameddine R, Issa HG, Mahmassani D, Osman MH. Prescribing antibiotics in adults with respiratory tract infections in Lebanon. Int J Clin Pract 2021; 75:e14514. [PMID: 34117820 DOI: 10.1111/ijcp.14514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 06/02/2021] [Accepted: 06/06/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Antibiotic resistance is a global concern that has significant health and economic burden. The inappropriate use of antibiotics is a major cause of antibiotic resistance; this includes both unnecessary and incorrect prescriptions. Most antibiotics are prescribed in primary care, mainly for respiratory tract infections. This study examines the prescribing practices of physicians for respiratory tract infections in ambulatory settings in Lebanon. METHODS The study was a cross-sectional review of prescriptions given to a group of employees working in two companies in Greater Beirut in Lebanon (n = 469) between September 2017 and March 2018. Prescriptions and related medical reports were reviewed. Data on the type of infection and the employees' demographics were collected. Antibiotic treatment was considered appropriate based on its adherence to international scientific societies' recommendations and clinical guidelines, including those of the Infectious Diseases Society of America. RESULTS A total of 372 medical reports and prescriptions were reviewed; 88.2% of these prescriptions included antibiotics. The rate of antibiotic treatment was 82.0% for a diagnosis of flu-like symptoms and 94.6% for acute pharyngitis, of which 34.5% included third generation cephalosporins and fluoroquinolones. Around 93.7% of patients with acute bronchitis without pneumonia received antibiotics, mostly broad-spectrum ones. A significant association was found between the specialty of the prescribing physicians and some types of upper respiratory tract infections. CONCLUSION This study reveals a high prevalence of inappropriate antibiotic prescribing for respiratory tract infections in the Lebanese ambulatory practice, contributing to the emergence of antimicrobial resistance in the country. It calls for urgent multifaceted interventions to limit unnecessary use and promote antibiotic stewardship.
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Affiliation(s)
- Najla A Lakkis
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | | | - Hanane G Issa
- Institute of Health Informatics, University College London, London, UK
| | - Dina Mahmassani
- Department of Emergency Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Mona H Osman
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
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72
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Pallon J, Rööst M, Sundqvist M, Hedin K. The aetiology of pharyngotonsillitis in primary health care: a prospective observational study. BMC Infect Dis 2021; 21:971. [PMID: 34535115 PMCID: PMC8446737 DOI: 10.1186/s12879-021-06665-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 09/07/2021] [Indexed: 11/12/2022] Open
Abstract
Background Few studies on pharyngotonsillitis have examined the clinical presentation of different aetiologies where pathogens have been detected using molecular methods. We aimed to assess how well clinical signs and symptoms can predict (1) the presence or absence of a broad range of viruses and bacteria, and (2) reconsultations for a sore throat or a complication. Methods In this descriptive observational prospective study in primary health care 220 patients aged 15–45 with suspected pharyngotonsillitis were sampled from nose, throat and blood and screened for 20 bacteria and viruses using polymerase chain reaction (PCR), culture and serology. Odds ratios (OR) and predictive values with 95% confidence intervals (CI) were used to show association between microbiological findings and clinical signs and symptoms. Patients were followed up after 3 months by reviewing electronic medical records. Results Both cough and coryza were more common in patients with only viruses (67%) than in patients with only bacteria (21%) (p < 0.001), whereas tonsillar coating was more common in patients with only bacteria (53%) than in patients with only viruses (29%) (p = 0.006). Tonsillar coating (adjusted OR 6.0; 95% CI 2.5–14) and a lack of cough (adjusted OR 3.5; 95% CI 1.5–8.0) were significantly associated with Streptococcus pyogenes (group A streptococci; GAS) and with any bacterial finding. A Centor score of 3–4 had a positive predictive value of 49% (95% CI 42–57) for GAS and 66% (95% CI 57–74) for any bacterial findings. The use of rapid antigen detection test for GAS increased the positive predictive value for this group to 93%. Conclusions Signs and symptoms, both single and combined, were insufficient to rule in GAS or other pathogens. However, both cough and coryza were useful to rule out GAS. The results support the clinical approach of restricting rapid antigen detection testing to patients with 3–4 Centor criteria. The low carriage rate of bacteria among asymptomatic controls implied that most detections in patients represented a true infection. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06665-9.
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Affiliation(s)
- Jon Pallon
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden. .,Department of Research and Development, Region Kronoberg, Växjö, Sweden. .,Department of Clinical Sciences, Malmö, Clinical Research Centre, Box 50332, 202 13, Malmö, Sweden.
| | - Mattias Rööst
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.,Department of Research and Development, Region Kronoberg, Växjö, Sweden
| | - Martin Sundqvist
- Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.,Futurum, Region Jönköping County, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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73
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Abstract
Point-of-care (POC) or near patient testing for infectious diseases is a rapidly expanding space that is part of an ongoing effort to bring care closer to the patient. Traditional POC tests were known for their limited utility, but advances in technology have seen significant improvements in performance of these assays. The increasing promise of these tests is also coupled with their increasing complexity, which requires the oversight of qualified laboratory-trained personnel.
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Affiliation(s)
- Linoj Samuel
- Clinical Microbiology, Department of Pathology and Laboratory Medicine, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
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74
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Ghosh S, King-Morris K, Shultz J. Concomitant Acute Rheumatic Fever and Acute Post Streptococcal Glomerulonephritis. Cureus 2021; 13:e16357. [PMID: 34395134 PMCID: PMC8359909 DOI: 10.7759/cureus.16357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 11/28/2022] Open
Abstract
Acute rheumatic fever (RF) and acute post Streptococcal glomerulonephritis (APSGN) are non-suppurative complications of a Group A Streptococcus (GAS) infection. The concomitant incidence of both complications in a patient is rare because nephritogenic and rheumatogenic strains belong to different serotypes of Group A beta-hemolytic Streptococcus (GABHS). We present a case of a 47-year-old female who had concomitant acute RF and APSGN from a Streptococcus pyogenes infection. It is important to have a high clinical suspicion for the sequela of GABHS infection in the setting of cardiac and renal disease following upper respiratory infection (URI) symptoms even in adults and in geographic locations with the nearly undetectable burden of acute RF because of the importance of secondary prophylaxis with an antibiotic.
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Affiliation(s)
- Somshukla Ghosh
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
| | | | - Joshua Shultz
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
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75
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Barros RR. Antimicrobial Resistance among Beta-Hemolytic Streptococcus in Brazil: An Overview. Antibiotics (Basel) 2021; 10:antibiotics10080973. [PMID: 34439023 PMCID: PMC8388994 DOI: 10.3390/antibiotics10080973] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/03/2021] [Accepted: 08/10/2021] [Indexed: 11/16/2022] Open
Abstract
Streptococcus pyogenes, Streptococcus agalactiae and Streptococcus dysgalactiae subsp. equisimilis (SDSE) are the beta-hemolytic streptococci species with the most clinical relevance to humans. These species are responsible for several infections, ranging from mild to life-threatening diseases. Although resistance to recommended drugs has not been so critical as detected in other species, it has occurred in diverse regions. In Brazil, it is possible to observe an increasing macrolide and lincosamide resistance trend due to the spread of polyclonal strains. Macrolide-lincosamide-streptogramin B (MLS) resistance phenotypes have been prevalent among S. agalactiae and S. pyogenes, while M phenotype (resistance only to macrolides) has prevailed among SDSE resistant isolates. Fluoroquinolone resistance is rare in this country, reported only in S.agalactiae and S.pyogenes. This is due to nucleotide substitutions in gyrA and parC genes. Reduced penicillin susceptibility and vancomycin resistance, detected in other regions, have not yet been reported in Brazil. Tetracycline is not a therapeutical option, and resistance has occurred at high levels, especially among S.agalactiae. These findings highlight the need for continuous monitoring in order to track the occurrence of antimicrobial resistance among beta-hemolytic streptococci species circulating in this country.
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Affiliation(s)
- Rosana Rocha Barros
- Departamento de Microbiologia e Parasitologia, Instituto Biomédico, Universidade Federal Fluminense, Niterói 24210-130, Brazil
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76
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Pernica JM, Smaill F, Kam AJ, Bartholomew A, Doan Q, Smieja M, Khan S, Sung M, Thabane L, Goldfarb DM. Single-centre, open-label, randomised, trial to compare rapid molecular point-of-care streptococcal testing to standard laboratory-based testing for the management of streptococcal pharyngitis in children: study protocol. BMJ Open 2021; 11:e047271. [PMID: 34380724 PMCID: PMC8359528 DOI: 10.1136/bmjopen-2020-047271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Streptococcal pharyngitis, which commonly occurs in children, should be treated with antibiotics. Clinical prediction rules to differentiate streptococcal pharyngitis from viral infection are not recommended in children. Rapid point-of-care (POC) antigen tests have limited sensitivity and so are not often used in Canadian paediatric emergency departments (EDs). Standard paediatric practice is to rely on laboratory-based testing, which often results in a delay before the results can be communicated to the patient; this may impede appropriate prescribing, decrease caregiver satisfaction and delay recovery. The objective of this study is to determine whether a novel rapid molecular POC assay for streptococcal pharyngitis leads to more appropriate antibiotic use in children seeking care in a paediatric ED than standard laboratory-based testing. METHODS AND ANALYSIS A randomised, superiority, open-label, trial with two parallel groups. Children presenting to a tertiary paediatric ED at least 3 years of age who have a throat swab ordered for diagnosis of streptococcal pharyngitis will be eligible; those who have taken antibiotics within 72 hours prior to presentation and those with additional active infections will be excluded. The primary study outcome will be appropriate antibiotic treatment at 3-5 days postenrolment. Secondary outcomes include time to symptom resolution, caregiver satisfaction, caregiver/child absenteeism, number of subsequent healthcare visits, clinician satisfaction and incremental cost-effectiveness of POC testing. A total of 352 participants will be needed. ETHICS AND DISSEMINATION All study documentation has been approved by the Hamilton Integrated Research Ethics board and informed consent will be obtained from all participants. Data from this trial will be presented at major conferences and published in peer-reviewed publications to facilitate collaborations with networks of clinicians experienced in the dissemination of clinical guidelines. TRIAL REGISTRATION NUMBER NCT04247243.
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Affiliation(s)
- Jeffrey M Pernica
- Paediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Fiona Smaill
- Department of Pathology and Molecular Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - April J Kam
- Paediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Amy Bartholomew
- Paediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Quynh Doan
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marek Smieja
- Department of Pathology and Molecular Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Khan
- Paediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Melani Sung
- Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - David M Goldfarb
- Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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77
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Pallon J, Sundqvist M, Rööst M, Hedin K. Association between bacterial finding, antibiotic treatment and clinical course in patients with pharyngotonsillitis: a registry-based study in primary healthcare in Sweden. BMC Infect Dis 2021; 21:779. [PMID: 34372771 PMCID: PMC8351112 DOI: 10.1186/s12879-021-06511-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/28/2021] [Indexed: 01/04/2023] Open
Abstract
Background The role of non-group A streptococci and Fusobacterium necrophorum in pharyngotonsillitis has been disputed and few prospective studies have evaluated the effect of antibiotic treatment. This study uses registry data to investigate the relation between antibiotic prescription for pharyngotonsillitis in primary healthcare and return visits for pharyngotonsillitis, complications, and tonsillectomy. Methods Retrospective data were extracted from the regional electronic medical record system in Kronoberg County, Sweden, for all patients diagnosed with pharyngotonsillitis between 2012 and 2016. From these data, two cohorts were formed: one based on rapid antigen detection tests (RADT) for group A streptococci (GAS) and one based on routine throat cultures for β-haemolytic streptococci and F. necrophorum. The 90 days following the inclusion visit were assessed for new visits for pharyngotonsillitis, complications, and tonsillectomy, and related to bacterial aetiology and antibiotic prescriptions given at inclusion. Results In the RADT cohort (n = 13,781), antibiotic prescription for patients with a positive RADT for GAS was associated with fewer return visits for pharyngotonsillitis within 30 days compared with no prescription (8.7% vs. 12%; p = 0.02), but not with the complication rate within 30 days (1.5% vs. 1.8%; p = 0.7) or with the tonsillectomy rate within 90 days (0.27% vs. 0.26%; p = 1). In contrast, antibiotic prescription for patients with a negative RADT was associated with more return visits for pharyngotonsillitis within 30 days (9.7% vs. 7.0%; p = 0.01). In the culture cohort (n = 1 370), antibiotic prescription for patients with Streptococcus dysgalactiae ssp. equisimilis was associated with fewer return visits for pharyngotonsillitis within 30 days compared with no prescription (15% vs. 29%; p = 0.03). Conclusions Antibiotic prescription was associated with fewer return visits for pharyngotonsillitis in patients with a positive RADT for GAS but with more return visits in patients with a negative RADT for GAS. There were no differences in purulent complications related to antibiotic prescription. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06511-y.
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Affiliation(s)
- Jon Pallon
- Department of Clinical Sciences in Malmö, Family Medicine, Clinical Research Centre, Lund University, Box 50332, 202 13, Malmö, Sweden. .,Department of Research and Development, Region Kronoberg, Växjö, Sweden.
| | - Martin Sundqvist
- Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mattias Rööst
- Department of Clinical Sciences in Malmö, Family Medicine, Clinical Research Centre, Lund University, Box 50332, 202 13, Malmö, Sweden.,Department of Research and Development, Region Kronoberg, Växjö, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences in Malmö, Family Medicine, Clinical Research Centre, Lund University, Box 50332, 202 13, Malmö, Sweden.,Futurum, Region Jönköping County, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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78
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Wi D, Choi SH. Positive Rate of Tests for Group a Streptococcus and Viral Features in Children with Acute Pharyngitis. CHILDREN-BASEL 2021; 8:children8070599. [PMID: 34356578 PMCID: PMC8304790 DOI: 10.3390/children8070599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/13/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022]
Abstract
Group A streptococcus (GAS) is an important cause of acute pharyngitis. We investigated the positive rate of GAS tests and clinical viral features in children with acute pharyngitis. A retrospective review was conducted for patients <15 years old with both rapid antigen detection test (RADT) and throat culture results. Patients were excluded if they were diagnosed with influenza or had received antibiotics within two weeks before these tests. A total of 377 patients were eligible. The median age of patients was 3.5 years, and 45.4% of total patients were <3 years old. Among all patients, 68.7% had at least one viral feature, and 39% had more than two. The overall positiv rate for GAS was 11.4%. The GAS positive rate was significantly lower in patients <3 years old than in older patients (1.8% vs. 19.4%, p < 0.0001). The overall sensitivity and specificity of RADT were 75.0% (95% CI: 57.8-87.9) and 97.9% (95% CI: 95.8-99.2), respectively. The GAS positive rate was not significantly different between patients with and without viral features (12.4% vs. 9.3%, p = 0.4854). In patients aged 3-14 years, the GAS positive rate was not associated with the modified Centor score or the frequency of clinical viral features. Despite a low prevalence of GAS pharyngitis, testing for GAS was frequently performed in children <3 years old in this study. Appropriate use of laboratory testing for GAS pharyngitis and judicious prescription of antibiotics were imperative.
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Affiliation(s)
- Dasom Wi
- Department of Pediatrics, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si 18450, Gyeonggi-do, Korea;
| | - Soo-Han Choi
- Department of Pediatrics, Pusan National University Hospital, Busan 49241, Korea
- Correspondence: ; Tel.: +82-51-240-7298
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79
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Rolf von den Baumen T, Crosby M, Tadrous M, Schwartz KL, Gomes T. Measuring the impacts of the Using Antibiotics Wisely campaign on Canadian community utilization of oral antibiotics for respiratory tract infections: a time-series analysis from 2015 to 2019. J Antimicrob Chemother 2021; 76:2472-2478. [PMID: 34223899 DOI: 10.1093/jac/dkab205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/24/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND On 1 November 2018, Choosing Wisely Canada launched their Using Antibiotics Wisely primary care campaign, which aimed to reduce unnecessary antibiotic prescriptions for respiratory tract infections (RTIs) through educational tools for patients and providers. OBJECTIVES We explored the impact of this campaign on antibiotic utilization in Canada. METHODS We conducted a population-based study in Canada between January 2015 and December 2019. We used interventional autoregressive integrated moving average models to study the impact of the Using Antibiotics Wisely campaign on the prescribing rate (prescriptions per 1000 population) of RTI-indicated antibiotics. We analysed prescription rates overall and stratified by age group, drug class and province, in each month over the study period. RESULTS There was a 1.5% reduction in the annual prescribing rate of RTI-indicated antibiotics over the study period, which was generally consistent across age groups and provinces. Following the 2018 Using Antibiotics Wisely clinician toolkit release, we observed no significant change in RTI-indicated antibiotic prescribing rates nationally (P = 0.13). This was consistent by age group (children, P = 0.91; adults, P = 0.58; and older adults, P = 0.67) and drug class (narrow-spectrum penicillins, P = 0.88; macrolides, P = 0.85; broad-spectrum penicillins, P = 0.60; cephalosporins, P = 0.45; tetracyclines, P = 0.55; and fluoroquinolones, P = 0.98). In our secondary analysis of prescription rates in provinces that self-identified as prioritizing Using Antibiotics Wisely, we observed no significant change following the launch of the campaign. CONCLUSIONS The introduction of the Using Antibiotics Wisely campaign in Canada has not caused a significant change in short-term antibiotic prescribing patterns. Community antibiotic stewardship campaigns that include components beyond education may be more impactful.
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Affiliation(s)
| | - Michael Crosby
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada.,Women's College Hospital Research Institute, Toronto, Ontario, Canada
| | - Kevin L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Unity Health Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada
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80
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Sayad E, Zeid CA, Hajjar RE, Cabrera NL, Radi Abou Jaoudeh RA, Malek AE. The burden of Arcanobacterium haemolyticum pharyngitis: A systematic review and management algorithm. Int J Pediatr Otorhinolaryngol 2021; 146:110759. [PMID: 34038812 DOI: 10.1016/j.ijporl.2021.110759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/22/2021] [Accepted: 05/06/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Arcanobacterium haemolyticum causes pharyngotonsillitis in children and young adults. It is rarely isolated in pharyngeal swabs as testing for it is not routine. Data on complications, management, and antibiotic susceptibility testing is limited. We sought to review the available literature on the presentation and management of A. haemolyticum pharyngotonsillitis in this age group. METHODS A systematic review of eligible studies reporting pharyngotonsillitis and related complications in children and young adults caused by A. haemolyticum was conducted. Literature from case reports, case series, and available cohorts was compiled. Data were analyzed using descriptive statistics. RESULTS The initial database search yielded 63 articles, after applying exclusion criteria 17 studies were included. 191 patients were identified with a median age of 16.5 years. The most common presentation was throat pain reported in 93.7% of patients. Tonsillar exudates, fever at presentation and rash were present in more than half of the reviewed cases. The diagnosis was established by a positive culture on a pharyngeal swab in 98.8% of swabs collected. Complications described included peritonsillar abscesses, Lemierre's syndrome, pneumonia, and sepsis. Penicillin was the first line antibiotic in 81% of patients followed by macrolides in 19 patients (18%). CONCLUSIONS A. haemolyticum occurs in children and young adults and may result in complications. Our review supports its susceptibility to penicillin. We suggest a diagnostic and management algorithm to guide clinicians in targeted testing and aid with decision making regarding timely and appropriate antibiotic therapy, in an effort to reduce the burden of its complications.
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Affiliation(s)
- Edouard Sayad
- Department of Pediatric Pulmonology, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St, Houston, TX, 77030, USA; Department of Pediatrics, Lebanese American University School of Medicine, Beirut, Lebanon.
| | - Cynthia Abou Zeid
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St, Houston, TX, 77030, USA.
| | - Rayan El Hajjar
- Faculty of Medicine, University of Balamand, Kalhat, Al-Kurah P.O. Box 100 Tripoli, Lebanon.
| | - Nicolo L Cabrera
- Division of Infectious Diseases, Department of Medicine, McGovern Medical School, University of Texas Health Science Center at 1515 Holcombe Blvd, Houston, TX, 77030, USA; Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | | | - Alexandre E Malek
- Division of Infectious Diseases, Department of Medicine, McGovern Medical School, University of Texas Health Science Center at 1515 Holcombe Blvd, Houston, TX, 77030, USA; Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
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81
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Leyva‐Grado V, Pugach P, Sadeghi‐Latefi N. A novel anti-inflammatory treatment for bradykinin-induced sore throat or pharyngitis. Immun Inflamm Dis 2021; 9:1321-1335. [PMID: 34153179 PMCID: PMC8589389 DOI: 10.1002/iid3.479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Often thought of as a minor health concern, sore throat or pharyngitis is an important public health issue. It is one of the most common symptoms of upper respiratory diseases including COVID-19 and is a leading cause of physician visits and antibiotic prescriptions. However, few over-the-counter medications are proven to heal sore throat inflammation. METHODS Adenocarcinomic human alveolar basal epithelial cells (A549 cells) and three dimensional organotypic human respiratory tissues were used to study inflammation and various treatment effects on respiratory epithelia. The cells and tissues were studied both in the presence and absence of bradykinin, one of the first inflammatory mediators of pharyngitis. Inflammation was measured by analyzing the levels of prostaglandin E2 (PGE2), interleukin 8 (IL-8), and leukotriene B4 (LTB4), transepithelial electrical resistance (TEER), and lactate dehydrogenase (LDH) release. Tissue morphology was analyzed by immunohistochemistry. RESULTS In studying pharyngitis using organotypic human respiratory tissue stimulated with bradykinin, we saw an increase in PGE2 and interleukin-8 (IL-8) in response to bradykinin. Acetyl salicylic acid (ASA), a nonspecific COX inhibitor, was able to mitigate a bradykinin-induced increase in PGE2 in our studies. However, ASA was inflammatory above its therapeutic window, increasing the levels of PGE2 and IL-8 above those seen with bradykinin stimulation alone. We describe a novel, scientifically validated treatment for sore throat, that contains a low dose of ASA and other anti-inflammatory ingredients. CONCLUSION This study elucidates the complex mechanisms involved in healing pharyngitis, an inflammatory condition of the upper respiratory epithelia. An ASA-based formula (Biovanta) mitigated bradykinin-induced inflammation more strongly than ASA alone in organotypic human respiratory tissues. Surprisingly, we found that many of the most common over the counter sore throat therapies exacerbate inflammation and IL-8 in organotypic human respiratory tissues, suggesting these common treatments may increase the likelihood of further respiratory complications.
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Affiliation(s)
| | - Pavel Pugach
- Applied Biological LaboratoriesBrooklynNew YorkUSA
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82
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Donders G, Greenhouse P, Donders F, Engel U, Paavonen J, Mendling W. Genital Tract GAS Infection ISIDOG Guidelines. J Clin Med 2021; 10:jcm10092043. [PMID: 34068785 PMCID: PMC8126195 DOI: 10.3390/jcm10092043] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/18/2021] [Accepted: 04/23/2021] [Indexed: 02/07/2023] Open
Abstract
There has been an increasing worldwide incidence of invasive group A streptococcal (GAS) disease in pregnancy and in the puerperal period over the past 30 years. Postpartum Group A streptococci infection, and in particular streptococcal toxic shock syndrome (TSS) and necrotizing fasciitis, can be life threatening and difficult to treat. Despite antibiotics and supportive therapy, and in some cases advanced extensive surgery, mortality associated with invasive group A streptococcal postpartum endometritis, necrotizing fasciitis, and toxic shock syndrome remains high, up to 40% of postpartum septic deaths. It now accounts for more than 75,000 deaths worldwide every year. Postpartum women have a 20-fold increased incidence of GAS disease compared to non-pregnant women. Despite the high incidence, many invasive GAS infections are not diagnosed in a timely manner, resulting in potentially preventable maternal and neonatal deaths. In this paper the specific characteristics of GAS infection in the field of Ob/Gyn are brought to our attention, resulting in guidelines to improve our awareness, early recognition and timely treatment of the disease. New European prevalence data of vaginal GAS colonization are presented, alongside two original case histories. Additionally, aerobic vaginitis is proposed as a supplementary risk factor for invasive GAS diseases.
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Affiliation(s)
- Gilbert Donders
- Femicare, Clinical Research for Women, 3300 Tienen, Belgium;
- Department of Obstetrics and Gynecology, University Hospital Antwerp, 2000 Antwerp, Belgium
- Regional Hospital H Hart, 3300 Tienen, Belgium
- Correspondence: ; Tel.: +32-38-214413
| | | | | | - Ulrike Engel
- Department of Ob/Gyn Maternité, Centre Hospitalier, 1210 Luxembourg, Luxembourg;
| | - Jorma Paavonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital, 00260 Helsinki, Finland;
| | - Werner Mendling
- German Centre for Infections in Gynaecology and Obstetrics, St. Anna Hospital, 42109 Wuppertal, Germany;
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83
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Rogers J, Eastland T. Understanding the most commonly billed diagnoses in primary care: Acute pharyngitis. Nurse Pract 2021; 46:48-54. [PMID: 33882043 DOI: 10.1097/01.npr.0000742908.69893.bb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
ABSTRACT This is a 12-part series on the most commonly billed diagnoses in primary care. The article discusses the pathophysiologic processes of acute pharyngitis as well as the clinical manifestations and treatments and how they are linked to disease pathogenesis.
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84
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Badr AF, Humedi RA, Alfarsi NA, Alghamdi HA. Rapid antigen detection test (RADT) for pharyngitis diagnosis in children: Public and pharmacist perception. Saudi Pharm J 2021; 29:677-681. [PMID: 34400861 PMCID: PMC8347703 DOI: 10.1016/j.jsps.2021.04.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/24/2021] [Indexed: 11/26/2022] Open
Abstract
Background Most common sought antibiotic-self treated infection globally is pharyngitis (sore throat). The aim of this study is to assess public's acceptance and potential use of Rapid Antigen Detection Test at community pharmacies in the diagnosis of bacterial pharyngitis in children prior to antibiotic dispensing in Saudi Arabia. Method A qualitative cross-sectional study was conducted on October 2017. Two self-conducted questionnaires were used. One targeted the public above 21 years old and was distributed via social media. The other randomly targeted community pharmacists in Jeddah. Result A total of 689 of the public and 40 community pharmacists completed the survey. Moreover, 571 (82.9%) of the public received antibiotics without a prescription; for symptoms related to sore throat (71%) followed by flu-like symptoms (24%). Only (3.77%) and (5%) of both public and community pharmacies have heard about RADT respectively, however the majority (93.03%) and (90%) of both respectively support its use in community pharmacies. Coded reasons for its use was mainly to decrease antibiotic misuse and/or abuse, increased specificity, decreased antibiotic side effects including bacterial resistance, and ease of use. Conclusion Both public and community pharmacists support the idea of using RADT. Future efforts should look into pharmacist's role in providing point of care tests that are cost-effective and convenient for the public.
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Affiliation(s)
- Aisha F Badr
- King Abdulaziz University, Department of Pharmacy Practice, Jeddah, Saudi Arabia
| | - Raneyah A Humedi
- King Abdulaziz University, Department of Pharmacy Practice, Jeddah, Saudi Arabia
| | - Nada A Alfarsi
- King Abdulaziz University, Department of Pharmacy Practice, Jeddah, Saudi Arabia
| | - Haifa A Alghamdi
- King Abdulaziz University, Department of Pharmacy Practice, Jeddah, Saudi Arabia
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85
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Chan KH, Veeraballi S, Ahmed E, Yakobi R, Slim J. A Case of Co-occurrence of COVID-19 and Group A Streptococcal Pharyngitis. Cureus 2021; 13:e14729. [PMID: 34084666 PMCID: PMC8163359 DOI: 10.7759/cureus.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has swept the world with over hundred million of cases and millions of deaths. Upper respiratory tract symptoms including acute pharyngitis are the common symptoms of COVID-19, with a reported incidence of about 5%-17.4%. Group A Streptococcus (GAS) pharyngitis is a common cause of bacterial pharyngitis, with highest incidence between age 5 and 15, and it can still occur in adults with peak incidence at age 40. Herein, we report a case of co-occurrence of GAS and COVID-19 in a middle-aged man who presented with fever, sore throat, cough, and runny nose. To the best of our knowledge, we are the first to report this unique co-occurrence. Our case report aimed to raise the awareness among physician particularly in ambulatory and emergency department of not to have a singular focus on COVID-19 and forget to screen patient with acute pharyngitis for GAS.
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Affiliation(s)
- Kok Hoe Chan
- Internal Medicine, Saint Michael's Medical Center, Newark, USA
| | | | - Eyad Ahmed
- Internal Medicine, Saint Michael's Medical Center, Newark, USA
| | - Ramy Yakobi
- Emergency Medicine, Saint Michael's Medical Center, Newark, USA
| | - Jihad Slim
- Infectious Diseases, Saint Michael's Medical Center, Newark, USA
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Tepolt F, Montag Schafer K, Budd J. Standardization of medication inventory in an urban family medicine clinic. J Am Pharm Assoc (2003) 2021; 61:e242-e248. [PMID: 33785265 DOI: 10.1016/j.japh.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/17/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recommendations on clinic-administered medications to stock in an urban family medicine clinic and how to manage an outpatient formulary are not well defined in the literature. Although there are numerous hypothesized incentives for a standardized medication inventory, the financial impact at the level of a single clinic is unknown. OBJECTIVES The purpose of this project was to develop clinic-administered medication inventory recommendations for urban family medicine clinics and to determine the financial impact of standardization at a single clinic. METHODS The current clinic-administered medication inventory was assessed using the following prespecified criteria: (1) clinic administration is required for successful patient outcomes, (2) use of the medication for intended indication is evidence-based, (3) appropriately trained staff and equipment are available to administer and monitor the medication, (4) most cost-effective dosage form of the medication is stocked in the clinic, and (5) quantity and location of medication stocked in the clinic match need. Changes to the medication inventory were made effective on August 1, 2018, based on physician group consensus. Monthly clinic medication cost during the study period was analyzed before and after intervention. RESULTS A total of 80 medications were identified; 45 medications remained after changes according to the prespecified criteria. The monthly cost of maintaining the inventory during the study period was $1947 preintervention compared with $1048 postintervention. The estimated average monthly cost savings of a standardized inventory in a single, urban family medicine clinic is $900, or $10,800 annually. CONCLUSION Standardizing a clinic-administered medication inventory in an urban family medicine clinic can help reduce unnecessary cost.
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Khademi F, Vaez H, Sahebkar A, Taheri RA. Group A Streptococcus Antibiotic Resistance in Iranian Children: A Meta-analysis. Oman Med J 2021; 36:e222. [PMID: 33585043 PMCID: PMC7868040 DOI: 10.5001/omj.2020.79] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/12/2019] [Indexed: 11/03/2022] Open
Abstract
Objectives Streptococcus pyogenes is associated with mild to severe infections, particularly in children and young adults. Proper antimicrobial treatment of S. pyogenes infections is important to prevent post-streptococcal complications. Therefore, the purpose of this meta-analysis was to evaluate the prevalence of S. pyogenes antibiotic resistance among Iranian children. Methods We identified all published studies up to 20 March 2019 related to S. pyogenes antibiotic resistance by searching Persian and English electronic databases. Search terms included S. pyogenes, children, and Iran. Out of 1022 publications, 12 articles were eligible and included based on the inclusion and exclusion criteria. Results Our analysis indicated the following prevalence pattern for S. pyogenes antimicrobial resistance in Iran: 4.2% to penicillin, 38.3% to amoxicillin, 5.4% to erythromycin, 12.0% to azithromycin, 12.6% to clarithromycin, 12.4% to clindamycin, 15.3% to rifampicin, 8.1% to ceftriaxone, 17.6% to cefixime, 36.9% to ampicillin, 14.1% to vancomycin, 8.4% to chloramphenicol, 30.4% to tetracycline, 8.8% to cefotaxime, 82.8% to trimethoprim/sulfamethoxazole, 39.6% to gentamicin, 11.9% to ofloxacin, 28.3% to carbenicillin, 3.1% to ciprofloxacin, 6.1% to imipenem, 18.2% to cephalothin, 57.6% to tobramycin, 49.3% to kanamycin, 79.0% to cloxacillin, 12.9% to cephalexin, 10.7% to cefazolin, and 89.5% to amoxicillin-clavulanic acid. Conclusions Our findings suggest penicillin (in non-allergic children) and macrolides, lincosamides, and narrow-spectrum cephalosporins (in penicillin-allergic children) as the treatments of choice in Iran.
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Affiliation(s)
- Farzad Khademi
- Department of Microbiology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Hamid Vaez
- Department of Microbiology, School of Medicine, Zabol University of Medical Sciences, Zabol, Iran
| | - Amirhossein Sahebkar
- Halal Research Center of IRI, FDA, Tehran, Iran.,Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ramezan Ali Taheri
- Nanobiotechnology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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88
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Update on Post-Streptococcal Reactive Arthritis: Narrative Review of a Forgotten Disease. Curr Rheumatol Rep 2021; 23:19. [PMID: 33569668 DOI: 10.1007/s11926-021-00982-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE OF THE REVIEW This topical review attempts to build the concepts of PSRA as an independent entity and discuss prevalent diagnostic criteria. It utilizes a search strategy to collate all clinical features of PSRA reported from across the world and also discusses laboratory and treatment options in brief. RECENT FINDINGS There are several immune-mediated diseases described after acute streptococcal infections. Post-streptococcal reactive arthritis (PSRA) is a sterile, self-limiting arthritis that occur as an immune sequelae to streptococcal infection. Though PSRA resembles the arthritis of acute rheumatic fever superficially, it is a separate entity in its own right. It is different from classical reactive arthritis too. It was being recognized worldwide and more frequently in the recent past, possibly due to heightened awareness amongst clinicians. However, research on this enigmatic immune phenomenon is limited. Most acceptable hypotheses suggest molecular mimicry sensitizing the immune system towards synovial peptides such as keratin, vimentin and laminin, leading to arthritis in a genetically predisposed individual. There is still much to be learnt from this unique disease about the vagaries of the immune system.
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89
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Antibiotic stewardship in direct-to-consumer telemedicine consultations leads to high adherence to best practice guidelines and a low prescription rate. Int J Infect Dis 2021; 105:130-134. [PMID: 33578013 DOI: 10.1016/j.ijid.2021.02.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To analyze the antibiotic prescription rate in low-risk patients evaluated at a telemedicine program that adopts antibiotic stewardship protocols. METHODS Adult patients who accessed a single direct-to-consumer telemedicine center (Jan/2019-Feb/2020) were retrospectively enrolled. Diseases amenable to antimicrobial treatment were classified under five diagnostic groups: upper respiratory tract infection (URI), acute pharyngotonsillitis (PT), acute sinusitis (AS), urinary tract infection (UTI), and acute diarrhea (AD). Physicians were trained on and advised to strictly follow the current guideline recommendations supported by institutional antibiotic stewardship protocols, readily available online during consultations. We analyzed the antibiotic prescription rate among patients, referral rate, and antibiotic class through descriptive statistics. RESULTS A total of 2328 patients were included in the study. A total of 2085 (89·6%) patients were discharged with usual recommendations, medication (if needed), and instructions about red flags, while 243 (10·4%) were referred to a face-to-face consultation. Among the discharged patients, the antibiotic prescription rates by the diagnostic group were URI - 2·5%, PT - 35·0%, AS - 51·8%, UTI - 91.6%, and AD - 1·6%. In most cases, prescribed antibiotics were in line with institutional stewardship protocols. CONCLUSIONS Low prescription rate of antibiotics can be achieved using antibiotic stewardship protocols at direct-to-consumer telemedicine consultations, showing high adherence to international guidelines. These results reinforce telemedicine as a cost-effective and safe strategy for the initial assessment of acute non-urgent symptoms.
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90
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Miller NE, Jensen TB, Nigon LM, Penza KS, Murray MA, Kronebusch BJ, Pecina JL. McIsaac score for group A streptococcal infection: Comparison of electronic visits versus face-to-face visits. J Telemed Telecare 2021:1357633X21990999. [PMID: 33535918 DOI: 10.1177/1357633x21990999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Acute sore throat is a common complaint traditionally completed with an in-person visit. However, non-face-to-face telemedicine visits offer greater access at reduced cost. We evaluated patient/caregiver asynchronous text-based electronic visits (eVisits) for acute sore throat and whether there was concordance for individual components and total McIsaac score compared to a clinician's assessment. eVisits were completed by patients and/or their caregivers via a secure patient portal. METHODS In this retrospective study, we manually reviewed charts between February 2017 and July 2019 of patients who had an eVisit, in-person visit and group A streptococcal (GAS) test performed on the same day for an acute sore throat. We calculated a McIsaac score for eVisits and in-person visits, and compared each component and total score using Cohen's kappa agreement statistic. RESULTS There were 320 instances of patients who had an eVisit, in-person visit and GAS testing done on the same day. Approximately a third of eVisits were missing at least one McIsaac component, with the physical examination elements missing most commonly. Individual score congruence was moderate for cough (0.41), fair for fever (0.34) and slight for tonsillar swelling/exudate and lymphadenopathy (0.17 and 0.08, respectively), with total congruence being slight to fair (0.09-0.37). A McIsaac score of ≤1 showed moderate agreement (0.44). Visits with complete individual score components demonstrated improved congruence: substantial for cough (0.64), moderate for fever (0.57), fair for tonsillar swelling (0.3) and slight for lymphadenopathy (0.13). DISCUSSION Overall agreement for individual score components was better for symptoms than it was for examination components, and was improved when data were complete. A McIsaac score of 1 or 0 had moderate agreement and thus could reasonably be safely used to exclude patients from GAS testing.
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Affiliation(s)
- Nathaniel E Miller
- Department of Family Medicine, Employee and Community Health, Mayo Clinic, USA
| | - Teresa B Jensen
- Department of Family Medicine, Employee and Community Health, Mayo Clinic, USA
| | | | | | | | | | - Jennifer L Pecina
- Department of Family Medicine, Employee and Community Health, Mayo Clinic, USA
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91
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Wijesundara NM, Lee SF, Cheng Z, Davidson R, Rupasinghe HPV. Carvacrol exhibits rapid bactericidal activity against Streptococcus pyogenes through cell membrane damage. Sci Rep 2021; 11:1487. [PMID: 33452275 PMCID: PMC7811018 DOI: 10.1038/s41598-020-79713-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 12/07/2020] [Indexed: 12/13/2022] Open
Abstract
Streptococcus pyogenes is an important human pathogen worldwide. The identification of natural antibacterial phytochemicals has renewed interest due to the current scarcity of antibiotic development. Carvacrol is a monoterpenoid found in herbs. We evaluated carvacrol alone and combined with selected antibiotics against four strains of S. pyogenes in vitro. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of carvacrol against S. pyogenes were 125 µg/mL (0.53 mM) and 250 µg/mL (1.05 mM), respectively. Kill curve results showed that carvacrol exhibits instantaneous bactericidal activity against S. pyogenes. We also demonstrated the potential mechanism of action of carvacrol through compromising the cell membrane integrity. Carvacrol induced membrane integrity changes leading to leakage of cytoplasmic content such as lactate dehydrogenase enzymes and nucleic acids. We further confirmed dose-dependent rupturing of cells and cell deaths using transmission electron microscopy. The chequerboard assay results showed that carvacrol possesses an additive-synergistic effect with clindamycin or penicillin. Carvacrol alone, combined with clindamycin or penicillin, can be used as a safe and efficacious natural health product for managing streptococcal pharyngitis.
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Affiliation(s)
- Niluni M Wijesundara
- Department of Plant, Food, and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, NS, Canada.,Department of Biology, Faculty of Science, Dalhousie University, Halifax, NS, Canada.,Department of Animal Science, Faculty of Animal Science and Export Agriculture, Uva Wellassa University, Badulla, Sri Lanka
| | - Song F Lee
- Department of Microbiology & Immunology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.,Department of Applied Oral Sciences, Faculty of Dentistry, Dalhousie University, Halifax, NS, Canada.,Canadian Center for Vaccinology, Nova Scotia Health Authority, and the Izaak Walton Killam Health Centre, Dalhousie University, Halifax, NS, Canada
| | - Zhenyu Cheng
- Department of Microbiology & Immunology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ross Davidson
- Department of Microbiology & Immunology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.,Canadian Center for Vaccinology, Nova Scotia Health Authority, and the Izaak Walton Killam Health Centre, Dalhousie University, Halifax, NS, Canada.,Department of Pathology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.,Division of Microbiology at the Queen Elizabeth II Health Sciences Centre, Department of Pathology and Laboratory Medicine, Nova Scotia Health Authority, Halifax, NS, Canada
| | - H P Vasantha Rupasinghe
- Department of Plant, Food, and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, NS, Canada. .,Department of Biology, Faculty of Science, Dalhousie University, Halifax, NS, Canada. .,Department of Pathology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada. .,National Institute of Fundamental Studies, Kandy, Sri Lanka.
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92
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Gajdács M, Ábrók M, Lázár A, Burián K. Beta-Haemolytic Group A, C and G Streptococcal Infections in Southern Hungary: A 10-Year Population-Based Retrospective Survey (2008-2017) and a Review of the Literature. Infect Drug Resist 2021; 13:4739-4749. [PMID: 33408489 PMCID: PMC7781025 DOI: 10.2147/idr.s279157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/18/2020] [Indexed: 01/06/2023] Open
Abstract
Introduction Pyogenic β-hemolytic streptococci (including Group A, C and G Streptococcus) are some of the most important Gram-positive bacterial pathogens in human medicine. Although effective therapy is available, invasive streptococcal infections are associated with a significant disease burden. Methods In this retrospective study, the epidemiological characteristics of invasive Group A (iGAS) and Group C and G (iGCGS) streptococci, along with tonsillo-pharyngitis-causing pGAS and pGCGS infections, were assessed in Southern Hungary. A total of 1554 cases of streptococcal tonsillo-pharyngitis infections (26.5–44.1/100,000 persons, pGAS: 95.5%; n=1484) and 1104 cases of invasive streptococcal infections were detected (12.5–31.4/100,000 persons, iGAS: 77.9%; n=861). Results The average age of the affected patients in the various groups were the following: pGAS: 13.2±13.1 years, pGCGS: 21.0±15.0 years (p=0.039), iGAS: 49.1±12.8 years, iGCGS: 58.7±18.5 years (p>0.05). iGAS isolates originated from abscesses (47.1%), blood culture samples (24.1%), surgical samples (16.7%), biopsies (4.6%), pleural fluid (3.5%), pus (2.0%), synovial fluid (1.3%) and cerebrospinal fluid samples (0.7%). In contrast, iGCGS isolates mainly originated from blood culture samples (53.8%), abscesses (22.9%), surgical samples (12.3%), synovial fluid (5.1%), pleural fluid (3.7%), pus (1.8%) and cerebrospinal fluid samples (0.4%). All respective isolates were susceptible to benzyl-penicillin; overall resistance levels for erythromycin (10.5% for GAS, 21.4% for GCGS) and clindamycin (9.2% for GAS, 17.2% for GCGS) were significantly higher in GCGS isolates, while resistance levels for norfloxacin were higher in GAS isolates (13.5% for GAS, 6.9% for GCGS). Conclusion The rates of resistance to macrolides and clindamycin are a cause for concern (especially among GCGS isolates); however, resistance levels are still relatively low, compared to Southern European countries.
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Affiliation(s)
- Márió Gajdács
- Department of Pharmacodynamics and Biopharmacy, Faculty of Pharmacy, University of Szeged, Szeged 6720, Hungary
| | - Marianna Ábrók
- Institute of Clinical Microbiology, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Andrea Lázár
- Institute of Clinical Microbiology, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Katalin Burián
- Institute of Clinical Microbiology, Faculty of Medicine, University of Szeged, Szeged, Hungary.,Department of Medical Microbiology, Faculty of Medicine, University of Szeged, Szeged 6720, Hungary
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93
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Tu A. Sinusitis, Tonsillitis, and Pharyngitis. Fam Med 2021. [DOI: 10.1007/978-1-4939-0779-3_187-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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94
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Pelzman FN, Tung J. A Symptom-Directed Paradigm for the Evaluation and Management of Upper Respiratory Tract Infections. Med Clin North Am 2021; 105:199-212. [PMID: 33246520 DOI: 10.1016/j.mcna.2020.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Upper respiratory tract infections are one of the most common challenges in ambulatory medicine. Effective evaluation involves identification, primarily through the history, of the dominant set of patient symptoms leading to accurate diagnosis. Certain more morbid illnesses that mimic common upper respiratory symptoms can also be excluded with this approach. Treatment should address patient preferences through an understanding of the limited utility of antibiotics and through tailored advisement of the numerous pharmacologic options for symptom relief.
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Affiliation(s)
- Fred N Pelzman
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 505 East 70th Street, New York, NY 10021, USA.
| | - Judy Tung
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 505 East 70th Street, New York, NY 10021, USA. https://twitter.com/JudyTungMD
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95
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Zahlanie Y, Mang NS, Lin K, Hynan LS, Prokesch BC. Improved Antibiotic Prescribing Practices for Respiratory Infections Through Use of Computerized Order Sets and Educational Sessions in Pediatric Clinics. Open Forum Infect Dis 2020; 8:ofaa601. [PMID: 33553470 PMCID: PMC7849952 DOI: 10.1093/ofid/ofaa601] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/17/2020] [Indexed: 11/12/2022] Open
Abstract
Background Computerized clinical decision support systems (CDSS) have shown promising effectiveness in improving outpatient antibiotic prescribing. Methods We developed an intervention in the form of EPIC (Verona, WI, USA) order sets comprised of outpatient treatment pathways for 3 pediatric bacterial acute respiratory infections (ARIs) coupled with educational sessions. Four pediatric clinics were randomized into intervention and control arms over pre- and postimplementation study periods. In the intervention clinics, education was provided in between the 2 study periods and EPIC order sets became available at the beginning of the postimplementation period. The primary end point was the percentage of first-line antibiotic prescribing, and the secondary end points included antibiotic duration and antibiotic prescription modification within 14 days. Results A total of 2690 antibiotic prescriptions were included. During the pre-implementation phase, there was no difference in first-line antibiotic prescribing (74.9% vs 77.7%; P = .211) or antibiotic duration (9.69 ± 0.96 days vs 9.63 ± 1.07 days; P > .999) between the study arms. Following implementation, the intervention clinics had a higher percentage of first-line antibiotic prescribing (83.1% vs 77.7%; P = .024) and shorter antibiotic duration (9.28 ± 1.56 days vs 9.79 ± 0.75 days; P < .001) compared with the control clinics. The percentage of modified antibiotics was small in all clinics (1.1%-1.6%) and did not differ before and after the intervention (for all statistical comparisons, P ≤ .354). Conclusions A computerized CDSS involving treatment pathways in the form of order sets coupled with educational sessions was associated with a higher percentage of first-line antibiotic prescribing and shorter antibiotic duration for the outpatient treatment of pediatric bacterial ARIs.
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Affiliation(s)
- Yorgo Zahlanie
- Division of Infectious Diseases, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Norman S Mang
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Kevin Lin
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Linda S Hynan
- Department of Population and Data Sciences (Biostatistics), University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Bonnie C Prokesch
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Correspondence: Bonnie C. Prokesch, MD, 5325 Harry Hines Blvd, Dallas, TX 75390 ()
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96
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Dantuluri KL, Bruce J, Edwards KM, Banerjee R, Griffith H, Howard LM, Grijalva CG. Rurality of Residence and Inappropriate Antibiotic Use for Acute Respiratory Infections Among Young Tennessee Children. Open Forum Infect Dis 2020; 8:ofaa587. [PMID: 33511228 PMCID: PMC7814393 DOI: 10.1093/ofid/ofaa587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 12/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background Antibiotic use is common for acute respiratory infections (ARIs) in children, but much of this use is inappropriate. Few studies have examined whether rurality of residence is associated with inappropriate antibiotic use. We examined whether rates of ARI-related inappropriate antibiotic use among children vary by rurality of residence. Methods We conducted a retrospective cohort study of children aged 2 months-5 years enrolled in Tennessee Medicaid between 2007 and 2017 and diagnosed with ARI in the outpatient setting. Study outcomes included ARI, ARI-related antibiotic use, and ARI-related inappropriate antibiotic use. Multivariable Poisson regression was used to measure associations between rurality of residence, defined by the US Census Bureau, and the rate of study outcomes, while accounting for other factors including demographics and underling comorbidities. Results A total of 805 332 children met selection criteria and contributed 1 840 048 person-years (p-y) of observation. Children residing in completely rural, mostly rural, and mostly urban counties contributed 70 369 (4%) p-y, 479 121 (26%) p-y, and 1 290 558 p-y (70%), respectively. Compared with children in mostly urban counties (238 per 1000 p-y), children in mostly rural (450 per 1000 p-y) and completely rural counties (468 per 1000 p-y) had higher rates of inappropriate antibiotic use (adjusted incidence rate ratio [aIRR] = 1.34, 95% confidence interval [CI] = 1.33-1.35 and aIRR = 1.33, 95% CI = 1.32-1.35, respectively). Conclusions Inappropriate antibiotic use is common among young children with ARI, with higher rates in rural compared with urban counties. These differences should inform targeted outpatient antibiotic stewardship efforts.
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Affiliation(s)
- Keerti L Dantuluri
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jean Bruce
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathryn M Edwards
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ritu Banerjee
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hannah Griffith
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leigh M Howard
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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97
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Madaras-Kelly K, Hostler C, Townsend M, Potter EM, Spivak ES, Hall SK, Goetz MB, Nevers M, Ying J, Haaland B, Rovelsky SA, Pontefract B, Fleming-Dutra K, Hicks LA, Samore MH. Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship Within Veterans Health Administration Emergency Departments and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes. Clin Infect Dis 2020; 73:e1126-e1134. [PMID: 33289028 DOI: 10.1093/cid/ciaa1831] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use. We report the impact of core elements implementation within Veterans Health Administration sites. METHODS In this quasiexperimental controlled study, effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARIs) were assessed. Outcomes included per-visit antibiotic prescribing, treatment appropriateness, ARI revisits, hospitalization, and ARI diagnostic changes over a 3-year pre-implementation period and 1-year post-implementation period. Logistic regression adjusted for covariates (odds ratio [OR], 95% confidence interval [CI]) and a difference-in-differences analysis compared outcomes between intervention and control sites. RESULTS From 2014-2019, there were 16 712 and 51 275 patient visits within 10 intervention and 40 control sites, respectively. Antibiotic prescribing rates pre- and post-implementation within intervention sites were 59.7% and 41.5%, compared to 73.5% and 67.2% within control sites, respectively (difference-in-differences, P < .001). Intervention site pre- and post-implementation OR to receive appropriate therapy increased (OR, 1.67; 95% CI, 1.31-2.14), which remained unchanged within control sites (OR,1.04; 95% CI, .91-1.19). ARI-related return visits post-implementation (-1.3% vs -2.0%; difference-in-differences P = .76) were not different, but all-cause hospitalization was lower within intervention sites (-0.5% vs -0.2%; difference-in-differences P = .02). The OR to diagnose non-specific ARI compared with non-ARI diagnoses increased post-implementation forintervention (OR, 1.27; 95% CI, 1.21 -1.34) but not control (OR, 0.97; 95% CI, .94-1.01) sites. CONCLUSIONS Implementation of the core elements was associated with reduced antibiotic prescribing for RIs and a reduction in hospitalizations. Diagnostic coding changes were observed.
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Affiliation(s)
- Karl Madaras-Kelly
- Pharmacy Service, Boise VA Medical Center, Boise, Idaho, USA.,Department of Pharmacy Practice, Pharmacy Practice, College of Pharmacy, Idaho State University, Meridian, Idaho, USA
| | - Christopher Hostler
- Department of Medicine- Hostler (Mary Townsend is Pharmacy Service), Infectious Diseases Section, Durham VA Health Care System, Durham, North Carolina, USA
| | - Mary Townsend
- Department of Medicine- Hostler (Mary Townsend is Pharmacy Service), Infectious Diseases Section, Durham VA Health Care System, Durham, North Carolina, USA
| | - Emily M Potter
- Pharmacy Service, Dwight D. Eisenhower Veterans Affairs Medical Center, Leavenworth, Kansas, USA
| | - Emily S Spivak
- Medicine Service Spivak (Sarah Hall is Primary Care), VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA.,Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sarah K Hall
- Medicine Service Spivak (Sarah Hall is Primary Care), VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA.,Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Matthew Bidwell Goetz
- Medicine Service, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, California, USA
| | - McKenna Nevers
- Medicine Service Spivak (Sarah Hall is Primary Care), VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA.,Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jian Ying
- Medicine Service Spivak (Sarah Hall is Primary Care), VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA.,Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Benjamin Haaland
- Medicine Service Spivak (Sarah Hall is Primary Care), VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA.,Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | | | - Katherine Fleming-Dutra
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lauri A Hicks
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Matthew H Samore
- Medicine Service Spivak (Sarah Hall is Primary Care), VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA.,Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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98
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Minh NNQ, Toi PV, Qui LM, Tinh LBB, Ngoc NT, Kim LTN, Uyen NH, Hang VTT, Chinh B’Krong NTT, Tham NT, Khoa TD, Khuong HD, Vi PQ, Phuc NNH, Vien LTM, Pouplin T, Khanh DV, Phuong PN, Lam PK, Wertheim HFL, Campbell JI, Baker S, Parry CM, Bryant JE, Schultsz C, Hung NT, de Jong MD, van Doorn HR. Antibiotic use and prescription and its effects on Enterobacteriaceae in the gut in children with mild respiratory infections in Ho Chi Minh City, Vietnam. A prospective observational outpatient study. PLoS One 2020; 15:e0241760. [PMID: 33147269 PMCID: PMC7641406 DOI: 10.1371/journal.pone.0241760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/20/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Treatment guidelines do not recommend antibiotic use for acute respiratory infections (ARI), except for streptococcal pharyngitis/tonsillitis and pneumonia. However, antibiotics are prescribed frequently for children with ARI, often in absence of evidence for bacterial infection. The objectives of this study were 1) to assess the appropriateness of antibiotic prescriptions for mild ARI in paediatric outpatients in relation to available guidelines and detected pathogens, 2) to assess antibiotic use on presentation using questionnaires and detection in urine 3) to assess the carriage rates and proportions of resistant intestinal Enterobacteriaceae before, during and after consultation. MATERIALS AND METHODS Patients were prospectively enrolled in Children's Hospital 1, Ho Chi Minh City, Vietnam and diagnoses, prescribed therapy and outcome were recorded on first visit and on follow-up after 7 days. Respiratory bacterial and viral pathogens were detected using molecular assays. Antibiotic use before presentation was assessed using questionnaires and urine HPLC. The impact of antibiotic usage on intestinal Enterobacteriaceae was assessed with semi-quantitative culture on agar with and without antibiotics on presentation and after 7 and 28 days. RESULTS A total of 563 patients were enrolled between February 2009 and February 2010. Antibiotics were prescribed for all except 2 of 563 patients. The majority were 2nd and 3rd generation oral cephalosporins and amoxicillin with or without clavulanic acid. Respiratory viruses were detected in respiratory specimens of 72.5% of patients. Antibiotic use was considered inappropriate in 90.1% and 67.5%, based on guidelines and detected pathogens, respectively. On presentation parents reported antibiotic use for 22% of patients, 41% of parents did not know and 37% denied antibiotic use. Among these three groups, six commonly used antibiotics were detected with HPLC in patients' urine in 49%, 40% and 14%, respectively. Temporary selection of 3rd generation cephalosporin resistant intestinal Enterobacteriaceae during antibiotic use was observed, with co-selection of resistance to aminoglycosides and fluoroquinolones. CONCLUSIONS We report overuse and overprescription of antibiotics for uncomplicated ARI with selection of resistant intestinal Enterobacteriaceae, posing a risk for community transmission and persistence in a setting of a highly granular healthcare system and unrestricted access to antibiotics through private pharmacies. REGISTRATION This study was registered at the International Standard Randomised Controlled Trials Number registry under number ISRCTN32862422: http://www.isrctn.com/ISRCTN32862422.
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Affiliation(s)
- Ngo Ngoc Quang Minh
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Children’s Hospital 1, Ho Chi Minh City, Vietnam
| | - Pham Van Toi
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Le Minh Qui
- Children’s Hospital 1, Ho Chi Minh City, Vietnam
| | | | | | | | - Nguyen Hanh Uyen
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Vu Thi Ty Hang
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Nguyen Thi Tham
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Thai Dang Khoa
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Huynh Duy Khuong
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Pham Quynh Vi
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Ngoc Hong Phuc
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Le Thi Minh Vien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Thomas Pouplin
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Doan Van Khanh
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Pham Nguyen Phuong
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Phung Khanh Lam
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Heiman F. L. Wertheim
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Henry Wellcome Building for Molecular Physiology, Old Road Campus, Headington, Oxford, United Kingdom
| | - James I. Campbell
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Stephen Baker
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Christopher M. Parry
- Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, United Kingdom
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Juliet E. Bryant
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Constance Schultsz
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Department of Global Health-Amsterdam, Institute of Global Health and Development, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Menno D. de Jong
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Department of Medical Microbiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - H. Rogier van Doorn
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Henry Wellcome Building for Molecular Physiology, Old Road Campus, Headington, Oxford, United Kingdom
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Subramaniam G, Girish M. Antibiotic Resistance - A Cause for Reemergence of Infections. Indian J Pediatr 2020; 87:937-944. [PMID: 32026301 DOI: 10.1007/s12098-019-03180-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/31/2019] [Indexed: 11/27/2022]
Abstract
This article can rightly be called 'the rise of the microbial phoenix'; for, all the microbial infections whose doomsday was predicted with the discovery of antibiotics, have thumbed their noses at mankind and reemerged phoenix like. The hubris generated by Sir Alexander Fleming's discovery of Penicillin in 1928, exemplified best by the comment by William H Stewart, the US Surgeon General in 1967, "It is time to close the books on infectious diseases" has been replaced by the realisation that the threat of antibiotic resistance is, in the words of the Chief Medical Officer of England, Dame Sally Davies, "just as important and deadly as climate change and international terrorism". Antimicrobial resistance threatens to negate all the major medical advances of the last century because antimicrobial use is linked to many other fields like organ transplantation and cancer chemotherapy. Antibiotic resistance genes have been there since ancient times in response to naturally occurring antibiotics. Modern medicine has only driven further evolution of antimicrobial resistance by use, misuse, overuse and abuse of antibiotics. Resistant bacteria proliferate by natural selection when their drug sensitive comrades are removed by antibiotics. In this article the authors discuss the various causes of antimicrobial resistance and dwell in some detail on antibiotic resistance in gram-positive and gram-negative organisms. Finally they stress on the important role clinicians have in limiting the development and spread of antimicrobial resistance.
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Affiliation(s)
- Girish Subramaniam
- Department of Pediatrics, Children Hospital, Midas Heights, Ramdaspeth, Nagpur, India.
| | - Meenakshi Girish
- Department of Pediatrics, All India Institute of Medical Sciences, Nagpur, India
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100
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Evaluation of a pharmacist's impact on antimicrobial prescribing in an urgent care center. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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