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Efficacy and Safety of 5-Day Challenge for the Evaluation of Nonsevere Amoxicillin Allergy in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1673-1680. [PMID: 29425903 DOI: 10.1016/j.jaip.2018.01.030] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 01/17/2018] [Accepted: 01/28/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Penicillin allergy is the most frequent drug allergy, among which aminopenicillins are reputed for causing delayed rashes in children, particularly in the context of viral infections. Despite a negative allergy evaluation, a significant proportion of individuals continue to avoid penicillin antibiotics for fear of an allergic reaction. OBJECTIVE To evaluate the safety and efficacy of a 5-day challenge to amoxicillin and the proportion of subsequent use of amoxicillin. METHODS Pediatric patients with a history of a reaction to amoxicillin were prospectively recruited in the study. All patients were challenged, and those with negative immediate challenges underwent an ambulatory 5-day challenge to amoxicillin to rule out nonimmediate reactions. Patients were called 2 years after their initial allergy evaluation to assess subsequent amoxicillin use and tolerance. RESULTS One hundred thirty children with a history of amoxicillin allergy underwent a graded drug provocation test (DPT) to amoxicillin. Three patients had a positive immediate challenge, 3 had a positive nonimmediate challenge, and 2 were equivocal. Of the 122 patients with a negative challenge, 114 (93.4%) were reached 2 years after their initial allergy evaluation: 75 had used antibiotics since, of which only 1 (1.3%) had refused to reuse amoxicillin because of fear of an allergic reaction. Finally, the 5-day DPT resulted in a 24.1% decrease in future penicillin avoidance compared with classical single-dose graded DPT performed for 1 day in a historical cohort (P < .0001). CONCLUSION The 5-day challenge is a safe and effective way to rule out nonimmediate amoxicillin allergy, and it ensures better compliance with future penicillin use.
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Variations in Antibiotic and Azithromycin Prescribing for Children by Geography and Specialty-United States, 2013. Pediatr Infect Dis J 2018; 37:52-58. [PMID: 28746259 PMCID: PMC6622452 DOI: 10.1097/inf.0000000000001708] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Using antibiotics appropriately is critical to slow spread of antibiotic resistance, a major public health problem. Children, especially young children, receive more antibiotics than other age groups. Our objective was to describe antibiotic use in children in the United States and use of azithromycin, which is recommended infrequently for pediatric conditions. METHODS We used QuintilesIMS Xponent 2013 data to calculate the number and rate of oral antibiotic prescriptions for children by age (0-2, 3-9 and 10-19 years) and agent. We used log-binomial regression to calculate adjusted prevalence ratios and 95% confidence intervals to determine if specialty and patient age were associated with azithromycin selection when an antibiotic was prescribed. RESULTS In 2013, 66.8 million antibiotics were prescribed to US children ≤19 years of age (813 antibiotic prescriptions per 1000 children). Amoxicillin and azithromycin were the 2 most commonly prescribed agents (23.1 million courses, 35% of all antibiotics; 12.2 million, 18%, respectively). Most antibiotics for children were prescribed by pediatricians (39%) and family practitioners (15%). Family practitioners were more likely to select azithromycin when an antibiotic was prescribed in all age groups than pediatricians (for children 0-2 years of age: prevalence ratio: 1.79, 95% confidence interval: 1.78-1.80; 3-9 years: 1.40, 1.40-1.40 and 10-19 years: 1.18, 1.18-1.18). CONCLUSION Despite infrequent pediatric recommendations, variations in pediatric azithromycin use may suggest inappropriate antibiotic selection. Public health interventions focused on improving antibiotic selection in children as well as reducing antibiotic overuse are needed.
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Antibiotic Prescribing Patterns Across the Continuum of Care for Children Hospitalized With Community-Acquired Pneumonia. Pediatr Emerg Care 2018; 34:e7-e10. [PMID: 26555311 DOI: 10.1097/pec.0000000000000598] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to describe the variation in antibiotic prescribing practices for uncomplicated community-acquired pneumonia across the continuum of care for hospitalized pediatric patients to better inform future efforts at standardizing antibiotic therapy throughout a single hospitalization. METHODS This is a retrospective cohort study involving 4 hospitals caring for children aged 3 months to 18 years, hospitalized between January 1, 2011, and December 31, 2012, with diagnosis of uncomplicated pneumonia and without complex chronic medical conditions.Data collected include antibiotics prescribed before hospitalization, at the emergency department (ED) encounter, during hospitalization, and at hospital discharge. RESULTS Six hundred nine children met inclusion criteria, with a mean age of 5.3 years and median length of stay of 2 days. Emergency department providers prescribed narrow-spectrum therapy 27% of the time, whereas discharging providers prescribed narrow-spectrum therapy 56% of the time. Third- and fourth-generation cephalosporins were less often prescribed in the preadmission setting and at discharge but were more often prescribed in the ED and inpatient setting. There was an association between inpatient prescription of broad-spectrum antibiotics when a blood culture was obtained, when broad-spectrum antibiotics were prescribed in the ED, and with increasing length of stay. CONCLUSION Broad-spectrum antibiotic therapy for community-acquired pneumonia, especially third- and fourth-generation cephalosporins, often originates in the ED. When initiated in this setting, it is likely to be continued in the inpatient setting.
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Logan LK, Gandra S, Mandal S, Klein EY, Levinson J, Weinstein RA, Laxminarayan R. Multidrug- and Carbapenem-Resistant Pseudomonas aeruginosa in Children, United States, 1999-2012. J Pediatric Infect Dis Soc 2017; 6:352-359. [PMID: 27856730 PMCID: PMC5907855 DOI: 10.1093/jpids/piw064] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 09/27/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pseudomonas aeruginosa is a common cause of healthcare-associated infection. Multidrug-resistant (MDR) (>3 classes) and carbapenem-resistant (CR) P aeruginosa are significant threats globally. We used a large reference-laboratory database to study the epidemiology of P aeruginosa in children in the United States. METHODS Antimicrobial susceptibility data from the Surveillance Network were used to phenotypically identify MDR and CR P aeruginosa isolates in children aged 1 to 17 years between January 1999 and July 2012. Logistic regression analysis was used to calculate trends in the prevalence of MDR and CR P aeruginosa. Isolates from infants (<1 year old) and patients with cystic fibrosis were excluded. RESULTS Among the isolates tested, the crude proportion of MDR P aeruginosa increased from 15.4% in 1999 to 26% in 2012, and the proportion of CR P aeruginosa increased from 9.4% in 1999 to 20% in 2012. The proportion of both MDR and CR P aeruginosa increased each year by 4% (odds ratio [OR], 1.04 [95% confidence interval (CI), 1.03-1.04] and 1.04 [95% CI, 1.04-1.05], respectively). In multivariable analysis, both MDR and CR P aeruginosa were more common in the intensive care setting, among children aged 13 to 17 years, in respiratory specimens, and in the West North Central region. In addition, resistance to other antibiotic classes (aminoglycosides, fluoroquinolones, cephalosporins, and piperacillin-tazobactam) often used to treat P aeruginosa increased. CONCLUSIONS Rates of MDR and CR P aeruginosa infection in children are rising nationally. Aggressive prevention strategies, including instituting antimicrobial stewardship programs in pediatric settings, are essential for combating antimicrobial resistance.
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Affiliation(s)
- Latania K Logan
- Departments of Pediatrics
- Section of Pediatric Infectious Diseases, Rush Medical College, Rush University Medical Center, Chicago, Illinois
- Cook County Health and Hospitals System, Chicago, Illinois
| | - Sumanth Gandra
- Center for Disease Dynamics, Economics & Policy, Washington, DC
| | | | - Eili Y Klein
- Center for Disease Dynamics, Economics & Policy, Washington, DC
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jordan Levinson
- Center for Disease Dynamics, Economics & Policy, Washington, DC
| | - Robert A Weinstein
- Internal Medicine, Division of Infectious Diseases
- Cook County Health and Hospitals System, Chicago, Illinois
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, Washington, DC
- Public Health Foundation of India, New Delhi
- Princeton University, Princeton, New Jersey
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MacGeorge EL, Smith RA, Caldes EP, Hackman NM. Toward Reduction in Antibiotic Use for Pediatric Otitis Media: Predicting Parental Compliance with "Watchful Waiting" Advice. JOURNAL OF HEALTH COMMUNICATION 2017; 22:867-875. [PMID: 29077540 DOI: 10.1080/10810730.2017.1367337] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
"Watchful waiting" (WW) can reduce unnecessary antibiotic use in the treatment of pediatric otitis media (ear infection), but the utility of the strategy is impaired by underutilization and noncompliance. Guided by advice response theory (ART), the current study examines how parental compliance with WW and trust in the prescribing physician is predicted by evaluative and affective responses to the advice. Parents (N = 134) of at least one child aged 5 years or younger completed questionnaires that assessed responses to WW advice they received for their youngest child. Perceptions of the advantage from and capacity to undertake WW, the child's level of pain, and the tact (autonomy-granting politeness) of the health care provider predicted compliance and provider trust both directly and indirectly, through advice quality and negative affect. The study suggests modifications to ART that will extend its scope and provides practical guidance for health care providers seeking to improve parent compliance with WW advice.
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Affiliation(s)
- Erina L MacGeorge
- a Department of Communication Arts and Sciences , Pennsylvania State University , University Park , Pennsylvania , USA
| | - Rachel A Smith
- a Department of Communication Arts and Sciences , Pennsylvania State University , University Park , Pennsylvania , USA
| | - Emily P Caldes
- a Department of Communication Arts and Sciences , Pennsylvania State University , University Park , Pennsylvania , USA
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106
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Wang F, Tian Y, Chen L, Luo R, Sickler J, Liesenfeld O, Chen S. Accurate Detection of Streptococcus pyogenes at the Point of Care Using the cobas Liat Strep A Nucleic Acid Test. Clin Pediatr (Phila) 2017; 56:1128-1134. [PMID: 28006981 DOI: 10.1177/0009922816684602] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The performance of a polymerase chain reaction-based point-of-care assay, the cobas Strep A Nucleic Acid Test for use on the cobas Liat System (cobas Liat Strep A assay), for the detection of group A Streptococcus bacteria was evaluated in primary care settings. Throat swab specimens from 427 patients were tested with the cobas Liat Strep A assay and a rapid antigen detection test (RADT) by existing medical staff at 5 primary care clinics, and results were compared with bacterial culture. The cobas Liat Strep A assay demonstrated equivalent sensitivity (97.7%) and specificity (93.3%) to reference culture with a 15-minute turnaround time. In comparison to RADTs, the cobas Liat Strep A assay showed improved sensitivity (97.7% Liat vs 84.5% RADT). The Clinical Laboratory Improvement Amendments-waived cobas Liat Strep A assay demonstrated the ease of use and improved turnaround time of RADTs along with the sensitivity of culture.
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Affiliation(s)
| | - Yu Tian
- 1 Roche Molecular Systems, Marlborough, MA, USA
| | | | - Robert Luo
- 2 Roche Molecular Systems, Pleasanton, CA, USA
| | | | | | - Shuqi Chen
- 1 Roche Molecular Systems, Marlborough, MA, USA
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107
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Ruiz VE, Battaglia T, Kurtz ZD, Bijnens L, Ou A, Engstrand I, Zheng X, Iizumi T, Mullins BJ, Müller CL, Cadwell K, Bonneau R, Perez-Perez GI, Blaser MJ. A single early-in-life macrolide course has lasting effects on murine microbial network topology and immunity. Nat Commun 2017; 8:518. [PMID: 28894149 PMCID: PMC5593929 DOI: 10.1038/s41467-017-00531-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 07/05/2017] [Indexed: 12/17/2022] Open
Abstract
Broad-spectrum antibiotics are frequently prescribed to children. Early childhood represents a dynamic period for the intestinal microbial ecosystem, which is readily shaped by environmental cues; antibiotic-induced disruption of this sensitive community may have long-lasting host consequences. Here we demonstrate that a single pulsed macrolide antibiotic treatment (PAT) course early in life is sufficient to lead to durable alterations to the murine intestinal microbiota, ileal gene expression, specific intestinal T-cell populations, and secretory IgA expression. A PAT-perturbed microbial community is necessary for host effects and sufficient to transfer delayed secretory IgA expression. Additionally, early-life antibiotic exposure has lasting and transferable effects on microbial community network topology. Our results indicate that a single early-life macrolide course can alter the microbiota and modulate host immune phenotypes that persist long after exposure has ceased.High or multiple doses of macrolide antibiotics, when given early in life, can perturb the metabolic and immunological development of lab mice. Here, Ruiz et al. show that even a single macrolide course, given early in life, leads to long-lasting changes in the gut microbiota and immune system of mice.
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Affiliation(s)
- Victoria E Ruiz
- Departments of Medicine and Microbiology, New York University School of Medicine (NYUSM), New York, NY, 10016, USA
| | - Thomas Battaglia
- Departments of Medicine and Microbiology, New York University School of Medicine (NYUSM), New York, NY, 10016, USA
| | - Zachary D Kurtz
- Departments of Medicine and Microbiology, New York University School of Medicine (NYUSM), New York, NY, 10016, USA
| | - Luc Bijnens
- Janssen R&D, Janssen Pharmaceutical Companies of J&J, Turnhoutseweg 30, Beerse, 2340, Belgium
| | - Amy Ou
- Departments of Medicine and Microbiology, New York University School of Medicine (NYUSM), New York, NY, 10016, USA
| | - Isak Engstrand
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 77, Stockholm, Sweden
| | - Xuhui Zheng
- Departments of Medicine and Microbiology, New York University School of Medicine (NYUSM), New York, NY, 10016, USA
| | - Tadasu Iizumi
- Departments of Medicine and Microbiology, New York University School of Medicine (NYUSM), New York, NY, 10016, USA
| | - Briana J Mullins
- Departments of Medicine and Microbiology, New York University School of Medicine (NYUSM), New York, NY, 10016, USA
| | - Christian L Müller
- Center for Computational Biology, Flatiron Institute, Simons Foundation, New York, NY, 10010, USA
| | - Ken Cadwell
- Kimmel Center for Biology and Medicine at the Skirball Institute, NYUSM, New York, NY, 10016, USA
| | - Richard Bonneau
- Center for Computational Biology, Flatiron Institute, Simons Foundation, New York, NY, 10010, USA.,Department of Biology, Center for Genomics and Systems Biology, NYU, New York, NY, 10003, USA.,Courant Institute of Mathematical Sciences, NYU, New York, NY, 10012, USA
| | - Guillermo I Perez-Perez
- Departments of Medicine and Microbiology, New York University School of Medicine (NYUSM), New York, NY, 10016, USA
| | - Martin J Blaser
- Departments of Medicine and Microbiology, New York University School of Medicine (NYUSM), New York, NY, 10016, USA. .,New York Harbor Department of Veterans Affairs Medical Center, New York, NY, 10010, USA.
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108
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Kinlaw AC, Stürmer T, Lund JL, Pedersen L, Kappelman MD, Daniels JL, Frøslev T, Mack CD, Sørensen HT. Trends in Antibiotic Use by Birth Season and Birth Year. Pediatrics 2017; 140:e20170441. [PMID: 28808074 PMCID: PMC5574728 DOI: 10.1542/peds.2017-0441] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We examined 2 birth cohort effects on antibiotic prescribing during the first year of life (henceforth, infancy) in Denmark: (1) the birth season effect on timing and overall occurrence of antibiotic prescribing, and (2) the birth year effect amid emerging nationwide pneumococcal vaccination programs and changing prescribing guidelines. METHODS We linked data for all live births in Denmark from 2004 to 2012 (N = 561 729) across the National Health Service Prescription Database, Medical Birth Registry, and Civil Registration System. Across birth season and birth year cohorts, we estimated 1-year risk, rate, and burden of redeemed antibiotic prescriptions during infancy. We used interrupted time series methods to assess prescribing trends across birth year cohorts. Graphical displays of all birth cohort effect data are included. RESULTS The 1-year risk of having at least 1 redeemed antibiotic prescription during infancy was 39.5% (99% confidence interval [CI]: 39.3% to 39.6%). The hazard of a first prescription increased with age throughout infancy and varied by season; subsequently, Kaplan-Meier-derived risk functions varied by birth season cohort. After rollout of a first vaccination program and new antibiotic prescribing guidelines, 1-year risk decreased by 4.4% over 14 months (99% CI: 3.4% to 5.5%); it decreased again after rollout of a second vaccination program by 6.9% over 3 years (99% CI: 4.4% to 9.3%). CONCLUSIONS In Denmark, birth season and birth year cohort effects influenced timing and risk of antibiotic prescribing during infancy. Future studies of antibiotic stewardship, effectiveness, and safety in children should consider these cohort effects, which may render some children inherently more susceptible than others to downstream antibiotic effects.
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Affiliation(s)
- Alan C Kinlaw
- Cecil G. Sheps Center for Health Services Research,
- Departments of Epidemiology and
| | - Til Stürmer
- Cecil G. Sheps Center for Health Services Research
- Departments of Epidemiology and
| | | | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Michael D Kappelman
- Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Trine Frøslev
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Christina D Mack
- Departments of Epidemiology and
- QuintilesIMS, Durham, North Carolina; and
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
- Division of Epidemiology, Department of Health Research and Policy, Stanford University, Stanford, California
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109
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Chang LY, Lai CC, Chen CJ, Cho CY, Luo YC, Jeng MJ, Wu KG. Recent trends in prescribing antibiotics for acute tonsillitis in pediatric ambulatory care in Taiwan, 2000–2009: A nationwide population-based study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 50:500-506. [DOI: 10.1016/j.jmii.2015.08.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/05/2015] [Accepted: 08/27/2015] [Indexed: 11/17/2022]
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Wei X, Yin J, Walley JD, Zhang Z, Hicks JP, Zhou Y, Sun Q, Zeng J, Lin M. Impact of China's essential medicines scheme and zero-mark-up policy on antibiotic prescriptions in county hospitals: a mixed methods study. Trop Med Int Health 2017; 22:1166-1174. [PMID: 28665490 DOI: 10.1111/tmi.12922] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the impact of the national essential medicines scheme and zero-mark-up policy on antibiotic prescribing behaviour. METHODS In rural Guangxi, a natural experiment compared one county hospital which implemented the policy with a comparison hospital which did not. All outpatient and inpatient records in 2011 and 2014 were extracted from the two hospitals. Primary outcome indicator was antibiotic prescribing rate (APR) among children aged 2-14 presenting in outpatients with a primary diagnosis of upper respiratory tract infection (URTI). We organised independent physician reviews to determine inappropriate prescribing for inpatients. Difference-in-difference analyses based on multivariate regressions were used to compare APR over time after adjusting potential confounders. We conducted 12 in-depth interviews with paediatricians, hospital directors and health officials. RESULTS A total of 8219 and 4142 outpatient prescriptions of childhood URTIs were included in the intervention and comparison hospitals, respectively. In 2011, APR was 30% in the intervention and 88% in the comparison hospital. In 2014, the intervention hospital significantly reduced outpatient APR by 21% (95% CI:-23%, -18%), intravenous infusion by 58% (95% CI: -64%, -52%) and prescription cost by 31 USD (95% CI: -35, -28), compared with the controls. We collected 251 inpatient records, but did not find reductions in inappropriate antibiotic use. Interviews revealed that the intervention hospital implemented a thorough antibiotics stewardship programme containing training, peer review of prescriptions and restrictions for overprescribing. CONCLUSION The national essential medicines scheme and zero-mark-up policy, when implemented with an antimicrobial stewardship programme, may be associated with reductions in outpatient antibiotic prescribing and intravenous infusions.
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Affiliation(s)
- Xiaolin Wei
- Division of Clinical Public Health, and Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jia Yin
- Shandong University, Jinan, China
| | - John D Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - Joseph P Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Yu Zhou
- China Global Health Research and Development, Shenzhen, China
| | | | - Jun Zeng
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Mei Lin
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
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111
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Elango S, Szymczak JE, Bennett IM, Beidas RS, Werner RM. Changing Antibiotic Prescribing in a Primary Care Network: The Role of Readiness to Change and Group Dynamics in Success. Am J Med Qual 2017; 33:154-161. [PMID: 28728423 DOI: 10.1177/1062860617716541] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Overuse of broad-spectrum antibiotics in outpatient pediatrics remains a significant issue and there is limited evidence on how to effectively implement outpatient stewardship interventions. This study examines the relationship between readiness to change and modifiable factors affecting success of a primary care network antibiotic stewardship intervention. A survey designed to measure readiness to accept a health care innovation was administered to 209 clinicians. Practices were split in half into "high" versus "low" readiness to change. Semistructured qualitative interviews were conducted with 2 to 3 clinicians from 6 practices in each readiness group. High readiness practices trended toward greater improvements between years (8% to 26% vs 2% to 10% mean improvement). High readiness practice clinicians described more open communication, active group change process, and supportive underlying group cohesion. Low readiness practice clinicians functioned more independently and were influenced more by external forces but were developing group cohesion through the initiative. System-wide interventions should be appropriately tailored to different levels of readiness to change, specifically addressing group dynamics and their differing foci of influence.
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Affiliation(s)
- Suratha Elango
- 1 University of Pennsylvania, Philadelphia, PA.,2 Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | - Rachel M Werner
- 1 University of Pennsylvania, Philadelphia, PA.,4 Crescenz VA Medical Center, Philadelphia, PA
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112
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Song YK, Han N, Kim MG, Chang HJ, Sohn HS, Ji E, Oh JM. A national pharmacoepidemiological study of antibiotic use in Korean paediatric outpatients. Arch Dis Child 2017; 102:660-666. [PMID: 28119402 DOI: 10.1136/archdischild-2016-310981] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 01/02/2017] [Accepted: 01/03/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Information on the use of antibiotics in Eastern Asian children is limited. The objectives of this study were to evaluate in Korean paediatric outpatients (1) the nationwide pattern of prescribing antibiotics according to age group and medical institution and (2) the adherence of antibiotic use for acute respiratory tract infections to both national guidelines and European antibiotic prescribing quality indicators. METHOD This population-based study used the national insurance reimbursement database for 2011. The study subjects were outpatients younger than 18 years old prescribed systemic antibiotics. Patterns of antibiotic prescription were compared according to diagnostic conditions, age group and medical institution. The disease-specific proportion of recommended antibiotic or quinolone use for acute respiratory tract infections was evaluated on the basis of clinical practice guidelines and European quality indicators. RESULTS The data consisted of 70.7 million prescription records for 7.9 million paediatric outpatients, which means that 79.3% of the whole paediatric population used antibiotics. Broad-spectrum antibiotics made up 78.5% of the prescriptions, with broad-spectrum penicillins such as amoxicillin/clavulanate being the most commonly prescribed (50.2%). They were prescribed more commonly in younger paediatric patients (∼80%) than in adolescents (66.6%). The leading diagnosis accounting for antibiotic prescription was bronchitis (35.9%). The prescription proportion of recommended antibiotics in the European quality indicators was extremely low compared with the national guidelines: <0.1% for pharyngotonsillitis and 13.4% for acute otitis media. CONCLUSIONS Antibiotic use in children in Korea is inappropriately high. In addition, broad-spectrum antibiotics are used excessively.
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Affiliation(s)
- Yun-Kyoung Song
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Nayoung Han
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Myeong Gyu Kim
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Hyeu-Jin Chang
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Hyun Soon Sohn
- College of Pharmacy, CHA University, Gyeonggi-do, Republic of Korea
| | - Eunhee Ji
- College of Pharmacy, Gachon University, Incheon, Republic of Korea
| | - Jung Mi Oh
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
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Maltezou HC, Dedoukou X, Asimaki H, Kontou I, Ioannidou L, Mitromara K, Theodoridou K, Katerelos P, Theodoridou M. Consumption of antibiotics by children in Greece: a cross-sectional study. Int J Pediatr Adolesc Med 2017; 4:108-111. [PMID: 30805511 PMCID: PMC6372488 DOI: 10.1016/j.ijpam.2017.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/17/2017] [Accepted: 04/18/2017] [Indexed: 11/19/2022]
Abstract
Background Greece is among the European countries with the highest consumption of antibiotics. Objectives To study the rates and characteristics of consumption of antibiotics in the community by children in Greece. Methods Questionnaire-based study of parents of hospitalized children. Results A total of 549 children were studied; 247 (45%) received at least one course of antibiotics the previous year (mean number of antibiotic courses the past year: 1.9), including 427 (91.8%) following examination by a pediatrician, 6 (1.3%) following phone consultation, 2 (0.4%) following suggestion by a pharmacist and 2 (0.4%) as self-medication. Prevalent reasons for antibiotic consumption were acute otitis media (AOM) (27.3%), pharyngotonsillitiss (25.4%), and bronchitis (17.8%). Amoxicillin-clavulanate was the prevalent antibiotic for pharyngotonsillitis, urinary tract infection (UTI) and skin infection (30.5%, 35.7% and 36.4% of cases, respectively), amoxicillin for AOM and pneumonia (32.3% and 36.4% of cases, respectively), and clarithromycin for bronchitis (27.7%). We found 84.3%, 81.9%, 64.3%, 63.7%, and 50% of parents reporting treatment consisted with the national guidelines for AOM, pneumonia, UTI, skin infection, and pharyngotonsillitis, respectively. In the multivariate analysis, an age of 1-5 years and asthma were significantly associated with a higher probability for antibiotic consumption. Conclusions Antibiotic consumption of children in Greece is mainly driven by pediatricians. Continuing medical education is expected to further improve antibiotic prescription practices by pediatricians.
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Affiliation(s)
- Helena C. Maltezou
- Department for Interventions in Health-Care Facilities, Hellenic Center for Disease Control and Prevention, Athens, Greece
- Corresponding author. Department for Interventions in Health-Care Facilities, Hellenic Center for Disease Control and Prevention, 3-5 Agrafon Street, Athens, Greece.
| | - Xanthi Dedoukou
- Department for Interventions in Health-Care Facilities, Hellenic Center for Disease Control and Prevention, Athens, Greece
| | - Hara Asimaki
- First Department of Pediatrics, University of Athens, “Aghia Sophia” Children's Hospital, Athens, Greece
| | - Ioanna Kontou
- First Department of Pediatrics, University of Athens, “Aghia Sophia” Children's Hospital, Athens, Greece
| | - Loukia Ioannidou
- First Department of Pediatrics, University of Athens, “Aghia Sophia” Children's Hospital, Athens, Greece
| | - Konstantina Mitromara
- First Department of Pediatrics, University of Athens, “Aghia Sophia” Children's Hospital, Athens, Greece
| | - Kalliopi Theodoridou
- First Department of Pediatrics, University of Athens, “Aghia Sophia” Children's Hospital, Athens, Greece
| | - Panos Katerelos
- Department for Interventions in Health-Care Facilities, Hellenic Center for Disease Control and Prevention, Athens, Greece
| | - Maria Theodoridou
- First Department of Pediatrics, University of Athens, “Aghia Sophia” Children's Hospital, Athens, Greece
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Ville AP, Heyman MB, Medrano R, Wojcicki JM. Early Antibiotic Exposure and Risk of Childhood Obesity in Latinos. Child Obes 2017; 13:231-235. [PMID: 28165758 PMCID: PMC5444413 DOI: 10.1089/chi.2016.0235] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We investigated the relationship between early antibiotic exposure before 6 months age and risk for obesity at 2 years in a high-risk, low-income, urban Latino cohort (n = 97), with the hypothesis that antibiotic exposure would increase risk for obesity by 2 years. Data were collected through maternal report of infant 24-hour dietary intake at 4-6 weeks, 6 months, 1, and 2 years; and food frequency questionnaires at 4-6 weeks, 6 months, 1, and 2 years. Antibiotic use data, including type and frequency, were collected through maternal self-report at 6 months and 1 year. Cord blood levels of leptin and insulin were measured at birth. Chi-squared tests were used to assess the relationship between obesity and dichotomous predictors and Student's t-tests for continuous predictors. Multivariable logistic models were used to ascertain independent predictors of obesity at age 2. We found that early antibiotic exposure before 6 months was independently associated with increased risk for rapid infant weight gain [odds ratio (OR) 6.42, 95% confidence interval (CI, defined as the range in which sample will fall with 95% confidence: 1.17-35.06)] and obesity at age 2 [OR 6.15, 95% CI (1.03-36.70)]. These findings provide evidence promoting antibiotic stewardship in pediatric practices to minimize exposure in the first 6 months of life.
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Affiliation(s)
- Annette P. Ville
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Melvin B. Heyman
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Rosalinda Medrano
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Janet M. Wojcicki
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Francisco, San Francisco, CA
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115
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Bytyqi HQ, Hoxha R, Bahtiri E, Krasniqi V, Krasniqi S. Antibiotic Utilization in Pediatric Hospitalized Patients - A Single Center Study. Open Access Maced J Med Sci 2017; 5:256-260. [PMID: 28507638 PMCID: PMC5420784 DOI: 10.3889/oamjms.2017.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 02/23/2017] [Accepted: 02/25/2017] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Antibiotics are among the most commonly prescribed drugs in paediatrics. In most cases, antibiotics are started on an empirical basis, without proof of a bacterial infection, either before the start of therapy or afterwards. AIM: The main objective of this study was to analyse the consumption of antibiotics in hospitalised paediatric patients. MATERIAL AND METHODS: This retrospective study investigated the consumption of antimicrobials in defined daily doses (DDDs according to the Anatomical Therapeutical Chemical/DDD index) in Pulmonology, Gastroenterology and Nephrology Departments at Pediatric Clinic of the tertiary hospital. The data on the consumption of antimicrobials were collected for five years by using properly designed form. The consumption was related to days of hospital care. RESULTS: The most utilised antibiotics group in all three departments Pulmonology, Gastroenterology and Nephrology Departments were penicillins. Cephalosporins were mostly used in Pulmonology department. Metronidazole and Chloramphenicol were used in minimal quantities in all three departments. CONCLUSION: This study demonstrates that surveillance programs on antibiotic resistance should be established and accompanied by analyses of drug utilisation data which can aid in the creation of valid cross-national studies on antibiotic usage and resistance, to motivate improvements in prescribing and guideline-directed antibiotic prescribing.
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Affiliation(s)
- Hasime Qorraj Bytyqi
- The University of Prishtina, Faculty of Medicine, Institute of Pharmacology, Prishtina, Kosovo
| | - Rexhep Hoxha
- The University of Prishtina, Faculty of Medicine, Institute of Pharmacology, Prishtina, Kosovo
| | - Elton Bahtiri
- The University of Prishtina, Faculty of Medicine, Institute of Pharmacology, Prishtina, Kosovo
| | - Valon Krasniqi
- The University of Prishtina, Faculty of Medicine, Institute of Pharmacology, Prishtina, Kosovo
| | - Shaip Krasniqi
- The University of Prishtina, Faculty of Medicine, Institute of Pharmacology, Prishtina, Kosovo
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116
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Zhao SR, Griffin MR, Patterson BL, Mace RL, Wyatt D, Zhu Y, Talbot HK. Risk Factors for Outpatient Use of Antibiotics in Children with Acute Respiratory Illnesses. South Med J 2017; 110:172-180. [PMID: 28257541 DOI: 10.14423/smj.0000000000000622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Antibiotics for acute respiratory illness (ARI) constitute most pediatric medication use and contribute to the emergence of antimicrobial resistance. We investigated antibiotic prescription risk factors for ARI in pediatric clinics and clinical follow-up in individuals prescribed and not prescribed antibiotics. METHODS In this observational study, we enrolled children ages 2 to 17 years old presenting with ARI with fever to two academic pediatric primary care outpatient clinics during influenza season 2013-2014. We collected information on demographics, initial symptoms, medical conditions, laboratory tests, discharge diagnoses, treatments, and 30 days of follow-up medical encounters. Factors associated with antibiotic prescription receipt were evaluated using logistic regression. RESULTS Of 206 consented and enrolled children, 59 (29%) were prescribed antibiotics, 51 of 59 (86%) for indicated diagnoses: 34 for streptococcal pharyngitis, 15 for acute otitis media (AOM), and 2 for pneumonia. Discharge diagnoses were the only factors independently associated with an antibiotic prescription. Of children prescribed/not prescribed an antibiotic, 17%/17% received follow-up telephone calls and 27%/17% had follow-up visits related to ARI within 30 days. Two children with AOM were prescribed a second antibiotic during follow-up, and one developed Clostridium difficile colitis. Eighteen of 206 (9%) additional children were prescribed antibiotics within 30 days for ARI symptoms, 17 for streptococcal pharyngitis, AOM, pneumonia, or sinusitis; one was prescribed antibiotics for influenza-like illness. CONCLUSIONS Among study children 2 to 17 years old with outpatient ARI, 29% were prescribed antibiotics at the initial visit and another 9% were prescribed antibiotics during the 30-day follow-up (most were for appropriate indications). Further decreasing antibiotic use in similar settings will likely require wider implementation of watchful waiting for AOM, a change in guidelines for pharyngitis management, and/or reductions in these diseases.
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Affiliation(s)
- Sophie R Zhao
- From the Departments of Medicine and Health Policy, Vanderbilt University Medical Center, the Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt University, and the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Marie R Griffin
- From the Departments of Medicine and Health Policy, Vanderbilt University Medical Center, the Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt University, and the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Barron L Patterson
- From the Departments of Medicine and Health Policy, Vanderbilt University Medical Center, the Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt University, and the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Rachel L Mace
- From the Departments of Medicine and Health Policy, Vanderbilt University Medical Center, the Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt University, and the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Dayna Wyatt
- From the Departments of Medicine and Health Policy, Vanderbilt University Medical Center, the Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt University, and the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Yuwei Zhu
- From the Departments of Medicine and Health Policy, Vanderbilt University Medical Center, the Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt University, and the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - H Keipp Talbot
- From the Departments of Medicine and Health Policy, Vanderbilt University Medical Center, the Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt University, and the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
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117
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Impact of an Educational Intervention to Improve Antibiotic Prescribing for Nurse Practitioners in a Pediatric Urgent Care Center. J Pediatr Health Care 2017; 31:184-188. [PMID: 27567148 DOI: 10.1016/j.pedhc.2016.07.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 07/05/2016] [Accepted: 07/08/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Up to 21% of pediatric visits result in an antibiotic prescription, and a large portion of these are unnecessary. OBJECTIVE To determine if educational sessions would reduce inappropriate antibiotic use. METHODS Intervention study evaluating antibiotic prescribing following educational sessions for urinary tract infection, skin and soft tissue infection, pharyngitis, upper respiratory tract infection, acute otitis media, and acute bacterial sinusitis. RESULTS A total of 26 out of 43 (60%) nurse practitioners in 4 urgent care centers were enrolled in the study. The rate of inappropriate antibiotic use among all conditions was 10% before and 8% after the intervention (p = .02). A decrease in inappropriate antibiotic prescribing was seen after the educational session (p < .01). The most common reasons for inappropriate antibiotic prescribing were too broad (41%), wrong dosage (22%), and not indicated (17%). CONCLUSIONS Educational sessions led to improvement in overall inappropriate antibiotic use. Additional stewardship interventions are needed to further reduce unnecessary antibiotic use.
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118
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Youngster I, Avorn J, Belleudi V, Cantarutti A, Díez-Domingo J, Kirchmayer U, Park BJ, Peiró S, Sanfélix-Gimeno G, Schröder H, Schüssel K, Shin JY, Shin SM, Simonsen GS, Blix HS, Tong A, Trifirò G, Ziv-Baran T, Kim SC. Antibiotic Use in Children - A Cross-National Analysis of 6 Countries. J Pediatr 2017; 182:239-244.e1. [PMID: 28012694 DOI: 10.1016/j.jpeds.2016.11.027] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 09/13/2016] [Accepted: 11/07/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To describe the rates of pediatric antibiotic use across 6 countries on 3 continents. STUDY DESIGN Cross-national analysis of 7 pediatric cohorts in 6 countries (Germany, Italy, South Korea, Norway, Spain, and the US) was performed for 2008-2012. Antibiotic dispensings were identified and grouped into subclasses. We calculated the rates of antimicrobial prescriptions per person-year specific to each age group, comparing the rates across different countries. RESULTS A total of 74 744 302 person-years from all participating centers were included in this analysis. Infants in South Korea had the highest rate of antimicrobial consumption, with 3.41 prescribed courses per child-year during the first 2 years of life. This compares with 1.6 in Lazio, Italy; 1.4 in Pedianet, Italy; 1.5 in Spain; 1.1 in the US; 1.0 in Germany; and 0.5 courses per child-year in Norway. Of antimicrobial prescriptions written in Norway, 64.8% were for first-line penicillins, compared with 38.2% in Germany, 31.8% in the US, 27.7% in Spain, 25.1% in the Italian Pedianet population, 9.8% in South Korea, and 8% in the Italian Lazio population. CONCLUSIONS We found substantial differences of up to 7.5-fold in pediatric antimicrobial use across several industrialized countries from Europe, Asia, and North America. These data reinforce the need to develop strategies to decrease the unnecessary use of antimicrobial agents.
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Affiliation(s)
- Ilan Youngster
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA.
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Anna Cantarutti
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Javier Díez-Domingo
- Health Services Research Unit, Center for Public Health Research, Valencia, Spain
| | - Ursula Kirchmayer
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Byung-Joo Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Salvador Peiró
- Health Services Research Unit, Center for Public Health Research, Valencia, Spain
| | | | - Helmut Schröder
- Wissenschaftliches Institut der AOK WIdO (Scientific Institute of the AOK), Berlin, Germany
| | - Katrin Schüssel
- Wissenschaftliches Institut der AOK WIdO (Scientific Institute of the AOK), Berlin, Germany
| | - Ju-Young Shin
- Korea Institute of Drug Safety and Risk Management, Seoul, Republic of Korea
| | - Sun Mi Shin
- Korea Institute of Drug Safety and Risk Management, Seoul, Republic of Korea
| | - Gunnar Skov Simonsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - Hege Salvesen Blix
- Department of Pharmacoepidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Angela Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Gianluca Trifirò
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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119
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Coxeter PD, Mar CD, Hoffmann TC. Parents' Expectations and Experiences of Antibiotics for Acute Respiratory Infections in Primary Care. Ann Fam Med 2017; 15:149-154. [PMID: 28289114 PMCID: PMC5348232 DOI: 10.1370/afm.2040] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 11/28/2016] [Accepted: 12/08/2016] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Primary care visits for children with acute respiratory infections frequently result in antibiotic prescriptions, although antibiotics have limited benefits for common acute respiratory infections and can cause harms, including antibiotic resistance. Parental demands are often blamed for antibiotic prescription. We aimed to explore parents' beliefs about antibiotic necessity, quantify their expectations of antibiotic benefit, and report experiences of other management options and exposure to and preferences for shared decision making. METHODS We conducted computer-assisted telephone interviews in an Australia-wide community sample of primary caregivers, hereafter referred to as parents, of children aged 1 to 12 years, using random digit dialing of household landline telephones. RESULTS Of the 14,505 telephone numbers called, 10,340 were eligible numbers; 589 potentially eligible parents were reached, of whom 401 were interviewed. Most believed antibiotics provide benefits for common acute respiratory infections, especially for acute otitis media (92%), although not using them, particularly for acute cough and sore throat, was sometimes acceptable. Parents grossly overestimated the mean benefit of antibiotics on illness symptom duration by 5 to 10 times, and believed they reduce the likelihood of complications. The majority, 78%, recognized antibiotics may cause harm. Recalling the most recent relevant doctor visit, 44% of parents reported at least some discussion about why antibiotics might be used; shared decision making about antibiotic use was inconsistent, while 75% wanted more involvement in future decisions. CONCLUSIONS Some parents have misperceptions about antibiotic use for acute respiratory infections, highlighting the need for improved communication during visits, including shared decision making to address overoptimistic expectations of antibiotics. Such communication should be one of several strategies that is used to reduce antibiotic use.
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Affiliation(s)
- Peter D Coxeter
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
| | - Chris Del Mar
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
| | - Tammy C Hoffmann
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
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120
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Li J, Yang K, Ju T, Ho T, McKay CA, Gao Y, Forget SK, Gartner SR, Field CJ, Chan CB, Willing BP. Early life antibiotic exposure affects pancreatic islet development and metabolic regulation. Sci Rep 2017; 7:41778. [PMID: 28150721 PMCID: PMC5288777 DOI: 10.1038/srep41778] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 12/30/2016] [Indexed: 12/12/2022] Open
Abstract
Childhood antibiotic exposure has been recently linked with increased risk of metabolic disease later in life. A better understanding of this association would potentially provide strategies to reduce the childhood chronic disease epidemic. Therefore, we explored the underlying mechanisms using a swine model that better mimics human infants than rodents, and demonstrated that early life antibiotic exposure affects glucose metabolism 5 weeks after antibiotic withdrawal, which was associated with changes in pancreatic development. Antibiotics exerted a transient impact on postnatal gut microbiota colonization and microbial metabolite production, yet changes in the expression of key genes involved in short-chain fatty acid signaling and pancreatic development were detected in later life. These findings suggest a programming effect of early life antibiotic exposure that merits further investigation.
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Affiliation(s)
- Jiaying Li
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, T6G 2P5, Canada
| | - Kaiyuan Yang
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, T6G 2P5, Canada
| | - Tingting Ju
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, T6G 2P5, Canada
| | - Tracy Ho
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, T6G 2P5, Canada
| | - Catharine A McKay
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, T6G 2P5, Canada
| | - Yanhua Gao
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, T6G 2P5, Canada
| | - Shay K Forget
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, T6G 2P5, Canada
| | - Stephanie R Gartner
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, T6G 2P5, Canada
| | - Catherine J Field
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, T6G 2P5, Canada
| | - Catherine B Chan
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, T6G 2P5, Canada.,Department of Physiology, University of Alberta, Edmonton, AB, T6G 2H7, Canada
| | - Benjamin P Willing
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, T6G 2P5, Canada
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Butt AA, Navasero CS, Thomas B, Marri SA, Katheeri HA, Thani AA, Khal AA, Khan T, Abou-Samra AB. Antibiotic prescription patterns for upper respiratory tract infections in the outpatient Qatari population in the private sector. Int J Infect Dis 2017; 55:20-23. [DOI: 10.1016/j.ijid.2016.12.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 11/17/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022] Open
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Meropol SB, Stange KC, Jacobs MR, Weiss JK, Bajaksouzian S, Bonomo RA. Bacterial Colonization and Antibiotic Resistance in a Prospective Cohort of Newborn Infants During the First Year of Life. Open Forum Infect Dis 2016; 3:ofw221. [PMID: 27957505 PMCID: PMC5146758 DOI: 10.1093/ofid/ofw221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/13/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Infants are virtually sterile at birth and frequently use antibiotics; our objective was to (1) characterize the longitudinal colonization with bacterial pathogens and associated antibiotic resistance in a cohort of community-dwelling infants in Northeast Ohio and (2) describe longitudinal concurrent antibiotic and daycare exposures. METHODS For 35 newborns, nasopharyngeal swabs were cultured for Streptococcus pneumoniae, anterior nasal for Staphylococcus aureus, and perirectal for extended-spectrum beta-lactamase (ESBL)-producing Gram-negative enteric bacteria, at 3-month intervals for 12 months. Infant and household antibiotics and daycare exposure were assessed longitudinally. RESULTS Thirteen infants received perinatal or nursery antibiotics. By 3 months, at least 22 were colonized with Gram-negative bacteria; 2 with S pneumoniae (type 19A, resistant; 15C, susceptible), 5 with methicillin-susceptible S aureus. By 12 months, at least 22 of 35 infants received antibiotics, 20 had household members with antibiotics, and 12 attended daycare; 7 more had household members with daycare exposure. The ESBL-producing organisms were not identified. At least 10 infants were colonized at some time with an antibiotic-resistant organism, 3 more with pathogens displaying intermediate resistance. Pathogen colonization and resistance were intermittent and inconsistent. CONCLUSIONS In a community-based cohort followed from birth, early antibiotic and daycare exposures are common, especially considering perinatal maternal exposures. Colonization patterns of Gram-negative bacteria, S pneumoniae, S aureus, and resistant pneumococci are strikingly dynamic. Further research can identify key areas for potential interventions to maximize clinical antibiotic outcomes while minimizing future resistance.
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Affiliation(s)
- Sharon B Meropol
- Departments ofPediatrics,; Epidemiology and Biostatistics,; The Center for Child Health and Policy, Case Western Reserve University School of Medicine and Rainbow Babies and Children's Hospital, Cleveland, Ohio; and
| | - Kurt C Stange
- Epidemiology and Biostatistics,; Family Medicine,; Oncology,; Sociology
| | | | | | | | - Robert A Bonomo
- Medicine,; Pharmacology, and; Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, Ohio;; Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
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Rogawski ET, Platts-Mills JA, Seidman JC, John S, Mahfuz M, Ulak M, Shrestha SK, Soofi SB, Yori PP, Mduma E, Svensen E, Ahmed T, Lima AA, Bhutta ZA, Kosek MN, Lang DR, Gottlieb M, Zaidi AK, Kang G, Bessong PO, Houpt ER, Guerrant RL. Use of antibiotics in children younger than two years in eight countries: a prospective cohort study. Bull World Health Organ 2016; 95:49-61. [PMID: 28053364 PMCID: PMC5180352 DOI: 10.2471/blt.16.176123] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/31/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To describe the frequency and factors associated with antibiotic use in early childhood, and estimate the proportion of diarrhoea and respiratory illnesses episodes treated with antibiotics. METHODS Between 2009 and 2014, we followed 2134 children from eight sites in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, South Africa and the United Republic of Tanzania, enrolled in the MAL-ED birth cohort study. We documented all antibiotic use from mothers' reports at twice-weekly visits over the children's first two years of life. We estimated the incidence of antibiotic use and the associations of antibiotic use with child and household characteristics. We described treatment patterns for diarrhoea and respiratory illnesses, and identified factors associated with treatment and antibiotic class. FINDINGS Over 1 346 388 total days of observation, 16 913 courses of antibiotics were recorded (an incidence of 4.9 courses per child per year), with the highest use in South Asia. Antibiotic treatment was given for 375/499 (75.2%) episodes of bloody diarrhoea and for 4274/9661 (44.2%) episodes of diarrhoea without bloody stools. Antibiotics were used in 2384/3943 (60.5%) episodes of fieldworker-confirmed acute lower respiratory tract illness as well as in 6608/16742 (39.5%) episodes of upper respiratory illness. Penicillins were used most frequently for respiratory illness, while antibiotic classes for diarrhoea treatment varied within and between sites. CONCLUSION Repeated antibiotic exposure was common early in life, and treatment of non-bloody diarrhoea and non-specific respiratory illnesses was not consistent with international recommendations. Rational antibiotic use programmes may have the most impact in South Asia, where antibiotic use was highest.
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Affiliation(s)
- Elizabeth T Rogawski
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA)
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA)
| | - Jessica C Seidman
- Fogarty International Center, National Institutes of Health, Bethesda, USA
| | | | - Mustafa Mahfuz
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Manjeswori Ulak
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | | | | | - Estomih Mduma
- Haydom Lutheran Hospital, Haydom, United Republic of Tanzania
| | | | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Aldo Am Lima
- Clinical Research Unit and Institute of Biomedicine, Federal University of Ceara, Fortaleza, Brazil
| | | | - Margaret N Kosek
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Dennis R Lang
- Foundation for the National Institutes of Health, Bethesda, USA
| | | | | | | | | | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA)
| | - Richard L Guerrant
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA)
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Emerging and Future Applications of Matrix-Assisted Laser Desorption Ionization Time-of-Flight (MALDI-TOF) Mass Spectrometry in the Clinical Microbiology Laboratory. J Mol Diagn 2016; 18:789-802. [DOI: 10.1016/j.jmoldx.2016.07.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 06/29/2016] [Accepted: 07/21/2016] [Indexed: 12/17/2022] Open
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125
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Santos-Cortez RLP, Hutchinson DS, Ajami NJ, Reyes-Quintos MRT, Tantoco MLC, Labra PJ, Lagrana SM, Pedro M, Llanes EGDV, Gloria-Cruz TL, Chan AL, Cutiongco-de la Paz EM, Belmont JW, Chonmaitree T, Abes GT, Petrosino JF, Leal SM, Chiong CM. Middle ear microbiome differences in indigenous Filipinos with chronic otitis media due to a duplication in the A2ML1 gene. Infect Dis Poverty 2016; 5:97. [PMID: 27799062 PMCID: PMC5088646 DOI: 10.1186/s40249-016-0189-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/26/2016] [Indexed: 11/10/2022] Open
Abstract
Background Previously rare A2ML1 variants were identified to confer otitis media susceptibility in an indigenous Filipino community and in otitis-prone US children. The goal of this study is to describe differences in the middle ear microbiome between carriers and non-carriers of an A2ML1 duplication variant that increases risk for chronic otitis media among indigenous Filipinos with poor health care access. Methods Ear swabs were obtained from 16 indigenous Filipino individuals with chronic otitis media, of whom 11 carry the A2ML1 duplication variant. Ear swabs were submitted for 16S rRNA gene sequencing. Results Genotype-based differences in microbial richness, structure, and composition were identified, but were not statistically significant. Taxonomic analysis revealed that the relative abundance of the phyla Fusobacteria and Bacteroidetes, and genus Fusobacterium were nominally increased in carriers compared to non-carriers, but were non-significant after correction for multiple testing. We also detected rare bacteria including Oligella that was reported only once in the middle ear. Conclusions These findings suggest that A2ML1-related otitis media susceptibility may be mediated by changes in the middle ear microbiome. Knowledge of middle ear microbial profiles according to genetic background can be potentially useful for therapeutic and prophylactic interventions for otitis media and can guide public health interventions towards decreasing otitis media prevalence within the indigenous Filipino community. Electronic supplementary material The online version of this article (doi:10.1186/s40249-016-0189-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Regie Lyn P Santos-Cortez
- Department of Molecular and Human Genetics, Center for Statistical Genetics, Baylor College of Medicine, Houston, TX, 77030, USA. .,Current affiliation: Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO, 80045, USA.
| | - Diane S Hutchinson
- Department of Molecular Virology and Microbiology, Alkek Center for Metagenomics and Microbiome Research (CMMR), Baylor College of Medicine, Houston, TX, 77030, USA
| | - Nadim J Ajami
- Department of Molecular Virology and Microbiology, Alkek Center for Metagenomics and Microbiome Research (CMMR), Baylor College of Medicine, Houston, TX, 77030, USA
| | - Ma Rina T Reyes-Quintos
- Philippine National Ear Institute, University of the Philippines Manila - National Institutes of Health (UPM-NIH), Manila, 1000, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine - Philippine General Hospital, Manila, 1000, Philippines
| | - Ma Leah C Tantoco
- Philippine National Ear Institute, University of the Philippines Manila - National Institutes of Health (UPM-NIH), Manila, 1000, Philippines
| | - Patrick John Labra
- Department of Otorhinolaryngology, University of the Philippines College of Medicine - Philippine General Hospital, Manila, 1000, Philippines
| | - Sheryl Mae Lagrana
- Philippine National Ear Institute, University of the Philippines Manila - National Institutes of Health (UPM-NIH), Manila, 1000, Philippines
| | - Melquiadesa Pedro
- Philippine National Ear Institute, University of the Philippines Manila - National Institutes of Health (UPM-NIH), Manila, 1000, Philippines
| | - Erasmo Gonzalo D V Llanes
- Philippine National Ear Institute, University of the Philippines Manila - National Institutes of Health (UPM-NIH), Manila, 1000, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine - Philippine General Hospital, Manila, 1000, Philippines
| | - Teresa Luisa Gloria-Cruz
- Philippine National Ear Institute, University of the Philippines Manila - National Institutes of Health (UPM-NIH), Manila, 1000, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine - Philippine General Hospital, Manila, 1000, Philippines
| | - Abner L Chan
- Philippine National Ear Institute, University of the Philippines Manila - National Institutes of Health (UPM-NIH), Manila, 1000, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine - Philippine General Hospital, Manila, 1000, Philippines
| | - Eva Maria Cutiongco-de la Paz
- Institute of Human Genetics, UPM-NIH, Manila, 1000, Philippines.,Philippine Genome Center, University of the Philippines, Diliman, Quezon City, 1101, Philippines
| | - John W Belmont
- Departments of Molecular and Human Genetics and Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA.,Current address: Illumina, Inc, San Diego, CA, 92122, USA
| | - Tasnee Chonmaitree
- Division of Pediatric Infectious Disease and Immunology, Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Generoso T Abes
- Philippine National Ear Institute, University of the Philippines Manila - National Institutes of Health (UPM-NIH), Manila, 1000, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine - Philippine General Hospital, Manila, 1000, Philippines
| | - Joseph F Petrosino
- Department of Molecular Virology and Microbiology, Alkek Center for Metagenomics and Microbiome Research (CMMR), Baylor College of Medicine, Houston, TX, 77030, USA
| | - Suzanne M Leal
- Department of Molecular and Human Genetics, Center for Statistical Genetics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Charlotte M Chiong
- Philippine National Ear Institute, University of the Philippines Manila - National Institutes of Health (UPM-NIH), Manila, 1000, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine - Philippine General Hospital, Manila, 1000, Philippines
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Santos-Cortez RLP, Reyes-Quintos MRT, Tantoco MLC, Abbe I, Llanes EGDV, Ajami NJ, Hutchinson DS, Petrosino JF, Padilla CD, Villarta RL, Gloria-Cruz TL, Chan AL, Cutiongco-de la Paz EM, Chiong CM, Leal SM, Abes GT. Genetic and Environmental Determinants of Otitis Media in an Indigenous Filipino Population. Otolaryngol Head Neck Surg 2016; 155:856-862. [PMID: 27484237 DOI: 10.1177/0194599816661703] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 07/08/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To identify genetic and environmental risk factors for otitis media in an indigenous Filipino population. STUDY DESIGN Cross-sectional study. SETTING Indigenous Filipino community. SUBJECTS AND METHODS Clinical history and information on breastfeeding, tobacco smoke exposure, and swimming were obtained from community members. Heads of households were interviewed for family history and personal beliefs on ear health. Height and weight were measured. Otoscopic findings were described for the presence and character of perforation or discharge. An A2ML1 duplication variant that confers otitis media susceptibility was Sanger sequenced in all DNA samples. Co-occurrence of middle ear bacteria detected by 16S rRNA gene sequencing was determined according to A2ML1 genotype and social cluster. RESULTS The indigenous Filipino population has a ~50% prevalence of otitis media. Young age was associated with otitis media (4 age strata; P = .004); however, age was nonsignificant as a bistratal or continuous variable. There was no association between otitis media and sex, body mass index, breastfeeding, tobacco exposure, or deep swimming. In multivariate analyses, A2ML1 genotype is the strongest predictor of otitis media, with an odds ratio of 3.7 (95% confidence interval: 1.3-10.8; P = .005). When otitis media diagnoses were plotted across ages, otitis media was observed within the first year of life, and chronic otitis media persisted up to adulthood, particularly in A2ML1-variant carriers. CONCLUSION Among indigenous Filipinos, A2ML1 genotype is the primary risk factor for otitis media and main determinant of disease progression, although age, the middle ear microbiome, and social clusters might modulate the effect of the A2ML1 genotype.
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Affiliation(s)
- Regie Lyn P Santos-Cortez
- Center for Statistical Genetics, Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Ma Rina T Reyes-Quintos
- Philippine National Ear Institute, University of the Philippines Manila-National Institutes of Health, Manila, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Ma Leah C Tantoco
- Philippine National Ear Institute, University of the Philippines Manila-National Institutes of Health, Manila, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Izoduwa Abbe
- Center for Statistical Genetics, Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Erasmo Gonzalo D V Llanes
- Philippine National Ear Institute, University of the Philippines Manila-National Institutes of Health, Manila, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Nadim J Ajami
- Alkek Center for Metagenomics and Microbiome Research (CMMR), Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Diane S Hutchinson
- Alkek Center for Metagenomics and Microbiome Research (CMMR), Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph F Petrosino
- Alkek Center for Metagenomics and Microbiome Research (CMMR), Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Carmencita D Padilla
- Institute of Human Genetics, University of the Philippines Manila-National Institutes of Health, Manila, Philippines.,Department of Pediatrics, University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines.,Philippine Genome Center, University of the Philippines Diliman, Quezon City, Philippines
| | - Romeo L Villarta
- Philippine National Ear Institute, University of the Philippines Manila-National Institutes of Health, Manila, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Teresa Luisa Gloria-Cruz
- Philippine National Ear Institute, University of the Philippines Manila-National Institutes of Health, Manila, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Abner L Chan
- Philippine National Ear Institute, University of the Philippines Manila-National Institutes of Health, Manila, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Eva Maria Cutiongco-de la Paz
- Institute of Human Genetics, University of the Philippines Manila-National Institutes of Health, Manila, Philippines.,Department of Pediatrics, University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines.,Philippine Genome Center, University of the Philippines Diliman, Quezon City, Philippines
| | - Charlotte M Chiong
- Philippine National Ear Institute, University of the Philippines Manila-National Institutes of Health, Manila, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Suzanne M Leal
- Center for Statistical Genetics, Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Generoso T Abes
- Philippine National Ear Institute, University of the Philippines Manila-National Institutes of Health, Manila, Philippines.,Department of Otorhinolaryngology, University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines
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127
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MacGeorge EL, Smith RA, Caldes EP, Hackman NM. Watchful Waiting for Cases of Pediatric Otitis Media: Modeling Parental Response to Physician Advice. JOURNAL OF HEALTH COMMUNICATION 2016; 21:919-926. [PMID: 27409041 DOI: 10.1080/10810730.2016.1177148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Watchful waiting (WW) can reduce unnecessary antibiotic use in the treatment of pediatric otitis media (ear infection), but its utility is impaired by underutilization and noncompliance. Guided by advice response theory, the current study proposes advantage and capacity as factors that predict how caregivers evaluate and respond affectively to WW. Parents (N = 373) of at least 1 child age 5 years or younger completed questionnaires that assessed responses to hypothetical WW advice for their youngest child. Perceptions of advantage from WW and the capacity to monitor and manage symptoms predicted advice quality, physician trust, and future compliance both directly and indirectly through negative affect. The findings suggest the elaboration of advice response theory to include more aspects of advice content evaluation (e.g., advantage) and the influence of negative affect. The study also provides practical guidance for physicians seeking to improve caregiver reception of WW advice.
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Affiliation(s)
- Erina L MacGeorge
- a Department of Communication Arts and Sciences , Pennsylvania State University , University Park , Pennsylvania , USA
| | - Rachel A Smith
- a Department of Communication Arts and Sciences , Pennsylvania State University , University Park , Pennsylvania , USA
| | - Emily P Caldes
- a Department of Communication Arts and Sciences , Pennsylvania State University , University Park , Pennsylvania , USA
| | - Nicole M Hackman
- b Department of Pediatrics , Pennsylvania State College of Medicine , Hershey , Pennsylvania , USA
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128
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Lee ML, Cho CY, Hsu CL, Chen CJ, Chang LY, Lee YS, Soong WJ, Jeng MJ, Wu KG. Recent trends in antibiotic prescriptions for acute respiratory tract infections in pediatric ambulatory care in Taiwan, 2000–2009: A nationwide population-based study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 49:554-60. [DOI: 10.1016/j.jmii.2014.08.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 08/11/2014] [Accepted: 08/23/2014] [Indexed: 11/29/2022]
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129
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Mueller T, Östergren PO. The correlation between regulatory conditions and antibiotic consumption within the WHO European Region. Health Policy 2016; 120:882-9. [PMID: 27460523 DOI: 10.1016/j.healthpol.2016.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 05/10/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In a global perspective, bacterial infections are still a major cause of morbidity and mortality; therefore, effective antibiotics are needed. However, the emergence of antibiotic resistance due to irrational use has now become a serious public health problem. Hence, the objective of this study was to analyse the association of regulatory aspects with antibiotic consumption. METHODS A data set representing 20 countries throughout the WHO European Region was chosen based on data availability so as to analyse the correlation between specific regulatory conditions and antibiotic consumption, using total consumption data for 2011 and information about national provisions regarding rational use of medicines. Linear regression models were designed in order to evaluate individual aspects as well as the overall level of regulation. RESULTS A high level of regulation, assessed by an overall index, was significantly correlated with lower antibiotic consumption; however, of all individual items analysed, only the presence of Standard Treatment Guidelines for hospital care as well as paediatric conditions, the non-availability of antibiotics without a prescription, and the existence of training modules for pharmacists covering rational use of medicines gave significant results, i.e. lower use of antibiotics, when regarded in isolation. CONCLUSION Although national regulatory conditions intended to foster rational use of antibiotics seem to be correlated with antibiotic consumption, this association is potentially influenced by a wide range of contextual aspects.
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Affiliation(s)
- Tanja Mueller
- Faculty of Medicine, Lund University, Clinical Research Centre, Jan Waldenströms Gata 35, SE-205 02 Malmö Sweden.
| | - Per-Olof Östergren
- Faculty of Medicine, Lund University, Clinical Research Centre, Jan Waldenströms Gata 35, SE-205 02 Malmö Sweden.
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130
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Faden HS, Ma CX. Trends in Oral Antibiotic, Proton Pump Inhibitor, and Histamine 2 Receptor Blocker Prescription Patterns for Children Compared With Adults: Implications for Clostridium difficile Infection in the Community. Clin Pediatr (Phila) 2016; 55:712-6. [PMID: 26350427 DOI: 10.1177/0009922815604596] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of antibiotics, proton pump inhibitor (PPI), and histamine 2 receptor blocker (H2B) was compared between children and adults in the community from 2005 through 2011. Antibiotic prescription rates remained stable for children, but increased significantly for adults, P = .03. PPI prescription rates increased for children, P = .02 and for adults, P = .009. H2B prescription rates increased for children, P = .03, but not for adults. Antibiotic prescription rates were significantly higher in children than adults in all 7 years, P < .0001. In contrast, PPI prescription rates were significantly higher in adults than children in all 7 years, P < .0001. H2B prescription rates were significantly higher in adults than children 1 to 18 years old P < .0001; however, H2B prescription rates were highest in children <1 year old, P = .0001. The high use of oral antibiotics, PPI, and H2B among outpatients may be a contributing factor to the rise of Clostridium difficile infection in the community.
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131
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Gidengil CA, Linder JA, Beach S, Setodji CM, Hunter G, Mehrotra A. Using Clinical Vignettes to Assess Quality of Care for Acute Respiratory Infections. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2016; 53:0046958016636531. [PMID: 27098876 PMCID: PMC4840477 DOI: 10.1177/0046958016636531] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 01/14/2016] [Indexed: 11/17/2022]
Abstract
Overprescribing of antibiotics for acute respiratory infections (ARIs) is common. Our objective was to develop and validate a vignette-based method to estimate clinician ARI antibiotic prescribing. We surveyed physicians (n = 78) and retail clinic clinicians (n = 109) between January and September 2013. We surveyed clinicians using a set of ARI vignettes and linked the responses to electronic health record data for all ARI visits managed by these clinicians during 2012. We then created a new measure of antibiotic prescribing, the comprehensive ARI management rate. This was defined as not prescribing antibiotics for antibiotic-inappropriate diagnoses and prescribing guideline-concordant antibiotics for antibiotic-appropriate diagnoses (and also included appropriate use of streptococcal testing for the pharyngitis vignettes). We compared the vignette-based and chart-based comprehensive ARI management at the clinician level. We then identified the combination of vignettes that best predicted comprehensive ARI management rates, using a partitioning algorithm. Responses to 3 vignettes partitioned clinicians into 4 groups with chart-based comprehensive ARI management rates of 61% (n = 121), 50% (n = 47), 31% (n = 12), and 22% (n = 7). Responses to 3 clinical vignettes can identify clinicians with relatively poor quality ARI antibiotic prescribing. Vignettes may be a mechanism to target clinicians for quality improvement efforts.
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Affiliation(s)
- Courtney A Gidengil
- RAND Corporation, Boston, MA, USA Boston Children's Hospital, Boston, MA Harvard Medical School, Boston, MA, USA
| | - Jeffrey A Linder
- Brigham and Women's Hospital, Boston, MA University of Pittsburgh, PA, USA
| | | | | | | | - Ateev Mehrotra
- RAND Corporation, Boston, MA, USA Harvard Medical School, Boston, MA, USA Beth Israel Deaconess Medical Center, Boston, MA, USA
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132
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Ivanovska V, Hek K, Mantel Teeuwisse AK, Leufkens HGM, Nielen MMJ, van Dijk L. Antibiotic prescribing for children in primary care and adherence to treatment guidelines. J Antimicrob Chemother 2016; 71:1707-14. [DOI: 10.1093/jac/dkw030] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 01/29/2016] [Indexed: 12/19/2022] Open
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133
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Wright H, Skinner AC, Jhaveri R. Evaluating Guideline-Recommended Antibiotic Practices for Childhood Respiratory Infections: Is It Time to Consider Case-Based Formats? Clin Pediatr (Phila) 2016; 55:118-21. [PMID: 25986442 DOI: 10.1177/0009922815587091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We sought to better understand barriers to adherence to published guidelines for respiratory infections among community providers. METHODS A case-based survey was developed and emailed to all members of the state pediatric society. Providers chose their preferred management for acute otitis media, acute bacterial sinusitis, and community-acquired pneumonia. An "answer key" and a follow-up questionnaire were distributed to assess reevaluation of current practices. RESULTS We received 173 completed surveys (15% response rate). While most responders followed guideline recommendations (6 of the 10 questions with ≥ 65% choosing recommended antibiotic), discrepancies existed in several cases. After receiving the answer key, respondents said they reviewed the guidelines (69%), adjusted their practice (26%), used cases for teaching (9%), and discussed guidelines with colleagues (21%). CONCLUSIONS The majority of respondents followed published guidelines, but there was a tendency to overuse azithromycin in certain cases. Future guidelines including case-based discussions may enhance adherence.
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Affiliation(s)
- Heather Wright
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | | | - Ravi Jhaveri
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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134
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Frenk SM, Kit BK, Lukacs SL, Hicks LA, Gu Q. Trends in the use of prescription antibiotics: NHANES 1999-2012. J Antimicrob Chemother 2016; 71:251-6. [PMID: 26462985 PMCID: PMC6326366 DOI: 10.1093/jac/dkv319] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 09/05/2015] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES The objectives of this study were: to examine trends in the use of prescription antibiotics overall and by population subgroups between 1999 and 2012; and to examine trends in the use of categories of antibiotics and individual antibiotics. METHODS Use of antibiotics was examined among 71 444 participants in the nationally representative National Health and Nutrition Examination Survey (NHANES; 1999-2012). Use of an antibiotic in the past 30 days was the main outcome variable. Analyses of trends were conducted overall and separately by population subgroups (i.e. age, sex, race/Hispanic origin, health insurance status and respiratory conditions) across four time periods (1999-2002, 2003-06, 2007-10 and 2011-12). RESULTS The percentage of the US population that used a prescription antibiotic in the past 30 days significantly declined from 6.1% in 1999-2002 to 4.1% in 2011-12 (P < 0.001). Declines were also identified for five age groups (0-1 year, 6-11 years, 12-17 years, 18-39 years and 40-59 years), both sexes, non-Hispanic white and non-Hispanic black persons, persons with and without insurance and among those who currently had asthma. Significant declines were also observed for three categories of antibiotics (penicillins, cephalosporins and macrolide derivatives). Of the most common antibiotics prescribed, only amoxicillin use decreased significantly. CONCLUSIONS Overall, there was a significant decline in the use of antibiotics between 1999-2002 and 2011-12. Due to concerns about antimicrobial resistance, it is important to continue monitoring the use of antibiotics.
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Affiliation(s)
- Steven M Frenk
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD, USA
| | - Brian K Kit
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD, USA United States Public Health Service, Rockville, MD, USA
| | - Susan L Lukacs
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD, USA United States Public Health Service, Rockville, MD, USA
| | - Lauri A Hicks
- United States Public Health Service, Rockville, MD, USA National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Qiuping Gu
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD, USA
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135
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Meropol SB, Edwards A. Development of the infant intestinal microbiome: A bird's eye view of a complex process. BIRTH DEFECTS RESEARCH. PART C, EMBRYO TODAY : REVIEWS 2015; 105:228-39. [PMID: 26663826 PMCID: PMC5637388 DOI: 10.1002/bdrc.21114] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Infants undergo profound shifts in colonizing intestinal microorganisms during their first year, especially during and after birth and during weaning. Microbiota are passed to infants through the placenta, during the vaginal birth process, and from early diet and other environmental exposures. These microbiota play an active role in the development of healthy infant metabolic and immunologic systems; profound shifts in microbiotal populations can be persistent, are associated with immediate alterations in gene expression, metabolic, immunologic, and neurologic function, and with downstream metabolic and immunologic consequences such as obesity, allergies, asthma, autoimmune diseases, and potentially neurologic conditions. Many modern exposures, including Cesarean section, formula feeding, and antibiotics, have been associated with microbiome shifts, and also with downstream diseases; while many published studies considered exposures individually, a more comprehensive understanding of their interaction and impact will consider the entirety of the infant's environment. It is not possible, nor desirable, to return to a world without toilets, sewers, tap water, delivery room antisepsis, Cesarean sections, antibiotics, immunizations, and refrigerators; our other alternative is to better understand these complex changes in infant developmental and molecular physiology. Protecting and repairing the developmental processes of the healthy infant microbiome is the modern medical frontier.
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Affiliation(s)
- Sharon B. Meropol
- The Center for Child Health and Policy, Case Western Reserve University School of Medicine and UH Rainbow Babies and Children’s Hospital, Cleveland, Ohio
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Case Western Reserve University School of Medicine and UH Rainbow Babies and Children’s Hospital, Cleveland, Ohio
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Amy Edwards
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Case Western Reserve University School of Medicine and UH Rainbow Babies and Children’s Hospital, Cleveland, Ohio
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136
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Affiliation(s)
- Emma Barry
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons, 123 St. Stephen's Green, Dublin 2, Ireland
| | - Susan M Smith
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons, 123 St. Stephen's Green, Dublin 2, Ireland.
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137
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Rogawski ET, Meshnick SR, Becker-Dreps S, Adair LS, Sandler RS, Sarkar R, Kattula D, Ward HD, Kang G, Westreich DJ. Reduction in diarrhoeal rates through interventions that prevent unnecessary antibiotic exposure early in life in an observational birth cohort. J Epidemiol Community Health 2015; 70:500-5. [PMID: 26621194 DOI: 10.1136/jech-2015-206635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/09/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Antibiotic treatment early in life is often not needed and has been associated with increased rates of subsequent diarrhoea. We estimated the impact of realistic interventions, which would prevent unnecessary antibiotic exposures before 6 months of age, on reducing childhood diarrhoeal rates. METHODS In data from a prospective observational cohort study conducted in Vellore, India, we used the parametric g-formula to model diarrhoeal incidence rate differences contrasting the observed incidence of diarrhoea to the incidence expected under hypothetical interventions. The interventions prevented unnecessary antibiotic treatments for non-bloody diarrhoea, vomiting and upper respiratory infections before 6 months of age. We also modelled targeted interventions, in which unnecessary antibiotic use was prevented only among children who had already stopped exclusive breast feeding. RESULTS More than half of all antibiotic exposures before 6 months (58.9%) were likely unnecessary. The incidence rate difference associated with removing unnecessary antibiotic use before 6 months of age was -0.28 (95% CI -0.46 to -0.08) episodes per 30 child-months. This implies that preventing unnecessary antibiotic exposures in just 4 children would reduce the incidence of diarrhoea by 1 from 6 months to 3 years of age. CONCLUSIONS Interventions to reduce unnecessary antibiotic use among young children could result in an important reduction in diarrhoeal rates. This work provides an example application of statistical methods which can further the aim of presenting epidemiological findings that are relevant to public health practice.
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Affiliation(s)
| | - Steven R Meshnick
- Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sylvia Becker-Dreps
- Department of Family Medicine, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Linda S Adair
- Department of Nutrition, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robert S Sandler
- Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, USA Department of Medicine, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rajiv Sarkar
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepthi Kattula
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Honorine D Ward
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Gagandeep Kang
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Daniel J Westreich
- Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
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138
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Abstract
BACKGROUND Clostridium difficile-associated diarrhea (CDAD) is increasingly diagnosed in children in community settings. This study aims to assess recent antibiotic use and other risk factors in children with community-associated (CA-) CDAD compared with children with other diarrheal illnesses in a tertiary care setting. METHODS Children with CA-CDAD evaluated at Texas Children's Hospital (Houston, TX) from January 1, 2012 to June 30, 2013 were identified. Two control subjects with community-associated diarrhea who tested negative for C. difficile were matched to case subjects. Data on demographics, medication exposure and outpatient healthcare encounters were collected from medical records. Multivariate logistic regression was performed to identify predictors of pediatric CA-CDAD. RESULTS Of 69 CA-CDAD cases, most (62.3%) had an underlying chronic medical condition and 40.6% had antibiotic exposure within 30 days of illness. However, no traditional risk factor for CDAD was identified in 23.2% and 15.9% of CA-CDAD cases within 30 and 90 days of illness onset, respectively. Outpatient healthcare encounters within 30 days were more common among CA-CDAD cases than control subjects (66.7% vs. 48.6%; P = 0.01). In the final multivariate model, CA-CDAD was associated with cephalosporin use within 30 days [odds ratio: 3.32; 95% confidence interval: 1.10-10.01] and the presence of a gastrointestinal feeding device (odds ratio: 2.59; 95% confidence interval: 1.07-6.30). CONCLUSIONS Recent use of cephalosporins and the presence of gastrointestinal feeding devices are important risk factors for community- associated CDAD in children. Reduction in the use of outpatient antibiotics may decrease the burden of CA-CDAD in children.
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139
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Affiliation(s)
- Sharon B. Meropol
- Departments of Pediatrics,,Biostatistics and Epidemiology, and,The Center for Child Health and Policy, Rainbow Babies and Children’s Hospital, Cleveland, Ohio
| | - Mark E. Votruba
- Economics, Weatherhead School of Management, and the,Center for Health Care Research and Policy, School of Medicine, and Case Western Reserve University, Cleveland, Ohio; and
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140
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Vaz LE, Kleinman KP, Lakoma MD, Dutta-Linn MM, Nahill C, Hellinger J, Finkelstein JA. Prevalence of Parental Misconceptions About Antibiotic Use. Pediatrics 2015; 136:221-31. [PMID: 26195539 PMCID: PMC4516948 DOI: 10.1542/peds.2015-0883] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Differences in antibiotic knowledge and attitudes between parents of Medicaid-insured and commercially insured children have been previously reported. It is unknown whether understanding has improved and whether previously identified differences persist. METHODS A total of 1500 Massachusetts parents with a child <6 years old insured by a Medicaid managed care or commercial health plan were surveyed in spring 2013. We examined antibiotic-related knowledge and attitudes by using χ(2) tests. Multivariable modeling was used to assess current sociodemographic predictors of knowledge and evaluate changes in predictors from a similar survey in 2000. RESULTS Medicaid-insured parents in 2013 (n = 345) were younger, were less likely to be white, and had less education than those commercially insured (n = 353), P < .01. Fewer Medicaid-insured parents answered questions correctly except for one related to bronchitis, for which there was no difference (15% Medicaid vs 16% commercial, P < .66). More parents understood that green nasal discharge did not require antibiotics in 2013 compared with 2000, but this increase was smaller among Medicaid-insured (32% vs 22% P = .02) than commercially insured (49% vs 23%, P < .01) parents. Medicaid-insured parents were more likely to request unnecessary antibiotics in 2013 (P < .01). Multivariable models for predictors of knowledge or attitudes demonstrated complex relationships between insurance status and sociodemographic variables. CONCLUSIONS Misconceptions about antibiotic use persist and continue to be more prevalent among parents of Medicaid-insured children. Improvement in understanding has been more pronounced in more advantaged populations. Tailored efforts for socioeconomically disadvantaged populations remain warranted to decrease parental drivers of unnecessary antibiotic prescribing.
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Affiliation(s)
- Louise Elaine Vaz
- Division of Pediatric Infectious Diseases, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon;
| | - Kenneth P Kleinman
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Matthew D Lakoma
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - M Maya Dutta-Linn
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - James Hellinger
- Neighborhood Health Plan, Boston, Massachusetts; Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts; and
| | - Jonathan A Finkelstein
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts; Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
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141
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Richards JR, Gaylor KA, Pilgrim AJ. Comparison of traditional otoscope to iPhone otoscope in the pediatric ED. Am J Emerg Med 2015; 33:1089-92. [DOI: 10.1016/j.ajem.2015.04.063] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 04/24/2015] [Accepted: 04/27/2015] [Indexed: 11/30/2022] Open
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142
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Moore AM, Ahmadi S, Patel S, Gibson MK, Wang B, Ndao MI, Deych E, Shannon W, Tarr PI, Warner BB, Dantas G. Gut resistome development in healthy twin pairs in the first year of life. MICROBIOME 2015; 3:27. [PMID: 26113976 PMCID: PMC4480905 DOI: 10.1186/s40168-015-0090-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/05/2015] [Indexed: 05/24/2023]
Abstract
BACKGROUND The early life of the human host marks a critically important time for establishment of the gut microbial community, yet the developmental trajectory of gut community-encoded resistance genes (resistome) is unknown. We present a longitudinal study of the fecal antibiotic resistome of healthy amoxicillin-exposed and antibiotic-naive twins and their mothers during the first year of life. RESULTS We extracted metagenomic DNA (mgDNA) from fecal samples collected from three healthy twin pairs at three timepoints (1 or 2 months, 6 or 7 months, and 11 months) and from their mothers (collected at delivery). The mgDNA was used to construct metagenomic expression libraries in an Escherichia coli host. These libraries were screened for antibiotic resistance, and functionally selected resistance genes were sequenced and annotated. A diverse fecal resistome distinct from the maternal resistome was apparent by 2 months of age, and infants' fecal resistomes included resistance to clinically important broad-spectrum beta-lactam antibiotics (e.g., piperacillin-tazobactam, aztreonam, cefepime) not found in their mothers. Dissemination of resistance genes among members of a given family was positively correlated with sharing of those same resistance genes between unrelated families, potentially identifying within-family sharing as a marker of resistance genes emerging in the human community at large. Finally, we found a distinct developmental trajectory for a community-encoded function: chloramphenicol resistance. All study subjects at all timepoints harbored chloramphenicol resistance determinants, but multidrug efflux pumps (rarely found in mothers) were the primary effectors of chloramphenicol resistance in young infants. Chloramphenicol acetyltransferases were more common in mothers than in infants and were found in nearly all the infants at later timepoints. CONCLUSIONS Our results suggest that healthy 1-2-month-old infants' gut microbes harbor clinically relevant resistance genes distinct from those of their mothers, and that family-specific shared environmental factors early in life shape resistome development.
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Affiliation(s)
- Aimee M. Moore
- />Department of Pediatrics, Washington University in St Louis School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
- />Center for Genome Sciences and Systems Biology, Washington University in St. Louis School of Medicine, 4444 Forest Park Boulevard, St. Louis, MO 63108 USA
| | - Sara Ahmadi
- />Department of Pathology and Immunology, Washington University in St. Louis School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
- />Center for Genome Sciences and Systems Biology, Washington University in St. Louis School of Medicine, 4444 Forest Park Boulevard, St. Louis, MO 63108 USA
| | - Sanket Patel
- />Department of Pathology and Immunology, Washington University in St. Louis School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
- />Center for Genome Sciences and Systems Biology, Washington University in St. Louis School of Medicine, 4444 Forest Park Boulevard, St. Louis, MO 63108 USA
| | - Molly K. Gibson
- />Center for Genome Sciences and Systems Biology, Washington University in St. Louis School of Medicine, 4444 Forest Park Boulevard, St. Louis, MO 63108 USA
| | - Bin Wang
- />Department of Pathology and Immunology, Washington University in St. Louis School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
- />Center for Genome Sciences and Systems Biology, Washington University in St. Louis School of Medicine, 4444 Forest Park Boulevard, St. Louis, MO 63108 USA
| | - Malick I. Ndao
- />Department of Pediatrics, Washington University in St Louis School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
| | - Elena Deych
- />Department of Biostatistics, Washington University in St. Louis School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
| | - William Shannon
- />Department of Biostatistics, Washington University in St. Louis School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
| | - Phillip I. Tarr
- />Department of Pediatrics, Washington University in St Louis School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
- />Department of Molecular Microbiology, Washington University in St. School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
| | - Barbara B. Warner
- />Department of Pediatrics, Washington University in St Louis School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
| | - Gautam Dantas
- />Department of Pathology and Immunology, Washington University in St. Louis School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
- />Center for Genome Sciences and Systems Biology, Washington University in St. Louis School of Medicine, 4444 Forest Park Boulevard, St. Louis, MO 63108 USA
- />Department of Biomedical Engineering, Washington University in St. Louis, One Brookings Drive, St. Louis, MO 63130 USA
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143
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Abstract
BACKGROUND Antibiotic treatment of childhood illnesses is common in India. In addition to contributing to antimicrobial resistance, antibiotics might result in increased susceptibility to diarrhea through interactions with the gastrointestinal microbiota. Breast milk, which enriches the microbiota early in life, may increase the resilience of the microbiota against perturbations by antibiotics. METHODS In a prospective observational cohort study, we assessed whether antibiotic exposures from birth to 6 months affected rates of diarrhea up to age 3 years among 465 children from Vellore, India. Adjusting for treatment indicators, we modeled diarrheal rates among children exposed and unexposed to antibiotics using negative binomial regression. We further assessed whether the effect of antibiotics on diarrheal rates was modified by exclusive breastfeeding at 6 months. RESULTS More than half of the children (n = 267, 57.4%) were given at least one course of antibiotics in the first 6 months of life. The adjusted relative incidence rate of diarrhea was 33% higher among children who received antibiotics under 6 months of age compared with those who did not (incidence rate ratio: 1.33, 95% confidence interval: 1.12, 1.57). Children who were exclusively breastfed until 6 months of age did not have increased diarrheal rates following antibiotic use. CONCLUSIONS Antibiotic exposures early in life were associated with increased rates of diarrhea in early childhood. Exclusive breastfeeding might protect against this negative impact.
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144
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Kourlaba G, Kourkouni E, Spyridis N, Gerber JS, Kopsidas J, Mougkou K, Lourida A, Zaoutis TE. Antibiotic prescribing and expenditures in outpatient paediatrics in Greece, 2010-13. J Antimicrob Chemother 2015; 70:2405-8. [PMID: 25881618 DOI: 10.1093/jac/dkv091] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/18/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The objectives of this study were to provide a nationally representative analysis of antibiotic prescribing in outpatient paediatrics and to assess overall and class-specific antibiotic costs in Greece. METHODS Data on antibiotic prescriptions for patients aged ≤19 years old between July 2010 and June 2013 in Greece were extracted from the IMS Health Xponent database. Antibiotics were grouped into narrow- and broad-spectrum agents. The number of prescribed antibiotics and census denominators were used to calculate prescribing rates. The total costs associated with prescribed antibiotics were calculated. RESULTS More than 7 million antibiotics were prescribed during the study period, with an annual rate of 1100 antibiotics/1000 persons. Prescribing rates were higher among children aged <10 years old. Acute respiratory tract infections (ARTIs) accounted for 80% of prescribed antibiotics, with acute otitis media (22.3%), acute tonsillitis (19.5%) and acute bronchitis/bronchiolitis (13.9%) being the most common clinical diagnoses. Cephalosporins (32.9%), penicillins (32.3%) and macrolides (32.1%) were the most commonly prescribed antibiotic classes. The majority (90.4%) of antibiotics were broad spectrum. Antibiotic expenditures totalled ∼€50 million. CONCLUSIONS Broad-spectrum antibiotic prescribing is common in outpatient paediatric patients. These data provide important targets to inform the development of an outpatient antimicrobial stewardship programme targeting specific practices, providers and conditions.
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Affiliation(s)
- Georgia Kourlaba
- The Stavros Niarchos Foundation - Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), University of Athens School of Medicine, Athens, Greece
| | - Eleni Kourkouni
- The Stavros Niarchos Foundation - Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), University of Athens School of Medicine, Athens, Greece
| | - Nikos Spyridis
- Aglaia Kyriakou Children's Hospital, Second Department of Pediatrics, University of Athens School of Medicine, Athens, Greece
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, UPENN School of Medicine, Philadelphia, PA, USA
| | - John Kopsidas
- The Stavros Niarchos Foundation - Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), University of Athens School of Medicine, Athens, Greece
| | - Katerina Mougkou
- The Stavros Niarchos Foundation - Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), University of Athens School of Medicine, Athens, Greece
| | - Athanasia Lourida
- The Stavros Niarchos Foundation - Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), University of Athens School of Medicine, Athens, Greece
| | - Theoklis E Zaoutis
- The Stavros Niarchos Foundation - Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), University of Athens School of Medicine, Athens, Greece Division of Infectious Diseases, Children's Hospital of Philadelphia, UPENN School of Medicine, Philadelphia, PA, USA
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145
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Saleh EA, Schroeder DR, Hanson AC, Banerjee R. Guideline-concordant antibiotic prescribing for pediatric outpatients with otitis media, community-acquired pneumonia, and skin and soft tissue infections in a large multispecialty healthcare system. CLINICAL RESEARCH IN INFECTIOUS DISEASES 2015; 2:1010. [PMID: 25879084 PMCID: PMC4394205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Antibiotics are commonly prescribed in pediatric outpatient settings; however, efforts to decrease inappropriate use have largely focused on inpatients. We obtained baseline metrics to identify conditions that may benefit from establishment of outpatient antimicrobial stewardship interventions (ASP). We evaluated rates and appropriateness of antibiotic prescribing for children with acute otitis media (AOM), community acquired pneumonia (CAP), and skin and soft tissue infections (SSTI) in ambulatory settings within a large healthcare system in the US Midwest. We retrospectively reviewed 77,821 visits and associated diagnostic codes for children less than 17 years seen in ambulatory settings within our health system from August 1, 2009 to July 31, 2010. We measured rates of antibiotic prescribing by location, provider type, patient age, and diagnosis, and assessed concordance with treatment guidelines for AOM, CAP, and SSTI. AOM, CAP, and SSTI comprised about 1/3 of all infections in the study population. Antibiotics were prescribed in 14,543 (18.7%) visits. Antibiotic prescribing rates were 1.1 to 1.2 times higher among Emergency Room (ER) providers compared to Pediatricians and Family Physicians. Antibiotics prescribed for AOM and SSTI were concordant with guidelines in approximately 97% of cases. In contrast, 47% of antibiotics prescribed for treatment of CAP in children < 5 years old were macrolides, which are not recommended first line therapy for CAP in this age group. Antibiotic prescribing for pediatric outpatients within our health system is not guideline-concordant for treatment of CAP.
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Affiliation(s)
- Ezzeldin A. Saleh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Darrell R. Schroeder
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Andrew C. Hanson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ritu Banerjee
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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146
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Cohen JF, Cohen R, Levy C, Thollot F, Benani M, Bidet P, Chalumeau M. Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: a systematic review and prospective multicentre external validation study. CMAJ 2014; 187:23-32. [PMID: 25487666 DOI: 10.1503/cmaj.140772] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Several clinical prediction rules for diagnosing group A streptococcal infection in children with pharyngitis are available. We aimed to compare the diagnostic accuracy of rules-based selective testing strategies in a prospective cohort of children with pharyngitis. METHODS We identified clinical prediction rules through a systematic search of MEDLINE and Embase (1975-2014), which we then validated in a prospective cohort involving French children who presented with pharyngitis during a 1-year period (2010-2011). We diagnosed infection with group A streptococcus using two throat swabs: one obtained for a rapid antigen detection test (StreptAtest, Dectrapharm) and one obtained for culture (reference standard). We validated rules-based selective testing strategies as follows: low risk of group A streptococcal infection, no further testing or antibiotic therapy needed; intermediate risk of infection, rapid antigen detection for all patients and antibiotic therapy for those with a positive test result; and high risk of infection, empiric antibiotic treatment. RESULTS We identified 8 clinical prediction rules, 6 of which could be prospectively validated. Sensitivity and specificity of rules-based selective testing strategies ranged from 66% (95% confidence interval [CI] 61-72) to 94% (95% CI 92-97) and from 40% (95% CI 35-45) to 88% (95% CI 85-91), respectively. Use of rapid antigen detection testing following the clinical prediction rule ranged from 24% (95% CI 21-27) to 86% (95% CI 84-89). None of the rules-based selective testing strategies achieved our diagnostic accuracy target (sensitivity and specificity>85%). INTERPRETATION Rules-based selective testing strategies did not show sufficient diagnostic accuracy in this study population. The relevance of clinical prediction rules for determining which children with pharyngitis should undergo a rapid antigen detection test remains questionable.
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Affiliation(s)
- Jérémie F Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Cohen J.F., Chalumeau), Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France; Department of Pediatrics (Cohen J.F., Chalumeau), Necker-Enfants-Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France; Association Clinique et Thérapeutique Infantile du Val-de-Marne (Cohen R., Levy, Benani), Saint-Maur-des-Fossés, France; Department of Microbiology (Cohen R.), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Clinical Research Center (Levy), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Association Française de Pédiatrie Ambulatoire (Thollot), Essey-lès-Nancy, France; Department of Microbiology (Bidet), Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Robert Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Cohen J.F., Chalumeau), Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France; Department of Pediatrics (Cohen J.F., Chalumeau), Necker-Enfants-Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France; Association Clinique et Thérapeutique Infantile du Val-de-Marne (Cohen R., Levy, Benani), Saint-Maur-des-Fossés, France; Department of Microbiology (Cohen R.), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Clinical Research Center (Levy), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Association Française de Pédiatrie Ambulatoire (Thollot), Essey-lès-Nancy, France; Department of Microbiology (Bidet), Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Corinne Levy
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Cohen J.F., Chalumeau), Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France; Department of Pediatrics (Cohen J.F., Chalumeau), Necker-Enfants-Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France; Association Clinique et Thérapeutique Infantile du Val-de-Marne (Cohen R., Levy, Benani), Saint-Maur-des-Fossés, France; Department of Microbiology (Cohen R.), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Clinical Research Center (Levy), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Association Française de Pédiatrie Ambulatoire (Thollot), Essey-lès-Nancy, France; Department of Microbiology (Bidet), Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Franck Thollot
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Cohen J.F., Chalumeau), Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France; Department of Pediatrics (Cohen J.F., Chalumeau), Necker-Enfants-Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France; Association Clinique et Thérapeutique Infantile du Val-de-Marne (Cohen R., Levy, Benani), Saint-Maur-des-Fossés, France; Department of Microbiology (Cohen R.), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Clinical Research Center (Levy), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Association Française de Pédiatrie Ambulatoire (Thollot), Essey-lès-Nancy, France; Department of Microbiology (Bidet), Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Mohamed Benani
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Cohen J.F., Chalumeau), Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France; Department of Pediatrics (Cohen J.F., Chalumeau), Necker-Enfants-Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France; Association Clinique et Thérapeutique Infantile du Val-de-Marne (Cohen R., Levy, Benani), Saint-Maur-des-Fossés, France; Department of Microbiology (Cohen R.), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Clinical Research Center (Levy), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Association Française de Pédiatrie Ambulatoire (Thollot), Essey-lès-Nancy, France; Department of Microbiology (Bidet), Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Philippe Bidet
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Cohen J.F., Chalumeau), Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France; Department of Pediatrics (Cohen J.F., Chalumeau), Necker-Enfants-Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France; Association Clinique et Thérapeutique Infantile du Val-de-Marne (Cohen R., Levy, Benani), Saint-Maur-des-Fossés, France; Department of Microbiology (Cohen R.), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Clinical Research Center (Levy), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Association Française de Pédiatrie Ambulatoire (Thollot), Essey-lès-Nancy, France; Department of Microbiology (Bidet), Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Cohen J.F., Chalumeau), Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France; Department of Pediatrics (Cohen J.F., Chalumeau), Necker-Enfants-Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France; Association Clinique et Thérapeutique Infantile du Val-de-Marne (Cohen R., Levy, Benani), Saint-Maur-des-Fossés, France; Department of Microbiology (Cohen R.), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Clinical Research Center (Levy), Centre Hospitalier Intercommunal de Créteil, Créteil, France; Association Française de Pédiatrie Ambulatoire (Thollot), Essey-lès-Nancy, France; Department of Microbiology (Bidet), Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, Sorbonne Paris Cité, Paris, France
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147
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Affiliation(s)
- Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts; RAND Health, Boston, Massachusetts, and Santa Monica, California; and Beth Israel Deaconess Hospital, Boston, Massachusetts
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