A community intervention trial to promote judicious antibiotic use and reduce penicillin-resistant Streptococcus pneumoniae carriage in children

Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts

OBJECTIVES

Reducing unnecessary antibiotic use, particularly among children, continues to be a public health priority. Previous intervention studies have been limited by size or design and have shown mixed results. The objective of this study was to determine the impact of a multifaceted, community-wide intervention on overall antibiotic use for young children and on use of broad-spectrum agents. In addition, we sought to compare the intervention's impact on commercially and Medicaid-insured children.

METHODS

We conducted a controlled, community-level, cluster-randomized trial in 16 nonoverlapping Massachusetts communities, studied from 1998 to 2003. During 3 years, we implemented a physician behavior-change strategy that included guideline dissemination, small-group education, frequent updates and educational materials, and prescribing feedback. Parents received educational materials by mail and in primary care practices, pharmacies, and child care settings. Using health-plan data, we measured changes in antibiotics dispensed per person-year of observation among children who were aged 3 to <72 months, resided in study communities, and were insured by a participating commercial health plan or Medicaid.

RESULTS

The data include 223,135 person-years of observation. Antibiotic-use rates at baseline were 2.8, 1.7, and 1.4 antibiotics per person-year among those aged 3 to <24, 24 to <48, and 48 to <72 months, respectively. We observed a substantial downward trend in antibiotic prescribing, even in the absence of intervention. The intervention had no additional effect among children aged 3 to <24 months but was responsible for a 4.2% decrease among those aged 24 to <48 months and a 6.7% decrease among those aged 48 to <72 months. The intervention effect was greater among Medicaid-insured children and for broad-spectrum agents.

CONCLUSIONS

A sustained, multifaceted, community-level intervention was only modestly successful at decreasing overall antibiotic use beyond substantial secular trends. The more robust impact among Medicaid-insured children and for specific medication classes provides an argument for specific targeting of resources for patient and physician behavior change.

A review of antimicrobial control strategies in hospitalized and ambulatory pediatric populations

Antimicrobial resistance is a growing crisis in healthcare. Various antimicrobial stewardship strategies have been used to control antibiotic use in efforts to reduce antibiotic resistance. We conducted a systematic review of antimicrobial stewardship programs in pediatric settings. Twenty-eight published studies met inclusion criteria. The majority (21 of 28) of studies had positive outcomes, but only 6 measured the impact of interventions on antimicrobial resistance. Prescriber education for a specific diagnosis (eg, otitis media) was the most effective intervention in the outpatient setting. Ancillary laboratory tests (eg, rapid diagnostic assays for viral pathogens) were most effective in the inpatient setting. Most studies had moderate to high risk of bias, mainly because of selection bias, inadequate preintervention data for time series analysis, and contamination between treatment groups. To date, there are a limited number of studies assessing antimicrobial stewardship in pediatric settings and these have heterogeneous study designs. Thus, it is difficult to determine the most effective interventions. Future studies should be designed to overcome the biases encountered in current publications.

Cluster-randomized trial to improve antibiotic use for adults with acute respiratory infections treated in emergency departments

STUDY OBJECTIVE

We evaluate the effectiveness of an educational program in hospital emergency departments (EDs) targeting reduction in antibiotic overuse for acute respiratory tract infections.

METHODS

Sixteen hospitals participated in the cluster randomized trial, selecting a Veterans Administration (VA) and non-VA hospital within each of 8 metropolitan regions. Intervention sites received performance feedback, clinician education, and patient educational materials, including an interactive computer kiosk located in the waiting room. Medical records were reviewed at each site during the baseline year 1 and intervention year 2. The primary measure of effect was the percentage of visits for upper respiratory tract infections and acute bronchitis that were treated with antibiotics. Secondary outcomes, including return visits and visit satisfaction, were assessed by follow-up telephone interviews of patients. Alternating logistic regression models were used to adjust for baseline treatment rates, case mix differences, and provider characteristics.

RESULTS

The adjusted antibiotic prescription level for upper respiratory tract infection/acute bronchitis visits was 47% for control sites and 52% for intervention sites in year 1. Antibiotic prescriptions at control sites increased by 0.5% between year 1 and year 2 (95% confidence interval -3% to 5%) and at intervention sites decreased by 10% (95% confidence interval -18% to -2%). There were no significant differences between control and intervention sites in the proportions of upper respiratory tract infection/bronchitis patients with return ED visits or in overall visit satisfaction.

CONCLUSION

Multidimensional educational interventions can reduce antibiotic overuse in the treatment of patients with upper respiratory tract infections and acute bronchitis in EDs. However, substantial antibiotic overuse persists despite this educational intervention.

Parental knowledge about antibiotic use: results of a cluster-randomized, multicommunity intervention

OBJECTIVE

The goal was to determine the impact of a community-wide educational intervention on parental misconceptions likely contributing to pediatric antibiotic overprescribing.

METHODS

We conducted a cluster-randomized trial of a 3-year, community-wide, educational intervention directed at parents of children < 6 years of age in 16 Massachusetts communities to improve parental antibiotic knowledge and attitudes and to decrease unnecessary prescribing. Parents in 8 intervention communities were mailed educational newsletters and exposed to educational materials during visits to local pediatric providers, pharmacies, and child care centers. We compared responses from mailed surveys in 2000 (before the intervention) and 2003 (after the intervention) for parents in intervention and control communities. Analyses were performed on the individual level, clustered according to community.

RESULTS

There were 1106 (46%) and 2071 (40%) respondents to the 2000 and 2003 surveys, respectively. Between 2000 and 2003, the proportion of parents who answered > or = 7 of 10 knowledge questions correctly increased significantly in both intervention (from 52% to 64%) and control (from 54% to 61%) communities. We did not detect a significant intervention impact on knowledge regarding appropriate antibiotic use in the population overall. In a subanalysis, we did observe a significant intervention effect among parents of Medicaid-insured children, who began with lower baseline knowledge scores.

CONCLUSIONS

Although knowledge regarding appropriate use of antibiotics is improving without additional targeted intervention among more socially advantaged populations, parents of Medicaid-insured children may benefit from educational interventions to promote judicious antibiotic use. These findings may have implications for other health education campaigns.

How to fight antimicrobial resistance

Antimicrobial misuse results in the development of resistance and superbugs. Over recent decades, resistance has been increasing despite continuing efforts to control it, resulting in increased mortality and cost. Many authorities have proposed local, regional and national guidelines to fight against this phenomenon, and the usefulness of these programmes has been evaluated. Multifaceted intervention seems to be the most efficient method to control antimicrobial resistance. Monitoring of bacterial resistance and antibiotic use is essential, and the methodology has now been homogenized. The implementation of guidelines and infection control measures does not control antimicrobial resistance and needs to be reinforced by associated measures. Educational programmes and rotation policies have not been evaluated sufficiently in the literature. Combination antimicrobial therapy is inefficient in controlling antimicrobial resistance.

Assessment of pathogen frequency and resistance patterns among pediatric patient isolates: Report from the 2004 SENTRY Antimicrobial Surveillance Program on 3 continents

Selecting empiric or directed therapy for pathogens isolated from pediatric patients can be problematic. Many antimicrobial agents are not indicated for use in pediatric patients, and regional variations of resistance mechanisms have been reported. The purpose of this study was to analyze antimicrobial resistance patterns and pathogen occurrence rates in pediatric-aged patient infections on 3 continents using data from the SENTRY Antimicrobial Surveillance Program. A total of 3537 clinical isolates were collected from 47 medical centers in 2004. With a protocol that dictated a sampling of 80 consecutive isolates from children (< or =18 years of age), all samples were forwarded to a central laboratory for reference susceptibility testing. Broth microdilution methods and current Clinical and Laboratory Standards Institute breakpoint criteria were used. The 15 most frequently observed pathogens accounted for 93.6% of all isolates. Staphylococcus aureus was the most common pathogen isolated in North America (27.4%) and Europe (19.0%), but Escherichia coli was most common in Latin America (19.3%). All Streptococcus pneumoniae strains from North America and Latin America were susceptible to the newer fluoroquinolones, gatifloxacin and levofloxacin. However, 2 S. pneumoniae strains from Italy were resistant to gatifloxacin, levofloxacin, and ciprofloxacin (> or =4 microg/mL). Ribotype and pulsed-field gel electrophoresis patterns found that these resistant pneumococci were clonal. Numerous strains of Klebsiella spp. (22.5%), E. coli (4.5%), and Proteus mirabilis (4.9%) exhibited phenotypic extended-spectrum beta-lactamase resistance patterns. Four Pseudomonas aeruginosa strains (3 from Latin America and 1 from Europe) were multidrug resistant, 2 P. aeruginosa isolates from Turkey were resistant to polymyxin B (> or =4 microg/mL), and 8.7% of Stenotrophomonas maltophilia isolates from Latin America were resistant to the "drug of choice", trimethoprim/sulfamethoxazole. Physicians should be aware of pathogen occurrences that vary by children's age, geographic location, and prior antimicrobial exposure. Therefore, continued surveillance will be necessary to monitor emerging antimicrobial resistance in the pediatric patient population, especially because new agents such as the fluoroquinolones are used to a greater extent in this age group.

Impact of pneumococcal conjugate vaccine and of reduction of antibiotic use on nasopharyngeal carriage of nonsusceptible pneumococci in children with acute otitis media

BACKGROUND

Penicillin resistance among pneumococci has increased in the past 15 years. The implementation of widespread vaccination with the heptavalent pneumococcal conjugate vaccine (PCV7) and the reduction of inappropriate antibiotic use could help reduce antibiotic resistance.

METHODS

Between September 2001 and June 2004, 89 pediatricians distributed throughout France took part in this prospective study. We obtained 1906 nasopharyngeal swabs for culture from children aged 6 to 24 months with acute otitis media (AOM). At the same time as PCV7 was introduced into the routine immunization schedule, a plan to promote judicious antibiotic use was established. We recorded the frequency of antibiotic use, as well as the dates of immunization with PCV7.

RESULTS

The proportion of PCV7-vaccinated children (> or =1 dose) increased from 8.2% (year 1) to 61.4% (year 3). The proportion of children who received antibiotics within 3 months before enrollment decreased from 51.8% in year 1 to 40.9% in year 3 (P < 0.001). Overall pneumococcal carriage and carriage of PCV7 serotypes decreased during the 3-year period by 16% (P < 0.001) and 35% (P < 0.001), respectively. Rates of highly penicillin resistant strains (PRP) decreased yearly: 15.4%, 10.6%, 6.7% (P < 0.001), respectively. Risks for PRP carriage were 4.2% for immunized children who had not received antibiotics, 8.6% for those vaccinated who also had received antibiotics, 10.3% for unimmunized children who had not received antibiotics, and 16.2% for unimmunized children who had received antibiotics (P < 0.001).

CONCLUSION

Implementation of PCV7, combined with a reduction in antibiotic use, in a country with a high prevalence of antibiotic-resistant pneumococci appears to have a strong impact on the carriage of penicillin nonsusceptible pneumococci in children with AOM.

Approaches to reduce antibiotic resistance in the community

During the last two decades, there has been an alarming worldwide increase of resistance to antibiotics of bacterial pathogens responsible for community-acquired infections. This dramatic evolution is generally attributed to the extensive use of antibiotics and the selective pressure on the bacterial strains. To decrease antibiotics resistance in the community, several approaches should be considered through: reducing unnecessary antibiotic prescriptions: inappropriate antibiotic treatments are becoming a major issue; however, few studies have shown a decrease of antibiotic resistance following a reduction of antibiotic use in the community;decreasing the prescriptions of the more selective antibiotic compounds for some bacterial species, eg macrolides and group A streptococcus (GAS), trimethoprim-sulfamethoxazole and pneumococcus; using an optimal dosage and duration of antibiotic regimens chosen; some studies have suggested that low dosage and long treatment duration could promote antibiotic resistance; and implementing the pneumococcal conjugate vaccines; several studies have shown a decline in the proportion of penicillin nonsusceptible Streptococcus pneumoniae isolated from invasive pneumococcal diseases or nasopharyngeal flora. The combination of these approaches, particularly the reduction of antibiotic use and pneumococcal immunization, could be synergistic.

Knowledge, attitudes, and practices regarding antibiotic use among Latinos in the United States: review and recommendations

Inappropriate use of antibiotics contributes to antimicrobial resistance worldwide. In Latin America, antibiotics are easily obtained over the counter. In the United States, the Latino population is the largest and fastest growing immigrant group. Hence, it is necessary to understand Latino cultural practices in regards to antibiotic use to develop effective interventions that reduce inappropriate antibiotic use among this population. We conducted a systematic review of descriptive and intervention studies measuring knowledge, attitudes, and practices of antibiotic use among Latinos in the United States. The search yielded only 11 descriptive studies and no interventions. The literature suggests that many Latinos in the United States self-prescribe antibiotics because of financial and sociocultural barriers and inaccurately believe that antibiotics help treat viral infections. Increased access to health care and appropriate culturally tailored interventions specific to Latinos are needed to promote judicious antibiotic use among Latinos.

Antibiotic prescribing for childhood febrile illness by primary care doctors in Malaysia

AIM

Fever in children, a mostly benign and self-limiting illness, is often viewed with consternation by the care givers. It results in early consultation and excessive use of antipyretics and antibiotics. In this study, we document the prescribing practice of doctors from three primary care settings in Malaysia and identify the predictors of antibiotic prescription.

METHODS

Interview of care givers bringing febrile children (age </= 12 years) to three primary care settings: public primary care clinics, private general practice clinics and a university-based primary care clinic.

RESULTS

Data from 649 children were analysed. Mean age of children 4.1 years and 55% were boys. One-third of the children had prior consultation for the same episode of fever. About 80% of the febrile children were diagnosed to have upper respiratory tract infection, viral fever and gastroenteritis. Overall antibiotic prescribing rate was 36.6% (public primary care clinic 26.8%, private general practice clinic 70.0% and university-based primary care clinic 32.2%). Independent predictors of antibiotic prescription were: clinic setting, longer duration of fever (>7 days), higher temperature (>38 degrees C) and the diagnosis of upper respiratory tract infections. After controlling for demographic and clinical factors, antibiotic prescription in private general practice clinic was seven times higher than public primary care clinic (odds ratio 7.1, 95% confidence interval 4.0-12.7), and 1.6 times higher than university-based primary care clinic (odds ratio 1.6, 95% confidence interval 1.0-2.5).

CONCLUSION

Differences in the patients' demographic and clinical characteristics could not adequately explain the high antibiotic prescribing rate in private general practice clinics. This inappropriately high antibiotic prescribing for febrile children in private general practice clinics is a suitable target for future intervention.

Decline in inappropriate antibiotic use over a decade by pediatricians in a Tennessee community

OBJECTIVE

Published data indicates that antibiotic use for pediatric respiratory tract infections has declined across the United States. We reviewed antibiotic use in 2 pediatrics practices in Memphis, Tennessee, to determine whether there has been a reduction in inappropriate antibiotic use in this region.

METHODS

Randomly selected charts in 7 offices of 2 practices were reviewed for respiratory tract infection visits during alternate years between 1992 and 2002. Antibiotics were considered inappropriate for viral respiratory tract and other viral syndromes, asthma, allergic rhinitis, and otitis media with effusion. Changes in inappropriate prescribing were evaluated by generalized estimating equations with year of visit as the explanatory variable and visits clustered by practice.

RESULTS

There were 1504 unique patient visits reviewed. The number of visits with an antibiotic prescription fell from 85% in 1992 to 67% in 2002. The likelihood of inappropriately prescribing an antibiotic declined between 1992 and 2002 (odds ratio 0.28, 95% confidence interval 0.20-0.38). Use of amoxicillin-clavulanic acid and azithromycin increased, and amoxicillin use decreased.

CONCLUSIONS

There has been a marked decline in inappropriate antibiotic use in this region with high prescribing rates. Pediatricians have increased their use of broad-spectrum antibiotic agents for respiratory tract infections. Continuing education of physicians regarding appropriate use should continue to maintain and improve on the gains achieved in the last decade.

The judicious use of antibiotics--an investment towards optimized health care

During the past century the excitement of discovering antibiotics as a treatment of infectious diseases has given way to a sense of complacency and acceptance that when faced with antimicrobial resistance there will always be new and better antimicrobial agents to use. Now, with clear indications of a decline in pharmaceutical company interest in anti-infective research, at the same time when multi-drug resistant micro-organisms continue to be reported, it is very important to review the prudent use of the available agents to fight these micro-organisms. Injudicious use of antibiotics is a global problem with some countries more affected than others. There is no dearth of interest in this subject with scores of scholarly articles written about it. While over the counter access to antibiotics is mentioned as an important contributor towards injudicious antibiotic use in developing nations, as shown in a number of studies, there are many provider, practice and patient characteristics which drive antibiotic overuse in developed nations such as the United States. Recognizing that a thorough review of this subject goes far and beyond the page limitations of a review article we provide a summary of some of the salient aspects of this global problem with a focus towards readers practicing in developing nations.

Mechanisms by which antibiotics promote dissemination of resistant pneumococci in human populations

Mechanisms by which antimicrobials contribute to dissemination of pneumococcal resistance are incompletely characterized. A serial cross-sectional study of nasopharyngeal pneumococcal carriage in healthy, home-living children <or=6 years of age was conducted in four rural communities-two in Utah (1998-2003) and two in Idaho (2002-2003). Prevalence odds ratios for carriage of resistant pneumococci (OR(res)) and of susceptible pneumococci (OR(sus)) were estimated. Dynamic transmission models were developed to facilitate a mechanistic interpretation of OR(res) and OR(sus) and to compare the population impact of distinct antimicrobial classes. A total of 5,667 cultures were obtained; 25% of the cultures were positive, and 29% of isolates exhibited reduced susceptibility to penicillin. The adjusted OR(res) for recent individual and sibling cephalosporin use was 2.2 (95% confidence interval: 1.4, 3.4) and 1.8 (95% confidence interval: 1.0, 3.3), respectively. Neither individual nor sibling penicillin use was associated with increased OR(res). Rather, recent use of penicillins was associated with decreased carriage of susceptible pneumococci (OR(sus) = 0.2, 95% confidence interval: 0.1, 0.3). In simulations, both types of effects promoted dissemination of resistant pneumococci at the population level. Findings show that oral cephalosporins enhance the risk of acquiring resistant pneumococci. Penicillins accelerate clearance of susceptible strains. The effect of penicillins in increasing resistance is shared equally by treated and untreated members of the population.

Implementing guidelines for the treatment of acute otitis media

The recently published Clinical Practice Guideline for the Diagnosis and Management of Acute Otitis Media represents a sincere effort by the AAP andthe AAFP to provide management guidelines for the practitioner based upon the best scientific evidence available. Despite many years of research and hundreds of clinical studies addressing various aspects of the epidemiology, clinical presentation, and treatment of acute otitis media, important questions remain unaddressed or have been addressed in a less than optimal fashion. These gaps in knowledge and deficiencies in several of the studies that formed the scientific basis for the proposed guidelines are the major reasons behind continued disagreement over certain recommendations. Until more comprehensive and careful analyses can be performed, disagreements are likely to persist. Even so, there is general agreement about most of the recommendations made in these guidelines, and these recommendations will provide a very valuable framework for the practicing physician as he or she cares for children with acute otitis media. To briefly review the major points, first is the critical importance of accurately diagnosing acute otitis media using a combination of clinical findings and observable abnormalities of the tympanic membrane and middle ear space. Particularly important is the differentiation of acute otitis media from otitis media with effusion. Second is the value of treating the pain associated with acute otitis media as a regular component of care, irrespective of any decision concerning antimicrobial treatment. Third is the option, for a select group of older patients with nonsevere disease, of withholding antimicrobial therapy for the first 48 to 72 hours, if close follow-up and active parental involvement can be guaranteed. Fourth is the recommendation that if an antimicrobial agent is used, high-dose amoxicillin (80 to 90 mg/kg/d) is the treatment of choice for most children at the time of initial presentation unless disease is particularly severe or the child has recently failed a previous course of the antibiotic. Finally highlighted is the importance of ongoing education efforts on the part of physicians in advising parents about the things they can do in their households to lessen the risk of future disease.

Impact of heptavalent pneumococcal conjugate vaccine on invasive disease, antimicrobial resistance and colonization in Alaska Natives: progress towards elimination of a health disparity

We evaluated invasive pneumococcal disease (IPD), antimicrobial resistance and nasopharyngeal colonization before and after introduction of pneumococcal conjugate vaccine (PCV7) in Alaska Natives (AN), a population with high IPD rates. We obtained IPD rates from population-based surveillance. Colonization was determined from annual surveys among rural AN of all ages and from urban children. After vaccine introduction, vaccine-type IPD rates declined by 91% among AN children <2 years, by 80% among non-Natives <2 years, and by 40% for adults of all races (P<0.001 each). IPD decreased for isolates resistant to penicillin, erythromycin and cotrimoxazole (P<0.001 each). Vaccine-type colonization decreased among rural and urban children <5 years and among rural adults (P<0.001 each). PCV7 vaccine has eliminated a longstanding disparity of vaccine-type IPD for AN children. Decreased vaccine-type colonization and IPD in adults demonstrate indirect vaccine effects.

Interventions to improve antibiotic prescribing practices in ambulatory care

BACKGROUND

The development of resistance to antibiotics by many important human pathogens has been linked to exposure to antibiotics over time. The misuse of antibiotics for viral infections (for which they are of no value) and the excessive use of broad spectrum antibiotics in place of narrower spectrum antibiotics have been well-documented throughout the world. Many studies have helped to elucidate the reasons physicians use antibiotics inappropriately.

OBJECTIVES

To systematically review the literature to estimate the effectiveness of professional interventions, alone or in combination, in improving the selection, dose and treatment duration of antibiotics prescribed by healthcare providers in the outpatient setting; and to evaluate the impact of these interventions on reducing the incidence of antimicrobial resistant pathogens.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialized register for studies relating to antibiotic prescribing and ambulatory care. Additional studies were obtained from the bibliographies of retrieved articles, the Scientific Citation Index and personal files.

SELECTION CRITERIA

We included all randomised and quasi-randomised controlled trials (RCT and QRCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies of healthcare consumers or healthcare professionals who provide primary care in the outpatient setting. Interventions included any professional intervention, as defined by EPOC, or a patient-based intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality.

MAIN RESULTS

Thirty-nine studies examined the effect of printed educational materials for physicians, audit and feedback, educational meetings, educational outreach visits, financial and healthcare system changes, physician reminders, patient-based interventions and multi-faceted interventions. These interventions addressed the overuse of antibiotics for viral infections, the choice of antibiotic for bacterial infections such as streptococcal pharyngitis and urinary tract infection, and the duration of use of antibiotics for conditions such as acute otitis media. Use of printed educational materials or audit and feedback alone resulted in no or only small changes in prescribing. The exception was a study documenting a sustained reduction in macrolide use in Finland following the publication of a warning against their use for group A streptococcal infections. Interactive educational meetings appeared to be more effective than didactic lectures. Educational outreach visits and physician reminders produced mixed results. Patient-based interventions, particularly the use of delayed prescriptions for infections for which antibiotics were not immediately indicated effectively reduced antibiotic use by patients and did not result in excess morbidity. Multi-faceted interventions combining physician, patient and public education in a variety of venues and formats were the most successful in reducing antibiotic prescribing for inappropriate indications. Only one of four studies demonstrated a sustained reduction in the incidence of antibiotic-resistant bacteria associated with the intervention.

AUTHORS' CONCLUSIONS

The effectiveness of an intervention on antibiotic prescribing depends to a large degree on the particular prescribing behaviour and the barriers to change in the particular community. No single intervention can be recommended for all behaviours in any setting. Multi-faceted interventions where educational interventions occur on many levels may be successfully applied to communities after addressing local barriers to change. These were the only interventions with effect sizes of sufficient magnitude to potentially reduce the incidence of antibiotic-resistant bacteria. Future research should focus on which elements of these interventions are the most effective. In addition, patient-based interventions and physician reminders show promise and innovative methods such as these deserve further study.

Reduction of Antibiotic Use in the Community Reduces the Rate of Colonization with Penicillin G--Nonsusceptible Streptococcus pneumoniae

BACKGROUND

There is a lack of evidence documenting the impact of optimized antibiotic use on the rates of colonization with penicillin G-nonsusceptible Streptococcus pneumoniae (PNSP) in children. This study evaluates the effect of community-based intervention strategies on the prevalence of pnsp colonization.

METHODS

A controlled, population-based pharmacoepidemiological trial was conducted from January through May 2000. Three French geographic areas were selected on the basis of demographic similarities. Two intervention strategies were implemented: (1) reduced antibiotic use, which was achieved by not prescribing antibiotics for presumed viral respiratory tract infections (the prescription-reduction group); and (2) better adaptation of dose and duration (the dose/duration group). A control group received no intervention. The target population was children aged 3-6 years who were attending kindergarten. Oropharyngeal pneumococcus colonization and antibiotic use were monitored throughout the 5-month study.

RESULTS

The prescription-reduction, dose/duration, and control groups included 601, 483, and 405 children, respectively. The interventions induced significantly larger decreases in antibiotic use in the prescription-reduction group (-18.8%) and dose/duration group (-17.1%) than in the control group (-3.8%), and the rates of PNSP colonization were initially similar for the 3 groups (52.5%, 55.1%, and 50.0%, respectively). At the end of the 5-month study, the rates of PNSP colonization were 34.5% for the prescription-reduction group (P=.05) and 44.3% for the dose/duration group (P=.8), compared with 46.2% for the control group.

CONCLUSIONS

Intensive educational strategies aimed at optimizing antibiotic use can significantly reduce the rate of PNSP colonization in areas with high resistance rates.

Effect of educational intervention on antibiotic prescription practices for upper respiratory infections in children: a multicentre study

OBJECTIVES

To evaluate the impact of an educational intervention on judicious antibiotic prescription for upper respiratory diseases in children.

METHODS

A multicentre before-and-after study was conducted in five major community child healthcentres in Israel. Antibiotic prescription data were collected for all visits of patients aged 3 months to 18 years with a diagnosis of acute otitis media, tonsillopharyngitis, sinusitis or upper respiratory tract infection from November 1999 through February 2000 (pre-intervention period) and from November 2000 through February 2001 (post-intervention period). The intervention consisted of a 1 day seminar on the diagnosis and judicious treatment of respiratory tract infections in children according to the recommendations of the Centers of Disease Control and Prevention. The patient files were reviewed for patient characteristics, specific respiratory disease, and specific antibiotics prescribed. The main outcome measures were the rates and appropriateness of antibiotic prescribing for the different respiratory diseases before and after an educational intervention for practising paediatricians.

RESULTS

A total of 4580 clinic visits were eligible for analysis in the pre-intervention period and 4364 in the post-intervention period. From the pre- to the post-intervention period, the odds ratio for appropriate antibiotic treatment was 1.8 for acute otitis media (95% CI 1.52-2.11, P < 0.01) and 1.35 for pharyngitis (95% CI 1.13-1.61, P < 0.01). Overall, use of antibiotics for acute otitis media decreased from 93% to 87.4% (P < 0.05), and for upper respiratory tract infection, from 13.8% to 11.5% (P < 0.05). There were no significant changes in these factors for sinusitis.

CONCLUSIONS

A targeted educational intervention can improve antibiotic prescription practices for respiratory infections in children and decrease unnecessary antibiotic use. Such studies can also pinpoint areas that require further attention.

Effectiveness of a parental educational intervention in reducing antibiotic use in children: a randomized controlled trial

OBJECTIVE

To determine whether an educational intervention aimed at parents leads to fewer antibiotic prescriptions for their children.

DESIGN

Placebo-controlled, randomized controlled trial.

SETTING

Offices of primary care pediatricians who are members of a regional practice-based research network.

PARTICIPANTS

Healthy children younger than 24 months old enrolled at the time of an office visit.

INTERVENTIONS

Parents of study children were randomized to receive either a pamphlet and videotape (featuring one of their child's pediatricians) promoting the judicious use of antibiotics (intervention group) or brochures about injury prevention (control group). A total of 499 eligible children were enrolled, and data on outpatient visits during a 12-month observation period were collected.

MAIN OUTCOME MEASURES

We compared the number of visits for upper respiratory tract infections (URIs), number of diagnoses and antibiotic prescriptions for otitis media and/or sinusitis and total number of antibiotics per patient among children in the intervention and control groups using Poisson regression analysis, adjusted for clustering into different practices.

RESULTS

: Data on 4924 visits were reviewed; 28.8% of these visits were because of URI symptoms. The mean number of visits per study patient for URI symptoms was 2.8. Including all visits, the mean number of diagnoses of otitis media in study children was 2.1, mean number of diagnoses of otitis media and/or sinusitis was 2.3 and mean number of antibiotic prescriptions was 2.4; there were no significant differences between children in the intervention and control groups for any of these outcomes. Overall physicians prescribed 1 or more antibiotics during 45.9% of visits for a chief complaint of URI symptoms; 92% of antibiotic usage in children presenting with URI symptoms was for a diagnosis of otitis media and/or sinusitis.

CONCLUSIONS

An educational intervention aimed at parents did not result in a decrease in the number of antibiotic prescriptions in their children. The use of antibiotics among children with URI symptoms was common; other interventions promoting the judicious use of these medications are needed.

Clinician knowledge and beliefs after statewide program to promote appropriate antimicrobial drug use

In 1999, Wisconsin initiated an educational campaign for primary care clinicians and the public to promote judicious antimicrobial drug use. We evaluated its impact on clinician knowledge and beliefs; Minnesota served as a control state. Results of pre- (1999) and post- (2002) campaign questionnaires indicated that Wisconsin clinicians perceived a significant decline in the proportion of patients requesting antimicrobial drugs (50% in 1999 to 30% in 2002; p<0.001) and in antimicrobial drug requests from parents for children (25% in 1999 to 20% in 2002; p = 0.004). Wisconsin clinicians were less influenced by nonpredictive clinical findings (purulent nasal discharge [p = 0.044], productive cough [p = 0.010]) in terms of antimicrobial drug prescribing. In 2002, clinicians from both states were less likely to recommend antimicrobial agent treatment for the adult case scenarios of viral respiratory illness. For the comparable pediatric case scenarios, only Wisconsin clinicians improved significantly from 1999 to 2002. Although clinicians in both states improved on several survey responses, greater overall improvement occurred in Wisconsin.

Modeling Community- and Individual-Level Effects of Child-Care Center Attendance on Pneumococcal Carriage

BACKGROUND

The prevalence of pneumococcal carriage varies widely across communities. This variation is not fully explained by risk factors at the individual level but may be explained by factors producing effects at both the individual and community levels, such as child-care center (CCC) attendance.

METHODS

We developed a transmission model to evaluate whether the combined risks of attending CCCs and associating with playmates who attend CCCs account for a large proportion of the variability in the prevalence of pneumococcal carriage across communities. We based parameters for the model on data from a multicommunity study.

RESULTS

According to our model, differences in the proportion of children who attend CCCs can account for a range of 4%-56% in the prevalence of pneumococcal carriage across communities. Our model, which was based on data collected from 16 Massachusetts communities, predicts that the odds of carriage associated with CCC attendance are 2-3 times the odds associated with no CCC attendance (individual-level effect). The model also predicts that the odds of carriage for nonattendees in a community with CCCs are up to 6 times the odds for children in a community without CCCs (community-level effect). In addition, the mean number of hours spent at CCCs by a single attendee appears to exert effects on pneumococcal carriage that are independent of either the proportion of CCC attendance in the community or the mean number of hours these attendees spend in child care.

CONCLUSIONS

We used data from multiple communities to develop a transmission model that explains marked differences in pneumococcal carriage across communities by variations in CCC attendance. This model only accounts for CCC attendance among young children and does not include other known risk factors for pneumococcal carriage.

The "minimizing antibiotic resistance in Colorado" project: impact of patient education in improving antibiotic use in private office practices

OBJECTIVE

To assess the marginal impact of patient education on antibiotic prescribing to children with pharyngitis and adults with acute bronchitis in private office practices.

DATA SOURCES/STUDY SETTING

Antibiotic prescription rates based on claims data from four managed care organizations in Colorado during baseline (winter 2000) and study (winter 2001) periods.

STUDY DESIGN

A nonrandomized controlled trial of a household and office-based patient educational intervention was performed. During both periods, Colorado physicians were mailed antibiotic prescribing profiles and practices guidelines as part of an ongoing quality improvement program. Intervention practices (n=7) were compared with local and distant control practices.

DATA COLLECTION/EXTRACTION METHODS

Office visits were extracted by managed care organizations using International Classification of Diseases-9-Clinical Modification codes for acute respiratory tract infections, and merged with pharmacy claims data based on visit and dispensing dates coinciding within 2 days.

PRINCIPAL FINDINGS

Adjusted antibiotic prescription rates during baseline and study periods increased from 38 to 39 percent for pediatric pharyngitis at the distant control practices, and decreased from 39 to 37 percent at the local control practices, and from 34 to 30 percent at the intervention practices (p=.18 compared with distant control practices). Adjusted antibiotic prescription rates decreased from 50 to 44 percent for adult bronchitis at the distant control practices, from 55 to 45 percent at the local control practices, and from 60 to 36 percent at the intervention practices (p<.002 and p=.006 compared with distant and local control practices, respectively).

CONCLUSIONS

In office practices, there appears to be little room for improvement in antibiotic prescription rates for children with pharyngitis. In contrast, patient education helps reduce antibiotic use for adults with acute bronchitis beyond that achieved by physician-directed efforts.

Non-antibiotic treatment recommendations: delivery formats and implications for parent resistance

This study draws on a database of 570 community-based acute pediatric encounters in the USA and uses conversation analysis as a methodology to identify two formats physicians use to recommend non-antibiotic treatment in acute pediatric care (using a subset of 309 cases): recommendations for particular treatment (e.g., "I'm gonna give her some cough medicine.") and recommendations against particular treatment (e.g., "She doesn't need any antibiotics."). The findings are that the presentation of a specific affirmative recommendation for treatment is less likely to engender parent resistance to a non-antibiotic treatment recommendation than a recommendation against particular treatment even if the physician later offers a recommendation for particular treatment. It is suggested that physicians who provide a specific positive treatment recommendation followed by a negative recommendation are most likely to attain parent alignment and acceptance when recommending a non-antibiotic treatment for a viral upper respiratory illness.

A Multifaceted Intervention to Improve Antimicrobial Prescribing for Upper Respiratory Tract Infections in a Small Rural Community

BACKGROUND

Antibiotic prescribing for upper respiratory tract infections (URTIs) is widespread, is often inappropriate, and may contribute to antibiotic resistance among community-acquired pathogens, such as Streptococcus pneumoniae.

METHODS

A multifaceted intervention involving health care professionals and patients was introduced to a small rural Utah community and included the repetitive use of printed diagnostic and treatment algorithms by professionals. Data on the quantity and class of antibiotic prescribing, which were collected from multiple sources, were measured for the intervention period (from January through June) in 2001 and compared with data for the baseline period during the same months in 2000.

RESULTS

Medicaid claims data revealed that the percentage of patients in the community who received antibiotics for URTIs during the intervention period was 15.6% less than that for the baseline period, whereas the percentage in the rest of rural Utah was relatively stable, with a 1.5% decrease (P=.006). The greatest impact of the intervention was on prescribing for acute bronchitis (decreases of 56.1% and 1.7% in the community and rural Utah, respectively; P=.024) and on prescribing of macrolides (decreases of 13.4% and 0.2% in the community and rural Utah, respectively; P<.001). Community pharmacy data likewise revealed a 17.5% decrease in the rate of antibiotic prescribing during the intervention period (P<.001), with the largest decrease observed for macrolide prescribing (50.9%; P<.001). Chart review data, in contrast, revealed no significant decrease in the percentage of patients with URTI who were prescribed an antibiotic (3.8%; P=.49), although there was a significant decrease of 11.2% in macrolide use (P=.045).

CONCLUSIONS

A multifaceted intervention involving the repetitive use of printed algorithms resulted in modest improvements in antibiotic prescribing for outpatient URTIs, although one data source did not corroborate this. However, macrolide prescribing decreased sharply, irrespective of the source of data.

Parent resistance to physicians' treatment recommendations: one resource for initiating a negotiation of the treatment decision

This article examines pediatrician-parent interaction in the context of acute pediatric encounters for children with upper respiratory infections. Parents and physicians orient to treatment recommendations as normatively requiring parent acceptance for physicians to close the activity. Through acceptance, withholding of acceptance, or active resistance, parents have resources with which to negotiate for a treatment outcome that is in line with their own wants. This article offers evidence that even in acute care, shared decision making not only occurs but, through normative constraints, is mandated for parents and physicians to reach accord in the treatment decision.

Changes before and after a policy to restrict antimicrobial usage in upper respiratory infections in Taiwan

The Bureau of National Health Insurance (BNHI) of Taiwan issued a new reimbursement regulation effective from 1 February 2001 forbidding the use of antimicrobials in ambulatory patients with upper respiratory infections (URI) without evidence of bacterial infection. We evaluated the effect of this regulation by analysing changes in the types of infections diagnosed and the amount of antibiotics prescribed in 1999, 2000 and 2001. Between 1999 and 2001, antimicrobials for respiratory infections decreased from 18.0 to 9.97 DDD/1000 per day or by 44.6% (P=0.0000+). Antimicrobials for URI decreased from 8.32 in 1999 to 3.28 DDD/1000 per day in 2001 or by 60.6% (P=0.0000+); from 2000 to 2001 the decrease was 55.8%. Reduction of antimicrobials for URI from 1999 to 2001 accounted for 62.8% of the reduction of antimicrobials in respiratory infections or 51.3% of the total reduction of antimicrobials. Reduction in aminopenicillins was responsible for most of the decrease.

Promoting appropriate antibiotic use for pediatric patients: a social ecological framework

During the 1990s, the number of prescriptions for antibiotics for children and adolescents finally decreased after more than a decade of alarming increases. The Centers for Disease Control and Prevention (CDC) and many other groups have designed and implemented interventions to promote appropriate prescribing of antibiotics, and these efforts appear to have contributed to recent decreases in rates of such prescribing. In this article, we describe the various types of interventions that the CDC and others are using to encourage appropriate use of antibiotics. A social ecological framework is used to describe the various factors contributing to prescribing and using antibiotics, as well as the interventions used for targeting these factors. Although most efforts promoting appropriate use of antibiotics have focused on reducing such use for viral infections, future efforts also should include a focus on ensuring the use of targeted agents when antibiotics are indicated.

Limited spread of penicillin-nonsusceptible pneumococci, Skåne County, Sweden

In response to increasing frequencies of penicillin-nonsusceptible pneumococci (PNSP), for which the MIC of penicillin was >0.12 mg/L, in Skåne County, southern Sweden, national recommendations were initiated in 1995 to limit the spread of pneumococci with high MICs (> or =0.5 mg/L) of penicillin (PRP), especially among children of preschool age. Traditional communicable disease control measures were combined with actions against inappropriate antimicrobial drug use. During the first 6 years that these recommendations were applied in Skåne County, the average frequency of penicillin-resistant pneumococci has been stable at =2.6%, as has the average PNSP frequency (7.4%). However, PNSP have been unevenly distributed in the county, with the highest frequencies in the southwest. Simultaneously, the rate of antimicrobial drug use for children <6 years of age was reduced by 20%. Thus the spread of PNSP between and within the municipalities in the county has been limited.

Penicillin and macrolide resistance in pneumococcal pneumonia: does in vitro resistance affect clinical outcomes?

In vitro resistance to antimicrobial agents is escalating among pathogens responsible for the most serious respiratory tract infections. Some reports have suggested that this has direct clinical implications. Because of penicillin and macrolide resistance in Streptococcus pneumoniae, current guidelines for the initial treatment of respiratory tract infections advocate less reliance on the use of either of these classes of drugs in single-agent therapy. Recent studies that have assessed the impact of beta -lactam and macrolide resistance on clinical outcomes in community-acquired pneumonia fail to provide incontrovertible evidence for a direct link between in vitro resistance and treatment failure. However, there are anecdotal reports of breakthrough bacteremia due to macrolide-resistant pneumococci among patients receiving macrolide therapy, unlike the situation for beta -lactams and penicillin-resistant pneumococci. Continued efforts, including in vitro surveillance, appropriate antibiotic use campaigns, and immunization programs, will be important in limiting the spread of drug-resistant S. pneumoniae.

Antibiotic Resistance in Streptococcus pneumoniae: What Does the Future Hold?

The recent emergence of strains of drug-resistant Streptococcus pneumoniae (DRSP) is a serious clinical and public health problem. Several interventions have been proposed to limit the further emergence and spread of DRSP, including campaigns for appropriate antibiotic use and the introduction of pneumococcal conjugate vaccines. Whether the current epidemic of drug resistance in S. pneumoniae is sustainable or will succumb to current efforts to limit its spread will be decided by an interaction of factors related to the pathogen (i.e., the relative fitness of the resistant strains), to the prescription of antibiotic treatment (i.e., changes in selection pressure), and to the host (i.e., the ability to slow the transmission of DRSP). Much investigation is still needed to better ascertain how maintenance of DRSP strains in the community at large is influenced by each factor and affected by current interventions that are based on these factors.

The Development of an Antimicrobial Stewardship Program at a Pediatric Hospital

This continuing feature will focus on recent advancements in the areas of pediatrics and neonatal pharmacology and on methods for reducing medication error risk in this patient population. Most pharmacological agents are designed with the adult in mind, and there is little literature-based data from which to derive dosing schedules and proper drug administration techniques for the pediatric and neonatal patient. Moreover, pharmacological response in this group is not well understood. We hope that this feature will help you provide pharmaceutical care to this high-risk population. Direct questions or comments to hospitalpharmacy@drugfacts.com .

Antibiotic treatment of acute respiratory tract infections in the elderly: effect of a multidimensional educational intervention

OBJECTIVES

: To measure and improve antibiotic use for acute respiratory tract infections (ARIs) in the elderly.

DESIGN

: Prospective, nonrandomized controlled trial.

SETTING

: Ambulatory office practices in Denver metropolitan area (n=4 intervention practices; n=51 control practices).

PARTICIPANTS

: Consecutive patients enrolled in a Medicare managed care program who were diagnosed with ARIs during baseline (winter 2000/2001) and intervention (winter 2001/2002) periods. A total of 4,270 patient visits were analyzed (including 341 patient visits in intervention practices).

INTERVENTION

: Appropriate antibiotic use and antibiotic resistance educational materials were mailed to intervention practice households. Waiting and examination room posters were provided to intervention office practices.

MEASUREMENTS

: Antibiotic prescription rates, based on administrative office visit and pharmacy data, for total and condition-specific ARIs.

RESULTS

: There was wide variation in antibiotic prescription rates for ARIs across unique practices, ranging from 21% to 88% (median=54%). Antibiotic prescription rates varied little by patient age, sex, and underlying chronic lung disease. Prescription rates varied by diagnosis: sinusitis (69%), bronchitis (59%), pharyngitis (50%), and nonspecific upper respiratory tract infection (26%). The educational intervention was not associated with greater reduction in antibiotic prescription rates for total or condition-specific ARIs beyond a modest secular trend (P=.79).

CONCLUSION

: Wide variation in antibiotic prescription rates suggests that quality improvement efforts are needed to optimize antibiotic use in the elderly. In the setting of an ongoing physician intervention, a patient education intervention had little effect. Factors other than patient expectations and demands may play a stronger role in antibiotic treatment decisions in elderly populations.

Educational interventions to improve antibiotic use in the community: report from the International Forum on Antibiotic Resistance (IFAR) colloquium, 2002

National and international strategies for the control of antibiotic resistance recommend education for health-care professionals and the public to promote prudent antibiotic use. This paper, based on discussions at the 2002 colloquium of the International Forum on Antibiotic Resistance (IFAR), provides an international discourse between theoretical approaches to behaviour change and practical experience gained in large-scale antibiotic use educational campaigns. Interventions are more likely to be effective if their aim is to change behaviour, rather than provide information. They should target all relevant groups, especially parents, children, day-care staff, and health-care professionals. They should use clear and consistent messages concerning bacterial versus viral infection, prudent antibiotic use, symptomatic treatment, and infection-control measures (eg, handwashing). Campaigns should use a range of communications using pilot-testing, strong branding, and sociocultural adaptation. Prime-time television is likely to be the most effective public medium, while academic detailing is especially useful for health-care professionals. Multifaceted interventions can improve antibiotic prescribing to some degree. However, there are few data on their effects on resistance patterns and patient outcomes, and on their cost-effectiveness. Current research aims include the application of behaviour-change models, the development and validation of prudent antibiotic prescribing standards, and the refinement of tools to assess educational interventions.

Trends in antimicrobial prescribing for bronchitis and upper respiratory infections among adults and children

OBJECTIVES

This study examined antimicrobial prescribing patterns for adults and children with bronchitis or upper respiratory infections (URIs) before and after release of nationally disseminated pediatric practice recommendations.

METHODS

Data from the 1993, 1995, 1997, and 1999 National Ambulatory Medical Care Survey were used to evaluate prescriptions for antimicrobials for URIs and bronchitis.

RESULTS

From 1993 to 1999, the proportion of children receiving antimicrobials after visits for URIs and bronchitis decreased. However, the use of broad-spectrum antimicrobials rose from 10.6% of bronchitis visits to 40.5%. Prescriptions of antimicrobials for adults with URIs or bronchitis showed a decrease between 1993 and 1999.

CONCLUSIONS

Although antimicrobial prescribing for URIs and bronchitis has decreased for both children and adults, the prescribing of broad-spectrum antibiotics among children has shown a proportional rise.

Appropriate antibiotic use and why it is important: the challenges of bacterial resistance

After the introduction of antibiotics in the mid-20th century, clinicians soon witnessed clinical failures secondary to bacterial resistance. Despite scientists' efforts to synthesize more potent antibiotics during the last five decades, bacterial resistance continues to evolve, in large part because of the overuse and misuse of antibiotics. The treatment of several pathogens, including methicillin-resistant Staphylococcus aureus, penicillin-resistant Streptococcus pneumoniae and vancomycin-resistant enterococci, is problematic. New solutions are needed to preserve the activity of our current antibiotic armamentarium, to lower the overall risk of bacterial resistance and to successfully treat patients with resistant bacterial infections. Options include: development of new antibiotics to treat resistant organisms; vaccination to prevent infections; and improved use of antibiotics. Because bacteria will eventually develop means to avoid being killed by antibiotics, judicious use of antibiotics by all clinicians is imperative. Appropriate antibiotic use involves selection of a "targeted spectrum" antibiotic, as well as an appropriate dose and duration.

Antibiotic use in Hispanic households, New York city

Trained interviewers visited 631 inner city households to determine community prevalence and predictors of antibiotic use. Infectious disease symptoms were reported in 911 (33.2%) of 2,743 household members in the previous 30 days: medical attention was sought by 441 (48.4%) of 911 persons, and 354 (38.9%) of 911 took antibiotics for symptoms. Reported symptoms were respiratory (68.9%), gastrointestinal (15.3%), fever (12.8%), and skin infection (2.8%). Medical attention was sought significantly more often among those with chronic illness, those born in the United States, and those with fever, runny nose, or skin infections (all p<0.05). Antibiotics were taken significantly more often among those with poor health, those who spent more time at home, and those with fever and respiratory symptoms. Interventions to promote judicious use of antibiotics must include clinicians and the public, and for the Hispanic population such interventions must also be culturally relevant and provided in Spanish.

Consumer attitudes and use of antibiotics

Recent antibiotic use is a risk factor for infection or colonization with resistant bacterial pathogens. Demand for antibiotics can be affected by consumers' knowledge, attitudes, and practices. In 1998-1999, the Foodborne Diseases Active Surveillance Network (FoodNet( conducted a population-based, random-digit dialing telephone survey, including questions regarding respondents' knowledge, attitudes, and practices of antibiotic use. Twelve percent had recently taken antibiotics; 27% believed that taking antibiotics when they had a cold made them better more quickly, 32% believed that taking antibiotics when they had a cold prevented more serious illness, and 48% expected a prescription for antibiotics when they were ill enough from a cold to seek medical attention. These misguided beliefs and expectations were associated with a lack of awareness of the dangers of antibiotic use; 58% of patients were not aware of the possible health dangers. National educational efforts are needed to address these issues if patient demand for antibiotics is to be reduced.

Increased diagnosis of Lemierre syndrome and other Fusobacterium necrophorum infections at a Children's Hospital

OBJECTIVE

To assess the apparent increase in the diagnosis of Lemierre syndrome (LS) and other Fusobacterium necrophorum infections at a large children's hospital. Infections with F necrophorum ranged from peritonsillar abscess to potentially fatal LS. LS is an oropharyngeal infection characterized by septic thrombophlebitis of head and neck veins, complicated by dissemination of septic emboli to pulmonary and systemic sites.

METHODS

Review of the medical and laboratory records was conducted of all patients who were seen at or admitted to the Children's Hospital of Wisconsin with the diagnosis of LS and/or isolation of F necrophorum from a clinical specimen between January 1995 and January 2002.

RESULTS

During the 7-year period of the study, there was an increase in the isolation of F necrophorum from patients who were seen at Children's Hospital of Wisconsin, as well as the number of cases of LS. There was 1 isolation of F necrophorum from clinical specimens per year from 1996 to 1999, which increased to 10 isolates of the organism from January 2000 to January 2002. During the most recent period, January 2001-January 2002, 5 cases of LS were diagnosed, a distinctive entity not recognized previously at the institution.

CONCLUSIONS

The cause for the recent increase in the number of serious infections caused by F necrophorum infection diagnosed at our institution is unclear but does not seem to be related to changes in microbiologic techniques or patient demography. We speculate that it could be attributable, in part, to alterations in antibiotic usage patterns in our region. Clinicians need to be aware of the increasing clinical importance of F necrophorum infections and the life-threatening nature of LS.

Antibiotic-resistant Streptococcus pneumoniae in the heptavalent pneumococcal conjugate vaccine era: predictors of carriage in a multicommunity sample

OBJECTIVE

Despite immunization with heptavalent pneumococcal conjugate vaccine (PCV7), the rising prevalence of antibiotic resistance makes Streptococcus pneumoniae a continuing threat to child health. Data on carriage of resistant organisms by healthy children in communities in which immunization with PCV7 has been implemented will help to define and decrease these risks further.

METHODS

Children who were <7 years old, resided in a study community, and presented for routine well care or a "sick" visit between March 13 and May 11, 2001, at 31 primary care practices in 16 geographically distinct Massachusetts communities were studied. Consenting parents provided demographic information and data on potential risk factors for carriage of S pneumoniae and of penicillin-nonsusceptible S pneumoniae (PNSP). S pneumoniae isolates from nasopharyngeal specimens were tested for resistance to commonly used antibiotics including penicillin, ceftriaxone, erythromycin, and trimethoprim/sulfamethoxazole. Isolates were serotyped and grouped into PCV7-included serotypes, potentially cross-reactive serotypes (ie, an organism of a serogroup included in the vaccine), or non-PCV7 serotypes. Diagnosis on the day of collection, history of recent antibiotic use, and history of PCV7 immunization were obtained by chart review. Separate bivariate and multivariate analyses were performed to identify correlates of colonization with S pneumoniae and colonization with PNSP, accounting for clustering within communities.

RESULTS

S pneumoniae was isolated from the nasopharynx of 190 (26%) of the 742 children studied. Of the 166 tested, 33% were nonsusceptible to penicillin, with 14% showing intermediate susceptibility (minimum inhibitory concentration [MIC] 0.12-1.0) and 19% fully resistant (MIC > or =2). Nonsusceptibility to other antibiotics was common, including ceftriaxone (14%), erythromycin (22%), and trimethoprim/sulfa (31%); 20% of S pneumoniae isolates were not susceptible to > or =3 antibiotics. Thirty-six percent of isolates were of serotypes covered by PCV7; 30% were of PCV7 serogroups and potentially cross-reactive, but not 1 of the 7 included serotypes; and 34% were unrelated to PCV7 serogroups. Nonsusceptibility to penicillin was more common in PCV7-included strains (45%) and potentially cross-reactive strains (51%) than in non-PCV7 serotypes (8%). Risk factors for PNSP colonization included child care attendance (odds ratio [OR]: 3.9; 95% confidence interval [CI]: 2.3-6.5), current respiratory tract infection (OR: 4.7; 95% CI: 2.5-8.6), and recent antibiotic use (OR: 1.7; 95% CI: 1.0-2.8). PCV7 immunization was associated with decreased carriage of PCV7-included serotypes but not with an overall decrease in S pneumoniae colonization or with a decline in PNSP colonization.

CONCLUSIONS

In this multicommunity sample, pneumococcal antibiotic resistance was common and was most frequently found in PCV7-included and PCV7 serogroup strains. The long-term impact of PCV7 immunization will be partially determined by the protection that it affords against invasive infection with potentially cross-reactive serotypes, as well as the virulence and future resistance patterns of unrelated serotypes.

[Survey of the judicious use of antibiotics in primary care]

OBJECTIVE

To identify pediatricians' antibiotic prescribing habits in acute otitis media and tonsillopharyngitis and to determine the interaction between parents and pediatricians concerning antibiotic use in the Autonomous Community of Valencia (Spain).

METHOD

Four hundred members of the Valencian Society of Pediatrics were randomly selected. A semi-structured questionnaire with non-excluding answers was sent by mail and, when responses were not obtained, a second one was sent. The confidentiality of the information was guaranteed.

RESULTS

Of 400 questionnaires sent, 143 (35.8 %) were completed; 88.1 % were completed by pediatricians and 51.1 % by primary care workers. A total of 48.3 % of pediatricians used antibiotics in all cases of acute otitis media and 94.5 % prescribed them when fever and otalgia persisted for more than 48 hours. Amoxicillin-clavulanate was the most frequently prescribed antibiotic (63.6 %). Less than 10 % of pediatricians prescribed antibiotics as empirical treatment in tonsillopharyngitis; amoxicillin was the most frequently prescribed antibiotic (54.6 %). Indications for antibiotic treatment were fever, odynophagia and adenomegaly (69.5 %) and tonsillar exudate (62.5 %). Inappropriate antibiotic use was mainly due to excess workload. Providing health education to parents could be the best way of reducing inappropriate use.

CONCLUSIONS

Antibiotic use is frequent in the treatment of acute otitis media. Amoxicillin-clavulanate and amoxicillin were the most frequently prescribed antibiotics in tonsillopharyngitis. Providing health education to parents and reducing pediatricians' workload would decrease inappropriate antibiotic use.

Combating bacterial resistance in otorhinolaryngology

Bacterial resistance appears to be an ever-increasing problem and is threatening to spiral out of control. The scare caused by the rapid spread of methicillin-resistant Staphylococcus aureus among hospitals in the UK is the most recent. Otorhinolaryngology is deeply involved in this problem, as one of the reasons often cited for increasing bacterial resistance is the use of antibiotics in suspected bacterial infections in ear, nose and throat by primary care physicians. This speciality is also involved in the development of guidelines for antimicrobial use by primary and secondary care. This review attempts to discuss the reason for the development of antimicrobial resistance especially in relation to otorhinolaryngology, what can be done to contain this menace and the surveillance system developed to monitor the trend in the development of bacterial resistance.

Decreased number of antibiotic prescriptions in office-based settings from 1993 to 1999 in children less than five years of age

OBJECTIVE

Increasing rates of antibiotic resistance have stimulated efforts to decrease antibiotic use. To assess the success of these efforts, we analyzed antibiotic prescribing trends in children younger than 5 years old, the group with the highest use, from 1993 to 1999.

METHODS

Data from the National Ambulatory Medical Care Survey were analyzed to determine antibiotic prescribing patterns for office-based visits from 1993 to 1999 for children <5 years old. Data were stratified by US regions, patient's race and gender. Antibiotic prescription rates per 1,000 population were calculated with population data from the US Census Bureau as the denominator. Specific prescribing of penicillins, cephalosporins, macrolides and sulfas was also assessed.

RESULTS

Overall antibiotic prescribing in the office-based setting peaked in 1995 at 1,191 antibiotic courses per 1,000 children, then declined to 698 per 1,000 in 1999, a decrease of 41%. Antibiotic prescribing was consistently higher in whites than blacks; however, declines in prescribing over time were observed in both groups. Although there was wide regional variation in antibiotic prescribing in the early 1990's, by the late 1990's prescribing rates were similar in all regions. Prescriptions for penicillins and cephalosporins combined comprised 77 and 70% of total prescriptions during 1993 to 1997 and 1998 to 1999, respectively. Macrolide prescriptions reached a nadir during 1993 to 1997, accounting for 9% of the total, but increased to 16% during 1998 to 1999.

CONCLUSION

Since 1995 the rates of antibiotic prescriptions in children <5 years of age have declined substantially. At the same time changes have occurred in the types of antibiotics prescribed. It appears that efforts to reduce antibiotic use have been successful. Whether this decrease in use will be accompanied by lower rates of antibiotic resistance will need to be determined.

Changes in antibiotic-prescribing practices and carriage of penicillin-resistant Streptococcus pneumoniae: A controlled intervention trial in rural Alaska

From 1998 to 2000, 13 rural Alaskan villages (population, 3326) were surveyed annually by nasopharyngeal cultures for Streptococcus pneumoniae carriage. Data regarding antibiotic use for the entire population was abstracted from clinic records. In 1999, education of medical providers and the community about appropriate antibiotic use began in 4 villages; this program was expanded to include all villages in 2000. Antibiotic courses per person decreased by 31% in the initial intervention villages and by 35% in the remaining villages after education (P<.01 for each). Samples were obtained for culture from a mean of 31% of the population each year; 31% carried pneumococcus. No sustained decrease in carriage of penicillin-nonsusceptible strains was observed. When linear regression was used, serotype accounted for 81% of the variance in pneumococcal minimum inhibitory concentrations after the intervention, compared with 7% for antibiotic use. This suggests that reducing the carriage of serotypes associated with antibiotic resistance by use of pneumococcal conjugate vaccines may have a greater short-term impact than does decreasing antibiotic use.