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Abstract
Rhinitis is defined as inflammation of the nose, which can extend into and affect the sinuses. The term rhinosinusitis is used to describe inflammation of both the nose and the sinuses. An example of rhinitis is allergic rhinitis, caused by sensitization and exposure to aeroallergens, which, along with other allergic diseases, such as asthma, affect up to one-third of women in the childbearing age. The most common type of rhinosinusitis is infectious, either acute or chronic, which commonly occurs secondarily to a viral respiratory tract infection. Both rhinitis and rhinosinusitis significantly affect the quality of life. The purpose of this chapter is to introduce and describe the differential diagnosis and treatment of these two common clinical entities during pregnancy.
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Affiliation(s)
- Jennifer A. Namazy
- Division of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, CA USA
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente Medical Center, San Diego, CA USA
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152
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Practical Guidance for Clinical Microbiology Laboratories: Viruses Causing Acute Respiratory Tract Infections. Clin Microbiol Rev 2018; 32:32/1/e00042-18. [PMID: 30541871 DOI: 10.1128/cmr.00042-18] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Respiratory viral infections are associated with a wide range of acute syndromes and infectious disease processes in children and adults worldwide. Many viruses are implicated in these infections, and these viruses are spread largely via respiratory means between humans but also occasionally from animals to humans. This article is an American Society for Microbiology (ASM)-sponsored Practical Guidance for Clinical Microbiology (PGCM) document identifying best practices for diagnosis and characterization of viruses that cause acute respiratory infections and replaces the most recent prior version of the ASM-sponsored Cumitech 21 document, Laboratory Diagnosis of Viral Respiratory Disease, published in 1986. The scope of the original document was quite broad, with an emphasis on clinical diagnosis of a wide variety of infectious agents and laboratory focus on antigen detection and viral culture. The new PGCM document is designed to be used by laboratorians in a wide variety of diagnostic and public health microbiology/virology laboratory settings worldwide. The article provides guidance to a rapidly changing field of diagnostics and outlines the epidemiology and clinical impact of acute respiratory viral infections, including preferred methods of specimen collection and current methods for diagnosis and characterization of viral pathogens causing acute respiratory tract infections. Compared to the case in 1986, molecular techniques are now the preferred diagnostic approaches for the detection of acute respiratory viruses, and they allow for automation, high-throughput workflows, and near-patient testing. These changes require quality assurance programs to prevent laboratory contamination as well as strong preanalytical screening approaches to utilize laboratory resources appropriately. Appropriate guidance from laboratorians to stakeholders will allow for appropriate specimen collection, as well as correct test ordering that will quickly identify highly transmissible emerging pathogens.
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153
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Dilger AE, Peters AT, Wunderink RG, Tan BK, Kern RC, Conley DB, Welch KC, Holl JL, Smith SS. Procalcitonin as a Biomarker in Rhinosinusitis: A Systematic Review. Am J Rhinol Allergy 2018; 33:103-112. [PMID: 30871341 DOI: 10.1177/1945892418810293] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES (1) To describe the existing literature on procalcitonin (PCT) as a biomarker in patients with acute rhinosinusitis (ARS), (2) to analyze outcomes in ARS patients who were treated with PCT-guided therapy versus traditional management, and (3) to compare PCT to other biomarkers used in diagnosis of bacterial ARS. Data Sources: PubMed and Embase. Review Methods: A systematic search in the PubMed and Embase databases was performed to identify studies related to PCT as a biomarker in ARS. After critical appraisal of validity by 2 authors, 6 studies with a total of 313 patients were selected for data extraction and analysis. We identified 2 randomized control trials (RCTs) of PCT-based guidelines for antibiotic management of ARS in outpatient settings and 4 observational studies that compared PCT to other biomarkers in patients with ARS. RESULTS The 2 RCTs demonstrated a reduction (41.6% in 1 study and 71% in the other) in antibiotic prescription rate in the PCT-guided group versus the control group with no change in the number of days with impaired activity due to illness (9.0 vs 9.0 days [ P = .96]; 8.1 vs 8.2 days [95% confidence interval -0.7 to 0.7]), number of days of work missed, and percentage of patients with persistent symptoms at 28 days. In the observational cohort studies, PCT did not consistently correlate with C-reactive protein, body temperature, and/or white blood cell counts. CONCLUSIONS The limited existing literature on the role of PCT in diagnosis, management, and prediction of clinical outcomes in ARS suggests that PCT-based guidelines for antibiotic prescription are a safe and effective method of minimizing unnecessary antibiotic use.
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Affiliation(s)
- Amanda E Dilger
- 1 Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anju T Peters
- 2 Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard G Wunderink
- 3 Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bruce K Tan
- 1 Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert C Kern
- 1 Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David B Conley
- 1 Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kevin C Welch
- 1 Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jane L Holl
- 4 Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephanie Shintani Smith
- 1 Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,4 Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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154
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Variation in Outpatient Antibiotic Dispensing for Respiratory Infections in Children by Clinician Specialty and Treatment Setting. Pediatr Infect Dis J 2018; 37:1248-1254. [PMID: 30408006 DOI: 10.1097/inf.0000000000002004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Antibiotics are commonly prescribed for children with acute respiratory infections (ARIs). This study describes the distribution of ARI diagnoses and specifically quantifies antibiotic dispensing for bronchitis and upper respiratory infection (URI) by treatment setting and specialty. METHODS This retrospective, observational cross-sectional study used data from the HealthCore Integrated Research Environment containing claims from 14 commercial health plans for 2012 to 2014. Children (2-17 years) with first-episode ARI were identified by diagnosis of acute otitis media (AOM), sinusitis, pharyngitis, bronchitis or URI with no competing infections or chronic illnesses. Treatment setting was where diagnoses were made: primary care offices, urgent care centers (UCC), retail health clinics (RHCs) or emergency departments. Primary outcome measure was antibiotic prescription fills from pharmacies within 2 days of start of ARI episode. RESULTS For URI, the highest proportions in antibiotic dispensing were ordered by office-based or UCC family physicians (28% and 30%, respectively) and office-based or UCC nurse practitioners/physician assistants (30% and 29%, respectively). Across all settings and specialties, there was high proportion of antibiotic dispensing for bronchitis (75%). Overall, 48% of 544,531 children diagnosed with ARI filled antibiotics. Nurse practitioners/physician assistants in RHC made the most diagnoses of AOM (24%) and streptococcal pharyngitis (22%). CONCLUSIONS Outreach efforts to decrease antibiotic dispensing for URI can be focused on office-based and UCC family physicians and nurse practitioners/physician assistants. All specialties need widespread interventions to reduce antibiotic dispensing for bronchitis. RHC nurse practitioners/physician assistants can be targeted to reduce high proportion of AOM and streptococcal pharyngitis diagnoses.
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155
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Tierney DM, Becker JS, Post BD, Rosborough TK. Point-of-Care Sinus Ultrasound: Impact Within a Large Internal Medicine Clinic and Review of Technique. South Med J 2018; 111:411-417. [PMID: 29978226 DOI: 10.14423/smj.0000000000000830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Outpatient diagnosis of acute bacterial sinusitis, using only traditional physical examination and clinical criteria, results in the overuse of antibiotics in patients with upper respiratory complaints. Point-of-care maxillary sinus ultrasound is easy to learn and quick to perform in a primary care clinic. The technique can reduce antibiotic prescribing by reassuring both patients and providers of the absence of fluid in the sinus, the hallmark of maxillary sinusitis. A review of the literature, description of technique, and results of sinus ultrasound implementation in a large internal medicine clinic are included.
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Affiliation(s)
- David M Tierney
- From the Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Joshua S Becker
- From the Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bryan D Post
- From the Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Terry K Rosborough
- From the Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, Minnesota
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156
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Yonts AB, Kronman MP, Hamdy RF. The Burden and Impact of Antibiotic Prescribing in Ambulatory Pediatrics. Curr Probl Pediatr Adolesc Health Care 2018; 48:272-288. [PMID: 30337150 DOI: 10.1016/j.cppeds.2018.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Antibiotics are one of the most commonly prescribed classes of medication for children and adolescents. While they are arguably the most powerful tool we possess against bacterial infections, they are frequently given to children whose illnesses are due to viruses or other non-infectious etiologies. When antibiotics are not used judiciously, the consequences can be serious and accumulate over time. This review article quantifies the burden of antimicrobial use in the pediatric outpatient setting in the United States, reviews recommended first line antibiotic regimens for common outpatient pediatric and adolescent conditions, investigates the reasons for inappropriate prescribing of antibiotics in outpatient healthcare settings, and explores the range of consequences of overuse and inappropriate use of antibiotics, from adverse drug reactions to impact on the microbiome to rising rates of antimicrobial resistance in common ambulatory conditions.
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Affiliation(s)
- Alexandra B Yonts
- Division of Infectious Diseases, Children's National Medical Center, Washington, D.C., United States
| | - Matthew P Kronman
- Division of Pediatric Infectious Diseases, University of Washington, Seattle, WA, United States
| | - Rana F Hamdy
- Division of Infectious Diseases, Children's National Medical Center, Washington, D.C., United States; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States.
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157
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Abstract
Infections of the head and neck are common and appropriately managed by primary care providers in most cases. However, some infections are associated with significant morbidity and require urgent recognition and management by specialty services. These include deep neck space infections originating in the oral cavity, pharynx, and salivary glands, as well as complicated otologic and sinonasal infection. This article provides a review of these conditions, including the pathophysiology, presenting features, and initial management strategy.
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Affiliation(s)
- Marika D Russell
- Otolaryngology-Head and Neck Surgery, University of California, San Francisco, 2233 Post Street, 3rd floor, San Francisco, CA 94115, USA.
| | - Matthew S Russell
- Otolaryngology-Head and Neck Surgery, University of California, San Francisco, 2233 Post Street, 3rd floor, San Francisco, CA 94115, USA
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158
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Abstract
Acute bacterial sinusitis (ABS) mostly occurs as a complication of acute viral upper respiratory tract infection (URI), which is a common condition encountered in an outpatient setting. ABS manifests with three different presentations, most commonly as persistent symptoms of viral URI (nasal drainage and or cough) for more than 10 days. ABS is also diagnosed when the patient presents with severe symptoms of a URI accompanied by fever >102.2°F and purulent nasal drainage for at least 3 days. Lastly, ABS can complicate viral URI around day 6 or 7 of illness after initial improvement in the symptoms of URI. Imaging studies are not recommended for diagnosing ABS, unless intracranial or orbital complications are suspected. Signs of proptosis, restriction of eye movements, ophthalmoplegia, and visual impairment are very specific for orbital involvement. Treatment of ABS with antibiotics is recommended based on the clinical scenario and has been shown to have higher cure rates as compared to placebo. [Pediatr Ann. 2018;47(10):e396-e401.].
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159
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Singer A, Kosowan L, Katz A, Jolin-Dahel K, Appel K, Lix LM. Prescribing and testing by primary care providers to assess adherence to the Choosing Wisely Canada recommendations: a retrospective cohort study. CMAJ Open 2018; 6:E603-E610. [PMID: 30530720 PMCID: PMC6287976 DOI: 10.9778/cmajo.20180053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Choosing Wisely Canada is an initiative to reduce overprescribing and overtesting. This study assessed adherence to 4 Choosing Wisely Canada recommendations for interventions commonly performed in primary care: (a) antibiotic prescriptions for infections that are probably viral in origin, (b) routine vitamin D tests in low-risk adults, (c) annual screening blood tests and (d) prescriptions of antipsychotic medication to treat symptoms of dementia. METHODS We conducted a retrospective cohort study of data from the electronic medical records of patients who had an encounter between 2014 and 2016 with a participating Manitoba Primary Care Research Network primary care provider in Manitoba, Canada. Patient encounter data were reviewed for prescribing and testing practices. Descriptive statistics and multivariable models assessed associations between patient and provider characteristics and rates of prescribing and testing. RESULTS Data for 164 195 patients from 230 providers were included in the study. Sixteen percent (n = 25 629) of patients had an encounter that involved potentially unnecessary diagnostic testing and treatment. A minority of providers contributed to above-average rates of prescribing and testing: 29% (n = 69) of providers prescribed antibiotics for a viral indication,11% (n = 24) prescribed an antipsychotic to a patient diagnosed with dementia, 9% (n = 24) ordered prostate-specific antigen tests and 14% (n = 34) ordered vitamin D tests at above-average rates, respectively. Patient and provider characteristics were associated with each of the prescribing and testing practices assessed. INTERPRETATION This study demonstrated that fewer than 30% of primary care providers contributed to interventions in direct contradiction to Choosing Wisely Canada recommendations. Improvement strategies specific to each prescription or testing recommendation should target specific providers to prevent patient harm and reduce unnecessary health care spending.
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Affiliation(s)
- Alexander Singer
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man
| | - Leanne Kosowan
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man.
| | - Alan Katz
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man
| | - Kheira Jolin-Dahel
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man
| | - Karen Appel
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man
| | - Lisa M Lix
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man
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160
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Durkin MJ, Keller M, Butler AM, Kwon JH, Dubberke ER, Miller AC, Polgreen PM, Olsen MA. An Assessment of Inappropriate Antibiotic Use and Guideline Adherence for Uncomplicated Urinary Tract Infections. Open Forum Infect Dis 2018; 5:ofy198. [PMID: 30191156 PMCID: PMC6121225 DOI: 10.1093/ofid/ofy198] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/08/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In 2011, The Infectious Diseases Society of America released a clinical practice guideline (CPG) that recommended short-course antibiotic therapy and avoidance of fluoroquinolones for uncomplicated urinary tract infections (UTIs). Recommendations from this CPG were rapidly disseminated to clinicians via review articles, UpToDate, and the Centers for Disease Control and Prevention website; however, it is unclear if this CPG had an impact on national antibiotic prescribing practices. METHODS We performed a retrospective cohort study of outpatient and emergency department visits within a commercial insurance database between January 1, 2009, and December 31, 2013. We included nonpregnant women aged 18-44 years who had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for a UTI with a concurrent antibiotic prescription. We performed interrupted time series analyses to determine the impact of the CPG on the appropriateness of the antibiotic agent and duration. RESULTS We identified 654 432 women diagnosed with UTI. The patient population was young (mean age, 31 years) and had few comorbidities. Fluoroquinolones, nonfirstline agents, were the most commonly prescribed antibiotic class both before and after release of the guidelines (45% vs 42%). Wide variation was observed in the duration of treatment, with >75% of prescriptions written for nonrecommended treatment durations. The CPG had minimal impact on antibiotic prescribing behavior by providers. CONCLUSIONS Inappropriate antibiotic prescribing is common for the treatment of UTIs. The CPG was not associated with a clinically meaningful change in national antibiotic prescribing practices for UTIs. Further interventions are necessary to improve outpatient antibiotic prescribing for UTIs.
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Affiliation(s)
- Michael J Durkin
- Division of Infectious Diseases, Department of Internal Medicine
| | - Matthew Keller
- Division of Infectious Diseases, Department of Internal Medicine
| | - Anne M Butler
- Division of Infectious Diseases, Department of Internal Medicine
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Jennie H Kwon
- Division of Infectious Diseases, Department of Internal Medicine
| | - Erik R Dubberke
- Division of Infectious Diseases, Department of Internal Medicine
| | | | - Phillip M Polgreen
- Department of Epidemiology, College of Public Health
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Margaret A Olsen
- Division of Infectious Diseases, Department of Internal Medicine
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
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161
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Miller JM, Binnicker MJ, Campbell S, Carroll KC, Chapin KC, Gilligan PH, Gonzalez MD, Jerris RC, Kehl SC, Patel R, Pritt BS, Richter SS, Robinson-Dunn B, Schwartzman JD, Snyder JW, Telford S, Theel ES, Thomson RB, Weinstein MP, Yao JD. A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis 2018; 67:e1-e94. [PMID: 29955859 PMCID: PMC7108105 DOI: 10.1093/cid/ciy381] [Citation(s) in RCA: 286] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 04/28/2018] [Indexed: 12/12/2022] Open
Abstract
The critical nature of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician/advanced practice provider and the microbiologists who provide enormous value to the healthcare team. This document, developed by experts in laboratory and adult and pediatric clinical medicine, provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions. This document presents a system-based approach rather than specimen-based approach, and includes bloodstream and cardiovascular system infections, central nervous system infections, ocular infections, soft tissue infections of the head and neck, upper and lower respiratory infections, infections of the gastrointestinal tract, intra-abdominal infections, bone and joint infections, urinary tract infections, genital infections, and other skin and soft tissue infections; or into etiologic agent groups, including arthropod-borne infections, viral syndromes, and blood and tissue parasite infections. Each section contains introductory concepts, a summary of key points, and detailed tables that list suspected agents; the most reliable tests to order; the samples (and volumes) to collect in order of preference; specimen transport devices, procedures, times, and temperatures; and detailed notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times. In addition, the pediatric needs of specimen management are also emphasized. There is intentional redundancy among the tables and sections, as many agents and assay choices overlap. The document is intended to serve as a guidance for physicians in choosing tests that will aid them to quickly and accurately diagnose infectious diseases in their patients.
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Affiliation(s)
| | - Matthew J Binnicker
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Karen C Carroll
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | | | - Peter H Gilligan
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill
| | - Mark D Gonzalez
- Department of Pathology, Children’s Healthcare of Atlanta, Georgia
| | - Robert C Jerris
- Department of Pathology, Children’s Healthcare of Atlanta, Georgia
| | | | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Bobbi S Pritt
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Barbara Robinson-Dunn
- Department of Pathology and Laboratory Medicine, Beaumont Health, Royal Oak, Michigan
| | | | - James W Snyder
- Department of Pathology and Laboratory Medicine, University of Louisville, Kentucky
| | - Sam Telford
- Department of Infectious Disease and Global Health, Tufts University, North Grafton, Massachusetts
| | - Elitza S Theel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Richard B Thomson
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, Illinois
| | - Melvin P Weinstein
- Departments of Medicine and Pathology & Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Joseph D Yao
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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162
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King LM, Hicks LA, Fleming-Dutra KE. Further Considerations Regarding Duration of Antibiotic Therapy for Sinusitis-Reply. JAMA Intern Med 2018; 178:1138-1139. [PMID: 30083743 PMCID: PMC6541207 DOI: 10.1001/jamainternmed.2018.3013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Laura M King
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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163
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Prevalence of Inappropriate Antibiotic Prescribing in Primary Care Clinics within a Veterans Affairs Health Care System. Antimicrob Agents Chemother 2018; 62:AAC.00337-18. [PMID: 29967028 DOI: 10.1128/aac.00337-18] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 06/05/2018] [Indexed: 01/12/2023] Open
Abstract
Data are needed from outpatient settings to better inform antimicrobial stewardship. In this study, a random sample of outpatient antibiotic prescriptions by primary care providers (PCPs) at our health care system was reviewed and compared to consensus guidelines. Over 12 months, 3,880 acute antibiotic prescriptions were written by 76 PCPs caring for 40,734 patients (median panel, 600 patients; range, 33 to 1,547). PCPs ordered a median of 84 antibiotic prescriptions per 1,000 patients per year. Azithromycin (25.8%), amoxicillin-clavulanate (13.3%), doxycycline (12.4%), amoxicillin (11%), fluoroquinolones (11%), and trimethoprim-sulfamethoxazole (10.6%) were prescribed most commonly. Medical records corresponding to 300 prescriptions from 59 PCPs were analyzed in depth. The most common indications for these prescriptions were acute respiratory tract infection (28.3%), urinary tract infection (23%), skin and soft tissue infection (15.7%), and chronic obstructive pulmonary disease (COPD) exacerbation (6.3%). In 5.7% of cases, no reason for the prescription was listed. No antibiotic was indicated in 49.7% of cases. In 12.3% of cases, an antibiotic was indicated, but the prescribed agent was guideline discordant. In another 14% of cases, a guideline-concordant antibiotic was given for a guideline-discordant duration. Therefore, 76% of reviewed prescriptions were inappropriate. Ciprofloxacin and azithromycin were most likely to be prescribed inappropriately. A non-face-to-face encounter prompted 34% of prescriptions. The condition for which an antibiotic was prescribed was not listed in primary or secondary diagnosis codes in 54.5% of clinic visits. In conclusion, there is an enormous opportunity to reduce inappropriate outpatient antibiotic prescriptions.
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164
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Davis CB, Marzec LN, Blea Z, Godfrey D, Bickley D, Michael SS, Reno E, Bookman K, Lemery JJ. Antibiotic Prescribing Patterns for Sinusitis Within a Direct-to-Consumer Virtual Urgent Care. Telemed J E Health 2018; 25:519-522. [PMID: 30020851 DOI: 10.1089/tmj.2018.0100] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Direct-to-consumer virtual visits are increasingly popular across both for-profit and nonprofit healthcare systems. Introduction: Virtual visits offer a convenient affordable way for patients to obtain medical care for simple conditions such as sinusitis and uncomplicated urinary tract infections. However, virtual visits have been associated with increased antibiotic utilization when compared with traditional in-person care. Methods: In this retrospective cohort study, antibiotic utilization for acute sinusitis was compared between patients treated through a direct-to-consumer virtual urgent care versus a matched cohort treated through traditional urgent care. Results: Fifty-seven patients were treated for acute sinusitis within the virtual care cohort, whereas 100 patients were treated in the traditional care arm. Antibiotic utilization for acute sinusitis was lower when care was delivered virtually using live-interactive video (67%) than when using traditional urgent care (92%) (p < 0.001). When care was delivered virtually, age, gender, and care delivery modality (telephone vs. video) were not associated with antibiotic utilization for acute sinusitis. Discussion: Concerns have been raised that care delivered virtually does not meet expected quality standards when compared with traditional care. Antibiotic utilization has been used as an example of this quality gap. In this study, we demonstrate that antibiotic utilization was lower in a virtual care cohort than when care was delivered by emergency medicine physicians based in an academic setting. This suggests that awareness and sensitivity to prescribing guidelines may be more important than care delivery modality as it relates to antibiotic utilization. Conclusions: It is possible to deliver care virtually for acute sinusitis without increasing antibiotic utilization.
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Affiliation(s)
- Christopher B Davis
- 1 Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Lucas N Marzec
- 2 Division of Cardiology, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Zachary Blea
- 3 University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Diana Godfrey
- 1 Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Daniel Bickley
- 1 Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Sean S Michael
- 1 Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Elaine Reno
- 1 Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Kelly Bookman
- 1 Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - John J Lemery
- 1 Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
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165
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King LM, Sanchez GV, Bartoces M, Hicks LA, Fleming-Dutra KE. Antibiotic Therapy Duration in US Adults With Sinusitis. JAMA Intern Med 2018; 178:992-994. [PMID: 29582085 PMCID: PMC5885211 DOI: 10.1001/jamainternmed.2018.0407] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study evaluates the duration of antibiotic therapy prescribed for US adults with sinusitis.
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Affiliation(s)
- Laura M King
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Guillermo V Sanchez
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Monina Bartoces
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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166
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Kabbani S, Hersh AL, Shapiro DJ, Fleming-Dutra KE, Pavia AT, Hicks LA. Opportunities to Improve Fluoroquinolone Prescribing in the United States for Adult Ambulatory Care Visits. Clin Infect Dis 2018; 67:134-136. [PMID: 29373664 PMCID: PMC6005119 DOI: 10.1093/cid/ciy035] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/19/2018] [Indexed: 01/21/2023] Open
Abstract
The Food and Drug Administration warned against fluoroquinolone use for conditions with effective alternative agents. An estimated 5.1% of adult ambulatory fluoroquinolone prescriptions were for conditions that did not require antibiotics, and 19.9% were for conditions where fluoroquinolones are not recommended first-line therapy. Unnecessary fluoroquinolone use should be reduced.
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Affiliation(s)
- Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Daniel J Shapiro
- Boston Combined Residency Program in Pediatrics, Boston Medical Center
- Boston Children’s Hospital, Massachusetts
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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167
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Bruce RD, Merlin J, Lum PJ, Ahmed E, Alexander C, Corbett AH, Foley K, Leonard K, Treisman GJ, Selwyn P. 2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With HIV. Clin Infect Dis 2018; 65:e1-e37. [PMID: 29020263 DOI: 10.1093/cid/cix636] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/19/2017] [Indexed: 12/27/2022] Open
Abstract
Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
- R Douglas Bruce
- Department of Medicine, Cornell Scott-Hill Health Center and Yale University, New Haven, Connecticut
| | - Jessica Merlin
- Divisions of Infectious Diseases and Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham
| | - Paula J Lum
- Division of HIV, Infectious Disease, and Global Medicine, University of California San Francisco
| | - Ebtesam Ahmed
- St. Johns University College of Pharmacy and Health Sciences, Metropolitan Jewish Health System Institute for Innovation in Palliative Care, New York
| | - Carla Alexander
- University of Maryland School of Medicine, Institute of Human Virology, Baltimore
| | - Amanda H Corbett
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Kathleen Foley
- Attending Neurologist Emeritus, Memorial Sloan Kettering Cancer Center, New York
| | - Kate Leonard
- Division of Neuroscience and Clinical Pharmacology, Cornell University, New York, New York
| | | | - Peter Selwyn
- Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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168
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Bruce RD, Merlin J, Lum PJ, Ahmed E, Alexander C, Corbett AH, Foley K, Leonard K, Treisman GJ, Selwyn P. 2017 HIV Medicine Association of Infectious Diseases Society of America Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With Human Immunodeficiency Virus. Clin Infect Dis 2018; 65:1601-1606. [PMID: 29091230 DOI: 10.1093/cid/cix848] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
- R Douglas Bruce
- Department of Medicine, Cornell Scott-Hill Health Center and Yale University, New Haven, Connecticut
| | - Jessica Merlin
- Divisions of Infectious Diseases and Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham
| | - Paula J Lum
- Division of HIV, Infectious Disease, and Global Medicine, University of California San Francisco
| | - Ebtesam Ahmed
- St. Johns University College of Pharmacy and Health Sciences, Metropolitan Jewish Health System Institute for Innovation in Palliative Care, New York, New York
| | - Carla Alexander
- University of Maryland School of Medicine, Institute of Human Virology, Baltimore
| | - Amanda H Corbett
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Kathleen Foley
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kate Leonard
- Division of Neuroscience and Clinical Pharmacology, Cornell University, New York, New York
| | | | - Peter Selwyn
- Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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169
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Low M, Almog R, Balicer RD, Liberman N, Raz R, Peretz A, Nitzan O. Infectious disease burden and antibiotic prescribing in primary care in Israel. Ann Clin Microbiol Antimicrob 2018; 17:26. [PMID: 29885657 PMCID: PMC5994243 DOI: 10.1186/s12941-018-0278-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotics are frequently prescribed at many of the visits to primary care clinics, often for conditions for which they provide no benefit, including viral respiratory tract infections. OBJECTIVES The aim was to evaluate primary care visits due to infectious diseases, and to estimate antibiotic prescribing and antibiotic dispensing by pharmacies. METHODS Diagnosis of infectious disease, antibiotic prescribing and dispensing data at the individual patient level were extracted for 2015 from Clalit Health Services' electronic medical records and linked to determine the condition for which the antimicrobial was prescribed. RESULTS There were 6.6 million visits due to infections, representing 22% of all primary care visits. The most common events were upper respiratory tract infections (38%) and pharyngitis (10%). Highest prescription rates were for urinary tract infections (80%), otitis media (64%), pharyngitis (71%), sinusitis (63%), and lower respiratory tract infections (76%). The highest rates of undispensed prescriptions were for acute gastroenteritis, urinary tract infections, and pharyngitis (24, 23, and 16%, respectively). CONCLUSIONS Infectious diseases constitute a heavy burden on primary care, with overprescribing of antibiotics. Intervention to reduce unwarranted antibiotic use is needed. In pediatric care, interventions should focus on better controlling antibiotic consumption and encouraging adherence to guidelines for upper respiratory tract infections, pharyngitis, and otitis media. In adults interventions should aim to monitor antibiotic prescribing for upper respiratory tract infections and improve adherence to guidelines for urinary tract infections.
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Affiliation(s)
- Marcelo Low
- Clalit Research Institute & Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel. .,School of Public Health, University of Haifa, Haifa, Israel.
| | - Ronit Almog
- School of Public Health, University of Haifa, Haifa, Israel.,Rambam Medical Center, Haifa, Israel
| | - Ran D Balicer
- Clalit Research Institute & Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel.,Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Nicky Liberman
- Clalit Health Services, Community Medicine Division, Tel-Aviv, Israel
| | - Raul Raz
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Avi Peretz
- Clinical Microbiology Laboratory, The Baruch Padeh Medical Center Poriya, Tiberias, Israel.,The Faculty of Medicine in the Galilee, Bar Ilan University, Zefat, Israel
| | - Orna Nitzan
- The Faculty of Medicine in the Galilee, Bar Ilan University, Zefat, Israel.,Infectious Disease Unit, Poriya Medical Center, Tiberias, Israel
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170
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Havers FP, Hicks LA, Chung JR, Gaglani M, Murthy K, Zimmerman RK, Jackson LA, Petrie JG, McLean HQ, Nowalk MP, Jackson ML, Monto AS, Belongia EA, Flannery B, Fry AM. Outpatient Antibiotic Prescribing for Acute Respiratory Infections During Influenza Seasons. JAMA Netw Open 2018; 1:e180243. [PMID: 30646067 PMCID: PMC6324415 DOI: 10.1001/jamanetworkopen.2018.0243] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
IMPORTANCE Acute respiratory infections (ARIs) are the syndrome for which antibiotics are most commonly prescribed; viruses for which antibiotics are ineffective cause most ARIs. OBJECTIVES To characterize antibiotic prescribing among outpatients with ARI during influenza season and to identify targets for reducing inappropriate antibiotic prescribing for common ARI diagnoses, including among outpatients with laboratory-confirmed influenza. DESIGN, SETTING, AND PARTICIPANTS Cohort study enrolling outpatients aged 6 months or older with ARI evaluated at outpatient clinics associated with 5 US Influenza Vaccine Effectiveness Network sites during the 2013-2014 and 2014-2015 influenza seasons. All patients received influenza testing by real-time reverse transcriptase-polymerase chain reaction for research purposes only. Antibiotic prescriptions, medical history, and International Classification of Diseases, Ninth Revision diagnosis codes were collected from medical and pharmacy records, as were group A streptococcal (GAS) testing results in a patient subset. EXPOSURE Visit for ARI, defined by a new cough of 7 days' duration or less. MAIN OUTCOMES AND MEASURES Antibiotic prescription within 7 days of enrollment. Appropriateness of antibiotic prescribing was based on diagnosis codes, clinical information, and influenza and GAS testing results. RESULTS Of 14 987 patients with ARI (mean [SD] age, 32 [24] years; 8638 [58%] women; 11 892 [80%] white), 6136 (41%) were prescribed an antibiotic. Among these 6136 patients, 2522 (41%) had diagnoses for which antibiotics are not indicated; 2106 (84%) of these patients were diagnosed as having a viral upper respiratory tract infection or bronchitis (acute or not otherwise specified). Among the 3306 patients (22%) not diagnosed as having pneumonia and who had laboratory-confirmed influenza, 945 (29%) were prescribed an antibiotic, accounting for 17% of all antibiotic prescriptions among patients with nonpneumonia ARI. Among 1248 patients with pharyngitis, 1137 (91%) had GAS testing; 440 of the 1248 patients (35%) were prescribed antibiotics, among whom 168 (38%) had negative results on GAS testing. Of 1200 patients with sinusitis and no other indication for antibiotic treatment who received an antibiotic, 454 (38%) had symptoms for 3 days or less prior to the outpatient visit, suggesting acute viral sinusitis not requiring antibiotics. CONCLUSIONS AND RELEVANCE Antibiotic overuse remains widespread in the treatment of outpatient ARIs, including among patients with laboratory-confirmed influenza, although study sites may not be representative of other outpatient settings. Identified targets for improved outpatient antibiotic stewardship include eliminating antibiotic treatment of viral upper respiratory tract infections and bronchitis and improving adherence to prescribing guidelines for pharyngitis and sinusitis. Increased access to sensitive and timely virus diagnostic tests, particularly for influenza, may reduce unnecessary antibiotic use for these syndromes.
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Affiliation(s)
- Fiona P. Havers
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauri A. Hicks
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jessie R. Chung
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Manjusha Gaglani
- Baylor Scott & White Health, Texas A&M University Health Science Center College of Medicine, Temple
| | - Kempapura Murthy
- Baylor Scott & White Health, Texas A&M University Health Science Center College of Medicine, Temple
| | | | - Lisa A. Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Joshua G. Petrie
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | - Huong Q. McLean
- Marshfield Clinic Research Foundation, Marshfield, Wisconsin
| | | | | | - Arnold S. Monto
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | | | | | - Alicia M. Fry
- Centers for Disease Control and Prevention, Atlanta, Georgia
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171
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Zetts RM, Stoesz A, Smith BA, Hyun DY. Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts. Pediatrics 2018; 141:peds.2017-4124. [PMID: 29793986 DOI: 10.1542/peds.2017-4124] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2018] [Indexed: 11/24/2022] Open
Abstract
Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician's prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance.
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Affiliation(s)
- Rachel M Zetts
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - Andrea Stoesz
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - Brian A Smith
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - David Y Hyun
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
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172
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Appropriateness of antibiotic prescriptions for acute sinusitis and pharyngitis in an integrated healthcare system. Infect Control Hosp Epidemiol 2018; 39:991-993. [PMID: 29807555 DOI: 10.1017/ice.2018.117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We evaluated the appropriateness of antibiotic prescriptions for acute sinusitis and pharyngitis. Overall, 81% of antibiotic prescriptions for acute sinusitis were inappropriate and 48% of antibiotic prescriptions for pharyngitis were inappropriate. Types of prescribing errors differed between the 2 infections, including lack of an indication for antibiotics and excessive duration in ~50% of sinusitis cases and incorrect antibiotic dose in ~33% of pharyngitis cases.Infect Control Hosp Epidemiol 2018; 0, 1-3.
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173
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Yan CH, Tangbumrungtham N, Maul XA, Ma Y, Nayak JV, Hwang PH, Patel ZM. Comparison of outcomes following culture-directed vs non-culture-directed antibiotics in treatment of acute exacerbations of chronic rhinosinusitis. Int Forum Allergy Rhinol 2018; 8:1028-1033. [DOI: 10.1002/alr.22147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 04/23/2018] [Accepted: 05/03/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Carol H. Yan
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford CA
| | - Navarat Tangbumrungtham
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford CA
- Department of Otorhinolaryngology; Ramathibodi Hospital; Bangkok Thailand
| | - Ximena A. Maul
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford CA
- Department of Otolaryngology; Pontificia Universidad Católica de Chile; Santiago Chile
| | - Yifei Ma
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford CA
| | - Jayakar V. Nayak
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford CA
| | - Peter H. Hwang
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford CA
| | - Zara M. Patel
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford CA
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174
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Matho A, Mulqueen M, Tanino M, Quidort A, Cheung J, Pollard J, Rodriguez J, Swamy S, Tayler B, Garrison G, Ata A, Sorum P. High-dose versus standard-dose amoxicillin/clavulanate for clinically-diagnosed acute bacterial sinusitis: A randomized clinical trial. PLoS One 2018; 13:e0196734. [PMID: 29738561 PMCID: PMC5940197 DOI: 10.1371/journal.pone.0196734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/17/2018] [Indexed: 11/18/2022] Open
Abstract
Background The recommended treatment for acute bacterial sinusitis in adults, amoxicillin with clavulanate, provides only modest benefit. Objective To see if a higher dose of amoxicillin will lead to more rapid improvement. Design, setting, and participants Double-blind randomized trial in which, from November 2014 through February 2017, we enrolled 315 adult outpatients diagnosed with acute sinusitis in accordance with Infectious Disease Society of America guidelines. Interventions Standard-dose (SD) immediate-release (IR) amoxicillin/clavulanate 875 /125 mg (n = 159) vs. high-dose (HD) (n = 156). The original HD formulation, 2000 mg of extended-release (ER) amoxicillin with 125 mg of IR clavulanate twice a day, became unavailable half way through the study. The IRB then approved a revised protocol after patient 180 to provide 1750 mg of IR amoxicillin twice a day in the HD formulation and to compare Time Period 1 (ER) with Time Period 2 (IR). Main measure The primary outcome was the percentage in each group reporting a major improvement—defined as a global assessment of sinusitis symptoms as “a lot better” or “no symptoms”—after 3 days of treatment. Key results Major improvement after 3 days was reported during Period 1 by 38.8% of ER HD versus 37.9% of SD patients (P = 0.91) and during Period 2 by 52.4% of IR HD versus 34.4% of SD patients, an effect size of 18% (95% CI 0.75 to 35%, P = 0.04). No significant differences in efficacy were seen at Day 10. The major side effect, severe diarrhea at Day 3, was reported during Period 1 by 7.4% of HD and 5.7% of SD patients (P = 0.66) and during Period 2 by 15.8% of HD and 4.8% of SD patients (P = 0.048). Conclusions Adults with clinically diagnosed acute bacterial sinusitis were more likely to improve rapidly when treated with IR HD than with SD but not when treated with ER HD. They were also more likely to suffer severe diarrhea. Further study is needed to confirm these findings. Trial registration ClinicalTrials.gov Identifier: NCT02340000.
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Affiliation(s)
- Andrea Matho
- Albany Medical Center Hospital, Albany, NY, United States of America
| | - Mary Mulqueen
- Albany Medical Center Hospital, Albany, NY, United States of America
| | - Miyuki Tanino
- Albany Medical Center Hospital, Albany, NY, United States of America
| | - Aaron Quidort
- Albany Medical Center Hospital, Albany, NY, United States of America
| | - Jesse Cheung
- Albany Medical College, Albany, NY, United States of America
| | | | | | - Supraja Swamy
- Albany Medical College, Albany, NY, United States of America
| | - Brittany Tayler
- Albany Medical College, Albany, NY, United States of America
| | - Gina Garrison
- Albany College of Pharmacy and Health Sciences, Albany, NY, United States of America
| | - Ashar Ata
- Department of Surgery, Albany Medical College, Albany, NY, United States of America
| | - Paul Sorum
- Departments of Medicine and Pediatrics, Albany Medical College, Albany, NY, United States of America
- * E-mail:
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175
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El Malik EFB, Manoranjan B, Ajani O, Zidan A. Hypophysitis Due to Paranasal Sinusitis: Neurosurgical Perspective from Developing World. World Neurosurg 2018; 115:162-165. [PMID: 29678705 DOI: 10.1016/j.wneu.2018.04.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Sinusitis is a common clinical condition, but sphenoid sinusitis is a less common form and even rarer is hypophysitis as a complication of the latter. Clinically, hypophysitis may mimic a pituitary neoplasm in presenting with mass effect and pituitary hormone dysfunction. CASE DESCRIPTION We present 5 cases of sinusitis-related hypophysitis treated at the Royal Care International Hospital in Khartoum, Sudan. Clinical symptoms at presentation included headache, fever, ptosis, ophthalmoplegia, and history of sinusitis with running nose (nasal discharge). None of the patients were immunocompromised or showed signs of meningitis. Laboratory tests indicated neutrophilia and elevated inflammatory indices, namely C-reactive protein and erythrocyte sedimentation rate. There was also a disturbance of the hypothalamic-pituitary hormone axis, particularly impaired cortisol level. Magnetic resonance imaging scans on all patients revealed swollen masses in the pituitary fossa and enhancement of the sellar region and paranasal sinuses, especially the sphenoid sinus. All cases were empirically treated with hydrocortisone and amoxicillin-clavulanate, resulting in reversal of symptoms. CONCLUSIONS Sinusitis is common in tropical regions where the climate is usually warm and often hot and dry. Here, the condition is considered a common incidental finding in magnetic resonance imaging examinations done for various indications. Hence it is not considered to be a serious health problem. Though our cohort of cases is small, we emphasize the importance of keeping a high index of suspicion for the diagnosis of hypophysitis in relevant case settings. This would help make an early diagnosis and ensure appropriate medical, perhaps nonsurgical, management.
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Affiliation(s)
| | - Branavan Manoranjan
- Department of Surgery, Michael G. DeGroote School of Medicine McMaster University, Hamilton, Ontario, Canada
| | - Olufemi Ajani
- Department of Surgery, Michael G. DeGroote School of Medicine McMaster University, Hamilton, Ontario, Canada
| | - Ahmed Zidan
- Department of Surgery, Royal Care International Hospital, Khartoum, Sudan
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176
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177
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Holmes L, Struwe L, Waltman N. Evaluation of an Antibiotic Stewardship Program in a University Health Center. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2017.11.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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178
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Autio TJ, Koskenkorva T, Koivunen P, Alho OP. Inflammatory Biomarkers During Bacterial Acute Rhinosinusitis. Curr Allergy Asthma Rep 2018; 18:13. [PMID: 29464415 DOI: 10.1007/s11882-018-0761-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Diagnosis of bacterial acute rhinosinusitis is difficult. Several attempts have been made to clarify the diagnostic criteria. Inflammatory biomarkers are easily obtainable variables that could shed light on both the pathophysiology and diagnosis of bacterial acute rhinosinusitis. The purpose of this review article is to assess literature concerning the course of inflammatory biomarkers during acute rhinosinusitis and the use of inflammatory biomarkers in diagnosing bacterial acute rhinosinusitis. RECENT FINDINGS We included C-reactive protein, erythrocyte sedimentation rate, white blood cell counts, procalcitonin, and nasal nitric oxide in this review and found that especially elevated C-reactive protein and erythrocyte sedimentation rate are related to a higher probability of a bacterial cause of acute rhinosinusitis. Still, normal levels of these two biomarkers are quite common as well, or the levels can be heightened even during viral respiratory infection without suspicion of bacterial involvement. Elevated levels of C-reactive protein or erythrocyte sedimentation rate support diagnosis of bacterial acute rhinosinusitis, but due to a lack of sensitivity, they should not be used to screen patients for bacterial acute rhinosinusitis.
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Affiliation(s)
- Timo J Autio
- Department of Otorhinolaryngology and Head and Neck Surgery, Oulu University Hospital, P.O. Box 21, FI-90029, OYS, Oulu, Finland. .,PEDEGO Research Unit, University of Oulu, Oulu, Finland. .,Medical Research Center Oulu, Oulu, Finland.
| | - Timo Koskenkorva
- Department of Otorhinolaryngology and Head and Neck Surgery, Oulu University Hospital, P.O. Box 21, FI-90029, OYS, Oulu, Finland.,PEDEGO Research Unit, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, Oulu, Finland
| | - Petri Koivunen
- Department of Otorhinolaryngology and Head and Neck Surgery, Oulu University Hospital, P.O. Box 21, FI-90029, OYS, Oulu, Finland.,PEDEGO Research Unit, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, Oulu, Finland
| | - Olli-Pekka Alho
- Department of Otorhinolaryngology and Head and Neck Surgery, Oulu University Hospital, P.O. Box 21, FI-90029, OYS, Oulu, Finland.,PEDEGO Research Unit, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, Oulu, Finland
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179
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Johnson TM, Lincicum AR. Management of Wound Infection and Acute Bacterial Rhinosinusitis After Sinus Elevation Surgery: A Case Report. Clin Adv Periodontics 2018; 8:54-60. [PMID: 32745378 PMCID: PMC7162002 DOI: 10.1902/cap.2017.170039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 07/20/2017] [Indexed: 11/23/2022]
Abstract
Introduction Sinus graft infection with consequent acute bacterial rhinosinusitis (ABRS) is a complication that can occur during the postoperative period following sinus augmentation surgery. A small group of bacteria appear to predominate in ABRS, and these bacteria are empirically susceptible to tetracycline antibiotics, barring the presence of resistant strains. Historically, clinicians have mixed tetracycline with various biomaterials or hydrated biomaterials in a dilute tetracycline solution in the treatment of periodontal disease and for ridge preservation/augmentation indications. Case Presentation In the present case, a 39‐year‐old African‐American male with sinus graft infection and signs and symptoms consistent with ABRS was successfully treated by removing the initial graft material, thoroughly debriding and irrigating the antrum, and placing a freeze‐dried bone allograft hydrated in an aqueous tetracycline solution. Conclusion Given the typical bacteria present in ABRS, locally applied tetracycline may be useful prophylactically in sinus elevation surgery or as an adjunct in managing postoperative sinus graft infection.
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Affiliation(s)
- Thomas M Johnson
- United States Army Advanced Education Program in Periodontics, Fort Gordon, GA.,Department of Periodontics, Army Postgraduate Dental School, Uniformed Services University of the Health Sciences, Fort Gordon, GA
| | - Adam R Lincicum
- United States Army Advanced Education Program in Periodontics, Fort Gordon, GA.,Department of Periodontics, Army Postgraduate Dental School, Uniformed Services University of the Health Sciences, Fort Gordon, GA
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180
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Gabaldón NG, Arnaiz CM, Cánovas LN, Armas JJ. [Management of Rhinosinusitis in Primary Care]. Semergen 2018; 44:492-499. [PMID: 29453018 DOI: 10.1016/j.semerg.2017.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 11/17/2017] [Indexed: 11/30/2022]
Abstract
Acute rhinosinusitis is an important health problem. Even though its frequency is not well documented in our country?, the economic burden it bears is not insignificant as it notably alters the quality of life of affected patients. Its diagnosis is generally clinical in nature, with further studies reserved only for the differential diagnoses of complications or tumour-like processes. The most frequent causes are viral infections, although Streptococcus pneumoniae and Haemophilus influenzae are the most commonly isolated bacterial agents. Although complications are uncommon nowadays, they can be serious when they occur, and commonly include orbital infections, closely followed in frequency by intracranial and bone infections. Treatment should consist of symptomatic measures, like saline rinses and antibiotics in cases of bacterial origin.
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Affiliation(s)
- N Gómez Gabaldón
- Servicio de ORL. Hospital de la GAI de Hellín, Albacete, España.
| | | | | | - J Juan Armas
- Centro de Salud Camargo Costa, Maliaño, Cantabria, España
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181
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Watson JR, Wang L, Klima J, Moore-Clingenpeel M, Gleeson S, Kelleher K, Jaggi P. Healthcare Claims Data: An Underutilized Tool for Pediatric Outpatient Antimicrobial Stewardship. Clin Infect Dis 2018; 64:1479-1485. [PMID: 28329388 DOI: 10.1093/cid/cix195] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/06/2017] [Indexed: 11/13/2022] Open
Abstract
Background. Healthcare claims are underutilized to identify factors associated with high outpatient antibiotic use. Methods. We evaluated ambulatory encounter claims of Medicaid-insured children in 34 Ohio counties in 2014. Rates of total antibiotic and azithromycin prescriptions dispensed were determined by county of patient residence. Standardized treatment rates by county were estimated for uncomplicated upper respiratory tract encounters (acute otitis media, pharyngitis, sinusitis, presumed viral infection) after adjusting for patient age and encounter provider type. Uncomplicated encounters included healthy children at initial presentation of illness. Adjusted odds of treatment were calculated for patient age, provider type, and county characteristics (rural vs metropolitan; poverty rate). Results. Retail pharmacies dispensed 255291 antibiotics to this cohort in 2014. More than 25% were to children <3 years. County rates of total antibiotic and azithromycin prescriptions dispensed were 530.4-1548.3 and 57.3-378.7 per 1000 person-years, respectively. Of 246866 uncomplicated upper respiratory tract encounters, antibiotics were dispensed (within 3 days) in 46.1%. Presumed viral infection accounted for 18.5% of antibiotics. Standardized treatment rates by county ranged widely from 35.9% (95% confidence interval [CI], 33.3%-38.5%) to 63.2% (95% CI, 61.5%-64.9%). Compared to encounters with pediatricians, adjusted odds ratio of treatment was 2.02 (95% CI, 1.96-2.07) for family physicians and 1.74 (95% CI, 1.68-1.79) for nurse practitioners. Residence in rural or high-poverty counties increased odds of treatment. Conclusions. Healthcare claims were useful to identify populations and providers with high antibiotic use. Claims data could be considered to track and report antibiotic prescribing frequency, especially where electronic medical records are not available.
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Affiliation(s)
- Joshua R Watson
- Department of Pediatrics, The Ohio State University.,Nationwide Children's Hospital, Partners for Kids ; and
| | - Ling Wang
- Nationwide Children's Hospital, Partners for Kids; and
| | | | | | - Sean Gleeson
- Department of Pediatrics, The Ohio State University.,Nationwide Children's Hospital, Partners for Kids ; and
| | - Kelly Kelleher
- Department of Pediatrics, The Ohio State University.,Nationwide Children's Hospital, Partners for Kids ; and
| | - Preeti Jaggi
- Department of Pediatrics, The Ohio State University.,Nationwide Children's Hospital, Partners for Kids ; and
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182
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Trinh NTH, Chahwakilian P, Bruckner TA, Sclison S, Levy C, Chalumeau M, Milic D, Cohen R, Cohen JF. Discrepancies in national time trends of outpatient antibiotic utilization using different measures: a population-based study in France. J Antimicrob Chemother 2018; 73:1395-1401. [DOI: 10.1093/jac/dky018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 01/03/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nhung T H Trinh
- Inserm UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team, Research Centre for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), Paris Descartes University, Paris, France
| | | | - Tim A Bruckner
- Program in Public Health, University of California, Irvine, CA, USA
| | | | - Corinne Levy
- Association Clinique et Thérapeutique Infantile du Val-de-Marne (ACTIV), Saint-Maur-des-Fossés, France
- Clinical Research Centre, Centre Hospitalier Intercommunal de Créteil, Créteil, France
- Université Paris Est, IMRB-GRC GEMINI, Créteil, France
| | - Martin Chalumeau
- Inserm UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team, Research Centre for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), Paris Descartes University, Paris, France
- Department of General Paediatrics and Paediatric Infectious Disease, Necker—Enfants malades hospital, Assistance Publique—Hôpitaux de Paris, Paris Descartes University, Paris, France
| | | | - Robert Cohen
- Association Clinique et Thérapeutique Infantile du Val-de-Marne (ACTIV), Saint-Maur-des-Fossés, France
- Université Paris Est, IMRB-GRC GEMINI, Créteil, France
- Unité Court Séjour, Petits Nourrissons, Service de Néonatalogie, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Jérémie F Cohen
- Inserm UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team, Research Centre for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), Paris Descartes University, Paris, France
- Department of General Paediatrics and Paediatric Infectious Disease, Necker—Enfants malades hospital, Assistance Publique—Hôpitaux de Paris, Paris Descartes University, Paris, France
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183
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Pernica J, Harman S, Kam A, Bailey J, Carciumaru R, Khan S, Fulford M, Thabane L, Slinger R, Main C, Smieja M, Loeb M. Short-course antimicrobial therapy for paediatric respiratory infections (SAFER): study protocol for a randomized controlled trial. Trials 2018; 19:83. [PMID: 29391051 PMCID: PMC5796490 DOI: 10.1186/s13063-018-2457-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 01/04/2018] [Indexed: 12/17/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is commonly diagnosed in children. The Infectious Disease Society of America guidelines recommend 10 days of high-dose amoxicillin for the treatment of non-severe CAP but 5-day “short course” therapy may be just as effective. Randomized trials in adults have already demonstrated non-inferiority of 5-day short-course treatment for adults hospitalized with severe CAP and for adults with mild CAP treated as outpatients. Minimizing exposure to antimicrobials is desirable to avoid harms including diarrhoea, rashes, severe allergic reactions, increased circulating antimicrobial resistance, and microbiome disruption. Methods The objective of this multicentre, randomized, non-inferiority, controlled trial is to investigate whether 5 days of high-dose amoxicillin is associated with lower rates of clinical cure 14–21 days later as compared to 10 days of high-dose amoxicillin, the reference standard. Recruitment and enrolment will occur in the emergency departments of McMaster Children’s Hospital and the Children’s Hospital of Eastern Ontario. All children in the study will receive 5 days of amoxicillin after which point they will receive either 5 days of a different formulation of amoxicillin or a placebo. Assuming a clinical failure rate of 5% in the reference arm, a non-inferiority margin of 7.5%, one-sided alpha set at 0.025 and power of 0.80, 270 participants will be required. Participants from a previous feasibility study (n = 60) will be rolled over into the current study. We will be performing multiplex respiratory virus molecular testing, quantification of nasopharyngeal pneumococcal genomic loads, salivary inflammatory marker testing, and faecal microbiome profiling on participants. Discussion This is a pragmatic study seeking to provide high-quality evidence for front-line physicians evaluating children presenting with mild CAP in North American emergency departments in the post-13-valent pneumococcal, conjugate vaccine era. High-quality evidence supporting the non-inferiority of short-course therapy for non-severe paediatric CAP should be generated prior to making changes to established guidelines. Trial registration ClinicalTrials.gov, NCT02380352. Registered on 2 March 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2457-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jeffrey Pernica
- Division of Infectious Disease, Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Stuart Harman
- Division of Emergency Medicine, Department of Pediatrics, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - April Kam
- Division of Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Jacob Bailey
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Sarah Khan
- Division of Infectious Disease, Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Martha Fulford
- Division of Infectious Disease, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, Hamilton, ON, Canada
| | - Robert Slinger
- Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Cheryl Main
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Marek Smieja
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Mark Loeb
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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184
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Patient, Provider, and Practice Characteristics Associated with Inappropriate Antimicrobial Prescribing in Ambulatory Practices. Infect Control Hosp Epidemiol 2018; 39:307-315. [DOI: 10.1017/ice.2017.263] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVETo reduce inappropriate antimicrobial prescribing across ambulatory care, understanding the patient-, provider-, and practice-level characteristics associated with antibiotic prescribing is essential. In this study, we aimed to elucidate factors associated with inappropriate antimicrobial prescribing across urgent care, family medicine, and pediatric and internal medicine ambulatory practices.DESIGN, SETTING, AND PARTICIPANTSData for this retrospective cohort study were collected from outpatient visits for common upper respiratory conditions that should not require antibiotics. The cohort included 448,990 visits between January 2014 and May 2016. Carolinas HealthCare System urgent care, family medicine, internal medicine and pediatric practices were included across 898 providers and 246 practices.METHODSPrescribing rates were reported per 1,000 visits. Indications were defined using the International Classification of Disease, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) criteria. In multivariable models, the risk of receiving an antibiotic prescription was reported with adjustment for practice, provider, and patient characteristics.RESULTSThe overall prescribing rate in the study cohort was 407 per 1,000 visits (95% confidence interval [CI], 405–408). After adjustment, adult patients seen by an advanced practice practitioner were 15% more likely to receive an antimicrobial than those seen by a physician provider (incident risk ratio [IRR], 1.15; 95% CI, 1.03–1.29). In the pediatric sample, older providers were 4 times more likely to prescribe an antimicrobial than providers aged ≤30 years (IRR, 4.21; 95% CI, 2.96–5.97).CONCLUSIONSOur results suggest that patient, practice, and provider characteristics are associated with inappropriate antimicrobial prescribing. Future research should target antibiotic stewardship programs to specific patient and provider populations to reduce inappropriate prescribing compared to a “one size fits all” approach.Infect Control Hosp Epidemiol 2018;39:307–315
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185
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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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186
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Lee H. Diagnosis and treatment of acute rhinosinusitis in children. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2018. [DOI: 10.5124/jkma.2018.61.2.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Hyunju Lee
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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187
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Abstract
Acute bacterial rhinosinusitis (ABRS) is a highly prevalent disease associated with significant direct and indirect costs. It is paramount that a practitioner can distinguish between acute viral rhinosinusitis and ABRS to avoid unnecessary antibiotic usage. It is also important to understand that establishing a diagnosis of ABRS does not necessitate the prescribing of antibiotics, unless the ABRS patient presents with severe or worsening symptoms or an ABRS complication. Complications include extension of infection to the orbit and central nervous system. Injudicious use of antibiotics imparts societal costs in terms of financial expense as well as contributing to higher levels of bacterial resistance. This chapter reviews the epidemiology, clinical features, diagnosis, and treatment of ABRS.
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Affiliation(s)
- Marlene L. Durand
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts USA
| | - Daniel G. Deschler
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts USA
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188
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Tan C, Graves E, Lu H, Chen A, Li S, Schwartz KL, Daneman N. A decade of outpatient antimicrobial use in older adults in Ontario: a descriptive study. CMAJ Open 2017; 5:E878-E885. [PMID: 29273579 PMCID: PMC5741418 DOI: 10.9778/cmajo.20170100] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Antimicrobials are frequently prescribed to community-dwelling older adults. Our aim was to examine the prevalence, quantity and indications of antimicrobial prescriptions to older residents of Ontario. METHODS We conducted a population-based analysis of outpatient antimicrobial prescriptions to residents of Ontario aged 65 years or more from 2006 to 2015. Antimicrobial prescriptions, infectious disease diagnoses and prescriber information were determined from linked health care databases. Our analyses were primarily focused on antibiotics, which account for most antimicrobial use. RESULTS We identified 2 879 779 unique Ontario residents aged 65 years or more over our study period. On average, 40.7% (range 40.1%-41.5%) of older adult outpatients in any given year received 1 or more antibiotic prescriptions. Antibiotic use remained stable over the study period, averaging 25.1 (range 24.1-25.6) defined daily doses per 1000 person-days per year. Selection of antibiotics evolved, with increasing use of penicillins and decreasing use of fluoroquinolones and macrolides. For 65.7% of prescriptions, no infectious disease diagnoses were identified within 7 days of the prescription. Among prescriptions with an associated diagnosis, upper respiratory tract infection was most common (18.9%), followed by urinary tract infection (6.2%), skin/soft-tissue infection (4.3%), lower respiratory tract infection (4.2%) and other infection (1.2%). Most antibiotics were prescribed by family physicians. INTERPRETATION Antibiotic use among older adult outpatients in Ontario remained stable between 2006 and 2015. Current methods of measuring use are not capable of accurately determining indication, and, thus, additional data sources to monitor the appropriateness of community antimicrobial use are needed.
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Affiliation(s)
- Charlie Tan
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Erin Graves
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Hong Lu
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Anna Chen
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Shudong Li
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Kevin L Schwartz
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Nick Daneman
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
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189
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Butler DF, Myers AL. Changing Epidemiology of Haemophilus influenzae in Children. Infect Dis Clin North Am 2017; 32:119-128. [PMID: 29233576 DOI: 10.1016/j.idc.2017.10.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Haemophilus influenzae remains a common cause of illness in children throughout the world. Before the introduction of vaccination, H influenzae type b (Hib) disease was the leading cause of bacterial meningitis in young children and a frequent cause of pneumonia, epiglottitis, and septic arthritis. Clinicians should remain diligent in counseling parents on the dangers of Hib and provide vaccination starting at 2 months of age. The epidemiology of invasive H influenzae disease is shifting. It is imperative that clinicians recognize the changing epidemiology and antibiotic resistance patterns for H influenzae to optimize care in hospital and ambulatory settings.
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Affiliation(s)
- David F Butler
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, FA.2.112, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Angela L Myers
- Division of Pediatric Infectious Diseases, Children's Mercy, Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA.
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190
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Rosenfeld RM, Wyer PC. Stakeholder-Driven Quality Improvement: A Compelling Force for Clinical Practice Guidelines. Otolaryngol Head Neck Surg 2017; 158:16-20. [DOI: 10.1177/0194599817735500] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Clinical practice guideline development should be driven by rigorous methodology, but what is less clear is where quality improvement enters the process: should it be a priority-guiding force, or should it enter only after recommendations are formulated? We argue for a stakeholder-driven approach to guideline development, with an overriding goal of quality improvement based on stakeholder perceptions of needs, uncertainties, and knowledge gaps. In contrast, the widely used topic-driven approach, which often makes recommendations based only on randomized controlled trials, is driven by epidemiologic purity and evidence rigor, with quality improvement a downstream consideration. The advantages of a stakeholder-driven versus a topic-driven approach are highlighted by comparisons of guidelines for otitis media with effusion, thyroid nodules, sepsis, and acute bacterial rhinosinusitis. These comparisons show that stakeholder-driven guidelines are more likely to address the quality improvement needs and pressing concerns of clinicians and patients, including understudied populations and patients with multiple chronic conditions. Conversely, a topic-driven approach often addresses “typical” patients, based on research that may not reflect the needs of high-risk groups excluded from studies because of ethical issues or a desire for purity of research design.
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Affiliation(s)
- Richard M. Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Peter C. Wyer
- Department of Emergency Medicine, Columbia University Medical Center, New York, New York, USA
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191
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Sanchez GV, Shapiro DJ, Hersh AL, Hicks LA, Fleming-Dutra KE. Outpatient Macrolide Antibiotic Prescribing in the United States, 2008-2011. Open Forum Infect Dis 2017; 4:ofx220. [PMID: 29255725 DOI: 10.1093/ofid/ofx220] [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] [Received: 06/21/2017] [Accepted: 10/04/2017] [Indexed: 01/21/2023] Open
Abstract
National Ambulatory Medical Care Survey data were used to assess outpatient macrolide prescribing and selection. Conditions for which macrolides are firstline therapy represented 5% of macrolide prescribing. Family practitioners selected macrolides for children more frequently than pediatricians. Macrolides are an important antibiotic stewardship target.
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Affiliation(s)
- Guillermo V Sanchez
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Adam L Hersh
- Pediatric Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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192
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Dawson-Hahn EE, Mickan S, Onakpoya I, Roberts N, Kronman M, Butler CC, Thompson MJ. Short-course versus long-course oral antibiotic treatment for infections treated in outpatient settings: a review of systematic reviews. Fam Pract 2017; 34:511-519. [PMID: 28486675 PMCID: PMC6390420 DOI: 10.1093/fampra/cmx037] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To summarize the evidence comparing the effectiveness of short and long courses of oral antibiotics for infections treated in outpatient settings. METHODS We identified systematic reviews of randomized controlled trials for children and adults with bacterial infections treated in outpatient settings from Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews and The Database of Review of Effects. Data were extracted on the primary outcome of clinical resolution and secondary outcomes. RESULTS We identified 30 potential reviews, and included 9. There was no difference in the clinical cure for children treated with short or long course antibiotics for Group A streptococcal tonsillopharyngitis (OR 1.03, 95% CI:0.97, 1.11); community acquired pneumonia (RR 0.99, 95% CI:0.97, 1.01); acute otitis media [<2 years old OR: 1.09 (95% CI:0.76, 1.57); ≥2 years old OR: 0.85 (95% CI:0.60, 1.21)]; or urinary tract infection (RR 1.06, 95% CI:0.64, 1.76). There was no difference in the clinical cure for adults treated with short or long course antibiotics for acute bacterial sinusitis (RR 0.95, 95% CI:0.81, 1.21); uncomplicated cystitis in non-pregnant women (RR 1.10, 95% CI:0.96, 1.25), or elderly women (RR: 0.98, 95% CI:0.62, 1.54); acute pyelonephritis (RR 1.03, 95% CI:0.80, 1.32); or community acquired pneumonia (RR: 0.96, 95% CI:0.74, 1.26). We found inadequate evidence about the effect on antibiotic resistance. CONCLUSIONS This overview of systematic reviews has identified good quality evidence that short course antibiotics are as effective as longer courses for most common infections managed in ambulatory care. The impact on antibiotic resistance and associated treatment failure requires further study.
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Affiliation(s)
- Elizabeth E Dawson-Hahn
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Sharon Mickan
- Gold Coast Health and Griffith University, Queensland, Australia.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Igho Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Matthew Kronman
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Division of Infectious Diseases, Seattle Children's Hospital, Seattle, WA, USA
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,Primary Care Medicine, Cardiff University, Cardiff, Wales, UK
| | - Matthew J Thompson
- Department of Family Medicine, University of Washington, Seattle, WA, USA
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193
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Microbiology of Acute Rhinosinusitis in Immunosuppressed Patients. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2017. [DOI: 10.1097/ipc.0000000000000489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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194
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Shukla PJ, Behnam-Terneus M, Cunill-De Sautu B, Perez GF. Antibiotic Use by Pediatric Residents: Identifying Opportunities and Strategies for Antimicrobial Stewardship. Hosp Pediatr 2017; 7:553-558. [PMID: 28814443 DOI: 10.1542/hpeds.2017-0059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine the antibiotic prescribing practices of pediatric residents and assess how they acquire knowledge leading to prescribing behaviors. METHODS We performed a cross-sectional electronic survey of all pediatric residents at the Children's National Medical Center and Nicklaus Children's Hospital, assessing antibiotic prescribing patterns for common pediatric infections, use of antibiograms, and factors influencing antibiotic choice. RESULTS Eighty-five surveys (45%) were returned complete and included in the analysis. Increased deviations from clinical guideline recommendations were observed for antibiotic treatments of sinusitis and community-acquired pneumonia as compared with otitis media and group A streptococcal pharyngitis. Only 57% of residents reported having used antibiograms. General pediatric inpatient attending physicians were identified as the most influential source for house staff antibiotic knowledge. CONCLUSIONS Results illustrate the need for better promotion and integration of clinical guidelines with antibiograms when developing antibiotic education programs for residents in training. In addition, pediatric hospitalists should play an active role in the implementation of these programs and can provide valuable insight into the development of educational programs in conjunction with graduate medical education divisions.
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Affiliation(s)
| | - Maria Behnam-Terneus
- Miami Children's Health System, Nicklaus Children's Hospital, Miami, Florida; and
| | | | - Geovanny F Perez
- Division of Pulmonary and Sleep Medicine, .,Department of Pediatrics, School of Medicine and Health Sciences, and.,Department of Integrative Systems Biology, George Washington University, Washington, District of Columbia.,Center for Genetic Research Medicine, Children's National Medical Center, Washington, District of Columbia
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195
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Antibiotic prescriptions for outpatient acute rhinosinusitis in Canada, 2007-2013. PLoS One 2017; 12:e0181957. [PMID: 28750020 PMCID: PMC5531515 DOI: 10.1371/journal.pone.0181957] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 05/19/2017] [Indexed: 11/19/2022] Open
Abstract
Introduction Acute rhinosinusitis (ARS) is a respiratory disease commonly caused by viral infections. Physicians regularly prescribe antibiotics despite bacterial etiologies being uncommon. This is of concern, as this use adds to the selection pressure for resistance. Here we present the descriptive epidemiology of acute rhinosinusitis and corresponding antibiotic prescribing practices by Canadian outpatient physicians from 2007–2013. Materials/Methods Diagnosis and antibiotic prescription data for ARS were extracted from the Canadian Disease and Therapeutic Index for 2007 to 2013, and population data were acquired from Statistics Canada. ARS diagnosis and antibiotic prescription rates and frequencies of antibiotic classes were calculated. Results Eighty-eight percent of patients diagnosed with ARS in 2013 were adults, with a greater rate of antibiotic prescriptions observed among the adults relative to the pediatric patients (1632.9 and 468.6 antibiotic prescriptions per 10,000 inhabitants). Between 2007 and 2013, the ARS diagnosis rate decreased from 596 to 464 diagnoses per 10,000 inhabitants, while the percentage of diagnoses with antibiotic prescriptions at the national level remained stable (87% to 84%). From 2007 to 2013, prescription rates for macrolides decreased from 203.5 to 105.4 prescriptions per 10,000 inhabitants. In 2013, penicillins with extended spectrum were more commonly prescribed compared to macrolides among adult patients (153.5 and 105.4 prescriptions per 10,000 inhabitants, respectively). Conclusion This study is the first to describe physician antibiotic prescribing practices for treatment of ARS in Canada. Results show that antibiotic treatment for ARS represents an area for implementing antimicrobial stewardship, and through it, managing antibiotic resistance. Further work is required to better understand diagnosing practices and treatment criteria for ARS, and use this information to further assist physicians to limit unnecessary antibiotic prescribing practices.
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196
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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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197
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198
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Cevc G. Differential diagnosis and proper treatment of acute rhinosinusitis: Guidance based on historical data analysis. ALLERGY & RHINOLOGY 2017; 8:45-52. [PMID: 28583227 PMCID: PMC5468756 DOI: 10.2500/ar.2017.8.0206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background: The time course of rhinovirus positive and negative rhinosinusitis has not been quantified yet, which aggravates proper selection and justification of the optimum treatment for this illness. Such quantitative information would facilitate an early and proper identification of the disease and its differentiation from acute bacterial rhinosinusitis, and could diminish harmful overuse of antibiotics, arguably driven by patients' want for attention and the treating physicians' inability to offer an adequate verbal comfort in its stead. Objective: Extraction of the quantitative information needed to identify rhinovirus positive or negative rhinosinusitis and to allow selection of the most appropriate treatment from the published time dependence of individual clinical symptoms of the disease. Methods: Scrutiny (and modeling) of temporal evolution of all noteworthy symptoms of rhinosinusitis with a simple mathematical expression that relies on two adjustable parameters per symptom (and potentially a general time offset as an extra adjustable parameter). Results: Adverse effects of rhinosinusitis can be grouped according to the sequence of their exponential appearance and ∼2.6 times slower exponential disappearance, rhinovirus negative rhinosinusitis generally improving ∼25% faster and being ∼40% less severe. The major early local symptoms (throat soreness and scratchiness, headache) vanish with a half-life of ∼1.8 days, whereas further local symptoms take ∼1.6 times longer to disappear. At least 50–60% improvement of two prominent early symptoms, sore throat and sneezing (but not of nasal discharge, cough, and hoarseness) by day 5 of the disease implies a nonbacterial origin of rhinitis and should exclude use of antibiotics. Conclusion: Temporal evolution of all rhinosinusitis symptoms is qualitatively similar, which makes the early symptom decay a good proxy for, and predictor of, the disease perspective. Knowing a symptom intensity at just three to four time points suffices for reconstructing its entire time course and total intensity or gravity. This permits an easy and early identification of rhinosinusitis, and its plausible differentiation from acute bacterial rhinosinusitis, disease treatment optimization, and corresponding clinical trials simplification and/or shortening.
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Affiliation(s)
- Gregor Cevc
- From the Advanced Treatments Institute, Gauting, Germany
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199
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Principi N, Esposito S. Nasal Irrigation: An Imprecisely Defined Medical Procedure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14050516. [PMID: 28492494 PMCID: PMC5451967 DOI: 10.3390/ijerph14050516] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/07/2017] [Accepted: 05/09/2017] [Indexed: 12/29/2022]
Abstract
Nasal irrigation (NI) is an old practice of upper respiratory tract care that likely originated in the Ayurvedic medical tradition. It is used alone or in association with other therapies in several conditions—including chronic rhinosinusitis and allergic rhinitis—and to treat and prevent upper respiratory tract infections, especially in children. However, despite it being largely prescribed in everyday clinical practice, NI is not included or is only briefly mentioned by experts in the guidelines for treatment of upper respiratory tract diseases. In this review, present knowledge about NI and its relevance in clinical practice is discussed to assist physicians in understanding the available evidence and the potential use of this medical intervention. Analysis of the literature showed that NI seems to be effective in the treatment of several acute and chronic sinonasal conditions. However, although in recent years several new studies have been performed, most of the studies that have evaluated NI have relevant methodologic problems. Only multicenter studies enrolling a great number of subjects can solve the problem of the real relevance of NI, and these studies are urgently needed. Methods for performing NI have to be standardized to determine which solutions, devices and durations of treatment are adequate to obtain favorable results. This seems particularly important for children that suffer a great number of sinonasal problems and might benefit significantly from an inexpensive and simple preventive and therapeutic measure such as NI.
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Affiliation(s)
- Nicola Principi
- Pediatric Highly Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, 20122 Milan, Italy.
| | - Susanna Esposito
- Pediatric Clinic, Università degli Studi di Perugia, 06123 Perugia, Italy.
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200
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Iwata K, Fukuchi T, Hirai M, Yoshimura K, Kanatani Y. Prevalence of inappropriate antibiotic prescriptions after the great east Japan earthquake, 2011. Medicine (Baltimore) 2017; 96:e6625. [PMID: 28403114 PMCID: PMC5403111 DOI: 10.1097/md.0000000000006625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Few studies have investigated the appropriateness of antibiotic use in postdisaster settings. We retrospectively evaluated clinical databases on health care delivered at clinics near shelters set up after the Great East Japan Earthquake, 2011. We defined appropriate, acceptable, and inappropriate antibiotic use for each diagnostic category, by applying and adopting precedent studies and clinical guidelines. From March to July, 2011, a total of 23,704 clinic visits occurred at 98 shelters with 7934 residents. Oral antibiotics were prescribed a total of 2253 times. The median age of the patients was 48.5 years old (range 0-97), and 43.7% were male. Of 2253 antibiotic prescriptions, 1944 were judged to be inappropriate (86.3% 95% CI 84.8%-87.7%). The most prescribed antibiotic was clarithromycin (646 times, 28.7%), followed by cefcapene pivoxil (644 times, 28.6%), levofloxacin (380, 16.9%), cefdinir (194, 8.6%), and cefditren pivoxil (98, 4.4%). The most frequent diagnosis for which antibiotics were prescribed was upper respiratory infection (URI, 1040 visits, 46.2%), followed by acute bronchitis (369, 16.4%), pharyngitis (298, 13.2%), traumatic injuries (194, 8.6%), acute gastroenteritis (136, 6.0%), urinary tract infections (UTIs, 123, 5.5%), and allergic rhinitis (5.1%). The majority of antibiotics prescribed at clinics after the Great East Japan Earthquake was inappropriate. Significant improvement of the use of antibiotics in postdisaster settings should be sought immediately in Japan.
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Affiliation(s)
- Kentaro Iwata
- Division of Infectious Diseases Therapeutics, Kobe University Graduate School of Medicine, Kobe
| | - Takahiko Fukuchi
- Department of General Medicine, Saitama Medical Center Jichi Medical University, Saitama
| | - Midori Hirai
- Department of Pharmacokinetics and Pharmaceutics, Kobe University Graduate School of Medicine, Kobe
| | - Kenichi Yoshimura
- Innovative Clinical Research Center (iCREK), Kanazawa University Hospital, Kanazawa
| | - Yasuhiro Kanatani
- Department of Health Crisis Management, National Institute of Public Health, Wako, Japan
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