1
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Wang Y, Zhao L, Wang J, Li X. The efficacy of perioperative antibiotic therapy in adenotonsillectomy children. Eur Arch Otorhinolaryngol 2024; 281:267-272. [PMID: 37737873 DOI: 10.1007/s00405-023-08244-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE To evaluate the role of perioperative antibiotics use in children after adenotonsillectomy. METHODS SPSS 27.0 was used for statistical analysis. Two independent samples mean T test was used to evaluate the throat pain scores consecutive 3 days after the surgery, the time to resume to normal diet, and the wound healing time. Logistic regression analysis was used to evaluate the independent risk factors of the two groups. The generalized estimation model was used to evaluate the correlation between age and postoperative pain scores, and the relationship between different tonsillar bed gradings and postoperative pain scores. RESULTS The pain scores were 5.83 ± 1.879, 5.20 ± 1.933, and 4.02 ± 1.936 in the observation group; and 6.83 ± 1.892, 6.17 ± 2.001, and 5.29 ± 2.068 in the control group on days 1-3 after surgery, respectively. The time of pain disappearance was 6.24 ± 2.121 days in the observation group and 7.73 ± 2.210 days in the control group. The wound repair time was 18.66 ± 2.200 days in the observation group and 18.70 ± 2.468 days in the control group. Logistic regression analysis showed that fever was an independent risk factor for the two groups and was negatively correlated (B = - 1.237, P < 0.001, OR = 0.290). Generalized estimation model showed that there was a positive correlation between age and pain scores (P < 0.001), and with the increasing grading of tonsillar bed, the higher the pain scores was (P < 0.001). CONCLUSIONS Perioperative use of antibiotics in children with adenotonsillectomy can effectively reduce postoperative fever, throat pain symptoms, and shorten the pain time. With the increasing of tonsillar bed grading, perioperative antibiotic therapy was more necessary.
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Affiliation(s)
- Ying Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062, People's Republic of China
| | - Limin Zhao
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062, People's Republic of China
| | - Jing Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062, People's Republic of China
| | - Xiaoyan Li
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, No.355, Luding Road, Shanghai, 200062, People's Republic of China.
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2
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Amati F, Bindo F, Stainer A, Gramegna A, Mantero M, Nigro M, Bussini L, Bartoletti M, Blasi F, Aliberti S. Identify Drug-Resistant Pathogens in Patients with Community-Acquired Pneumonia. Adv Respir Med 2023; 91:224-238. [PMID: 37366804 PMCID: PMC10295768 DOI: 10.3390/arm91030018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/27/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023]
Abstract
A substantial increase in broad-spectrum antibiotics as empirical therapy in patients with community-acquired pneumonia (CAP) has occurred over the last 15 years. One of the driving factors leading to that has been some evidence showing an increased incidence of drug-resistant pathogens (DRP) in patients from a community with pneumonia, including methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. Research has been published attempting to identify DRP in CAP through the implementation of probabilistic approaches in clinical practice. However, recent epidemiological data showed that the incidence of DRP in CAP varies significantly according to local ecology, healthcare systems and countries where the studies were performed. Several studies also questioned whether broad-spectrum antibiotic coverage might improve outcomes in CAP, as it is widely documented that broad-spectrum antibiotics overuse is associated with increased costs, length of hospital stay, drug adverse events and resistance. The aim of this review is to analyze the different approaches used to identify DRP in CAP patients as well as the outcomes and adverse events in patients undergoing broad-spectrum antibiotics.
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Affiliation(s)
- Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Francesco Bindo
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Anna Stainer
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Marco Mantero
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mattia Nigro
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Linda Bussini
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Infectious Diseases Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, 20089 Milan, Italy
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Infectious Diseases Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, 20089 Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
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Butler AM, Brown DS, Newland JG, Nickel KB, Sahrmann JM, O’Neil CA, Olsen MA, Zetts RM, Hyun DY, Durkin MJ. Comparative Safety and Attributable Healthcare Expenditures Following Inappropriate Versus Appropriate Outpatient Antibiotic Prescriptions Among Adults With Upper Respiratory Infections. Clin Infect Dis 2023; 76:986-995. [PMID: 36350187 PMCID: PMC10226742 DOI: 10.1093/cid/ciac879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/28/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about the clinical and financial consequences of inappropriate antibiotics. We aimed to estimate the comparative risk of adverse drug events and attributable healthcare expenditures associated with inappropriate versus appropriate antibiotic prescriptions for common respiratory infections. METHODS We established a cohort of adults aged 18 to 64 years with an outpatient diagnosis of a bacterial (pharyngitis, sinusitis) or viral respiratory infection (influenza, viral upper respiratory infection, nonsuppurative otitis media, bronchitis) from 1 April 2016 to 30 September 2018 using Merative MarketScan Commercial Database. The exposure was an inappropriate versus appropriate oral antibiotic (ie, non-guideline-recommended vs guideline-recommended antibiotic for bacterial infections; any vs no antibiotic for viral infections). Propensity score-weighted Cox proportional hazards models were used to estimate the association between inappropriate antibiotics and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable healthcare expenditures by infection type. RESULTS Among 3 294 598 eligible adults, 43% to 56% received inappropriate antibiotics for bacterial and 7% to 66% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and nausea/vomiting/abdominal pain (hazard ratio, 2.90; 95% confidence interval, 1.31-6.41 and hazard ratio, 1.10; 95% confidence interval, 1.03-1.18, respectively, for pharyngitis). Thirty-day attributable healthcare expenditures were higher among adults who received inappropriate antibiotics for bacterial infections ($18-$67) and variable (-$53 to $49) for viral infections. CONCLUSIONS Inappropriate antibiotic prescriptions for respiratory infections were associated with increased risks of patient harm and higher healthcare expenditures, justifying a further call to action to implement outpatient antibiotic stewardship programs.
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Affiliation(s)
- Anne M Butler
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Derek S Brown
- Brown School, Washington University, St. Louis, Missouri, USA
| | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, St. Louis, Missouri, USA
| | - Katelin B Nickel
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - John M Sahrmann
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Caroline A O’Neil
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Margaret A Olsen
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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Costanzo V, Roviello GN. The Potential Role of Vaccines in Preventing Antimicrobial Resistance (AMR): An Update and Future Perspectives. Vaccines (Basel) 2023; 11:vaccines11020333. [PMID: 36851210 PMCID: PMC9962013 DOI: 10.3390/vaccines11020333] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
In the modern era, the consumption of antibiotics represents a revolutionary weapon against several infectious diseases, contributing to the saving of millions of lives worldwide. However, the misuse of antibiotics for human and animal purposes has fueled the process of antimicrobial resistance (AMR), considered now a global emergency by the World Health Organization (WHO), which significantly increases the mortality risk and related medical costs linked to the management of bacterial diseases. The current research aiming at developing novel efficient antibiotics is very challenging, and just a few candidates have been identified so far due to the difficulties connected with AMR. Therefore, novel therapeutic or prophylactic strategies to fight AMR are urgently needed. In this scenario, vaccines constitute a promising approach that proves to be crucial in preventing pathogen spreading in primary infections and in minimizing the usage of antibiotics following secondary bacterial infections. Unfortunately, most of the vaccines developed against the main resistant pathogens are still under preclinical and clinical evaluation due to the complexity of pathogens and technical difficulties. In this review, we describe not only the main causes of AMR and the role of vaccines in reducing the burden of infectious diseases, but we also report on specific prophylactic advancements against some of the main pathogens, focusing on new strategies that aim at improving vaccine efficiency.
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Affiliation(s)
- Vincenzo Costanzo
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna Alma Mater Studiorum, 40126 Bologna, Italy
- Correspondence: (V.C.); (G.N.R.)
| | - Giovanni N. Roviello
- Italian National Council for Research (IBB-CNR), Area di Ricerca site and Headquartes, Via Pietro Castellino 111, 80131 Naples, Italy
- Correspondence: (V.C.); (G.N.R.)
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5
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Systemic quinolones and risk of retinal detachment III: a nested case-control study using a US electronic health records database. Eur J Clin Pharmacol 2022; 78:1019-1028. [PMID: 35290480 PMCID: PMC9107393 DOI: 10.1007/s00228-021-03260-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022]
Abstract
Background Quinolones are popular antibiotics that are known for their potency, broad coverage, and reasonable safety. Concerns have been raised about a possible association between quinolones and retinal detachment (RD). Methods We conducted a nested case–control study using electronic health records (EHR) from the Health Facts® Database. The initial cohort included all patients who were admitted between 2000 and 2016, with no history of eye disease, and had a minimum medical history of one year. Eligible cases comprised inpatients who were first admitted with a primary diagnosis of RD between 2010 and 2015. Each eligible case was matched without replacement to five unique controls by sex, race, age, and period-at-risk. We used conditional logistic regression to calculate RD risk, adjusting for exposure to other medications, and major risk factors. Results We identified 772 cases and 3860 controls. Whereas our primary analysis of all subjects revealed no quinolone-associated RD risk, elevated but non-significant risks were noted in African Americans (ciprofloxacin and levofloxacin), those aged 56–70 years old (moxifloxacin), and women (ciprofloxacin). Conclusion Our study did not identify an elevated RD risk within 30 days following systemic administration of quinolone antibiotics. Suggestions of increased risk observed in some population subgroups warrant further investigation. Supplementary Information The online version contains supplementary material available at 10.1007/s00228-021-03260-4.
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6
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Taher MK, Crispo JAG, Fortin Y, Moog R, McNair D, Bjerre LM, Momoli F, Mattison D, Krewski D. Systemic quinolones and risk of acute liver failure III: A nested case-control study using a US electronic health records database. J Gastroenterol Hepatol 2021; 36:2307-2314. [PMID: 33755266 PMCID: PMC8451826 DOI: 10.1111/jgh.15504] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/19/2021] [Accepted: 03/14/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Quinolones are globally popular antibiotics with proven potency, broad coverage, and reasonable safety. However, some concerns were raised as to their possible association with acute liver failure (ALF). The aim of this study is to assess ALF risk within 30 days of receiving a systemically administered quinolone antibiotic, in individuals with no history of liver/diseases. METHODS We conducted a nested case-control study using electronic health records from the Cerner Health Facts. The initial cohort (n = 35 349 943) included all patients who were admitted between 2000 and 2016, with no history of liver diseases, and had a minimum medical history of one year. Eligible cases were inpatients who were first diagnosed with ALF between 2010 and 2015. Using incidence density sampling, each case was matched with up to five unique controls by sex, race, age at index encounter, and period-at-risk. We used conditional logistic regression to calculate the odds ratio and 95% confidence interval for ALF risk, upon adjusting for exposure to other medications, and major confounders (diabetes mellitus and alcohol abuse). We used the STROBE Statement for reporting on our study. RESULTS We identified 3151 cases and 15 657 controls. Our primary analysis did not reveal an association between quinolones and ALF risk. However, some risk was identified among those with no or few comorbidities, those ≤ 60 years of age, women, men, African Americans, and Caucasians. CONCLUSION Although our study does not suggest an overall association between quinolones and ALF, elevated risks seen in some subgroups warrant further investigation.
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Affiliation(s)
- Mohamed Kadry Taher
- McLaughlin Centre for Population Health Risk Assessment, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada,School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Risk Sciences InternationalOttawaOntarioCanada
| | - James A G Crispo
- McLaughlin Centre for Population Health Risk Assessment, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada,Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA,Human Sciences DivisionNorthern Ontario School of MedicineSudburyOntarioCanada
| | - Yannick Fortin
- McLaughlin Centre for Population Health Risk Assessment, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada,Statistics CanadaOttawaOntarioCanada
| | - Ryan Moog
- Cerner CorporationKansas CityMissouriUSA
| | | | - Lise M Bjerre
- School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Department of Family MedicineUniversity of OttawaOttawaOntarioCanada,Institut du Savoir MontfortOttawaOntarioCanada
| | - Franco Momoli
- School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Risk Sciences InternationalOttawaOntarioCanada,Children's Hospital of Eastern Ontario Research InstituteOttawaOntarioCanada
| | - Donald Mattison
- McLaughlin Centre for Population Health Risk Assessment, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada,School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Risk Sciences InternationalOttawaOntarioCanada
| | - Daniel Krewski
- McLaughlin Centre for Population Health Risk Assessment, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada,School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Risk Sciences InternationalOttawaOntarioCanada
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Taher MK, Alami A, Gravel CA, Tsui D, Bjerre LM, Momoli F, Mattison DR, Krewski D. Systemic quinolones and risk of acute liver failure I: Analysis of data from the US FDA adverse event reporting system. JGH OPEN 2021; 5:778-784. [PMID: 34263072 PMCID: PMC8264239 DOI: 10.1002/jgh3.12585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/18/2021] [Accepted: 05/18/2021] [Indexed: 11/25/2022]
Abstract
Background and Aim Quinolones are a potent and globally popular group of antibiotics that are used to treat a wide range of infections. Some case reports have raised concern about their possible association with acute hepatic failure (AHF). Data from the US FDA Adverse Event Reporting System were evaluated for signals of AHF in association with systemically administered quinolone antibiotics. Methods AHF reports between 1969 and 2019q2, with a focus on 2010–2019q2, were analyzed. Specifically, AHF reports linked to non‐quinolone antibiotics of known hepatotoxicity were compared to reports with non‐quinolone, non‐hepatotoxic (reference) antibiotics; and AHF reports with quinolones were also compared to reports with the same group of reference antibiotics. Two disproportionality signal detection techniques (proportional reporting ratio, PRR, and empirical Bayes geometric mean, EBGM) were used to assess the AHF signal for both analyses. Results Only ciprofloxacin showed a marginal and significant AHF signal (PRR: 1.85 [1.21, 2.81]; EBGM: 1.54 [1.06, 1.81]); moxifloxacin, levofloxacin, and ofloxacin showed weak and nonsignificant signals. Conclusion Further pharmacovigilance studies are required to confirm the association between ciprofloxacin and AHF seen in the present analysis.
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Affiliation(s)
- Mohamed Kadry Taher
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine University of Ottawa Ottawa ON Canada.,School of Epidemiology and Public Health University of Ottawa Ottawa ON Canada.,Risk Sciences International Ottawa ON Canada
| | | | - Christopher A Gravel
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine University of Ottawa Ottawa ON Canada.,School of Epidemiology and Public Health University of Ottawa Ottawa ON Canada.,Department of Epidemiology, Biostatistics and Occupational Health McGill University Montreal QC Canada
| | - Derek Tsui
- Risk Sciences International Ottawa ON Canada
| | - Lise M Bjerre
- School of Epidemiology and Public Health University of Ottawa Ottawa ON Canada.,Department of Family Medicine University of Ottawa Ottawa ON Canada.,C.T. Lamont Primary Health Care Research Centre Bruyère Research Institute Ottawa ON Canada
| | - Franco Momoli
- School of Epidemiology and Public Health University of Ottawa Ottawa ON Canada.,Risk Sciences International Ottawa ON Canada.,Children's Hospital of Eastern Ontario Research Institute Ottawa ON Canada
| | - Donald R Mattison
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine University of Ottawa Ottawa ON Canada.,Risk Sciences International Ottawa ON Canada
| | - Daniel Krewski
- McLaughlin Centre for Population Health Risk Assessment, Faculty of Medicine University of Ottawa Ottawa ON Canada.,School of Epidemiology and Public Health University of Ottawa Ottawa ON Canada.,Risk Sciences International Ottawa ON Canada
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An Efflux Pumps Inhibitor Significantly Improved the Antibacterial Activity of Botanicals from Plectranthus glandulosus towards MDR Phenotypes. ScientificWorldJournal 2021; 2021:5597524. [PMID: 34054358 PMCID: PMC8131149 DOI: 10.1155/2021/5597524] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/04/2021] [Indexed: 01/28/2023] Open
Abstract
Bacterial multidrug resistance causes many therapeutic failures, making it more difficult to fight against bacterial diseases. This study aimed to investigate the antibacterial activity of extract, fractions, and phytochemicals from Plectranthus glandulosus (Lamiaceae) against multidrug-resistant (MDR) Gram-negative phenotypes expressing efflux pumps. The crude extract after extraction was subjected to column chromatography, and the structures of the isolated compounds were determined using spectrometric and spectroscopic techniques. Antibacterial assays of samples alone and in the presence of an efflux pump inhibitor (phenylalanine-arginine β-naphthylamide, PAβN) were carried out using the broth microdilution method. The phytochemical study of P. glandulosus plant extract afforded seven major fractions (A-G) which lead to the isolation of seventeen known compounds. The ethanol extract of P. glandulosus was not active at up to 1024 μg/mL, whereas its fractions showed MICs varying from 32 to 512 μg/mL on the studied bacteria. Fraction C of P. glandulosus showed the lowest MIC (32 μg/mL) on E. coli ATCC8739 strain. Fraction D presented the highest activity spectrum by inhibiting the growth of 90% (9/10) of the studied bacteria. The presence of PAβN has improved the activity of extract and all fractions. Overall, the tested phytochemicals showed low activity against the studied bacteria. The overall results obtained in this study show that some fractions from P. glandulosus, mainly fractions C and D, should be investigated more for their possible use to fight against MDR bacteria.
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Martínez-González NA, Keizer E, Plate A, Coenen S, Valeri F, Verbakel JYJ, Rosemann T, Neuner-Jehle S, Senn O. Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials. Antibiotics (Basel) 2020; 9:antibiotics9090610. [PMID: 32948060 PMCID: PMC7559694 DOI: 10.3390/antibiotics9090610] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 11/16/2022] Open
Abstract
C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I2 = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).
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Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, PO Box 4466, CH-6002 Lucerne, Switzerland
- Correspondence:
| | - Ellen Keizer
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp-Campus Drie Eiken, Doornstraat 331, 2610 Antwerp (Wilrijk), Belgium;
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp-Campus Drie Eiken, Universiteitsplein 1, 2610 Antwerp (Wilrijk), Belgium
| | - Fabio Valeri
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Jan Yvan Jos Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven (University of Leuven), Kapucijnenvoer 33, 3000 Leuven, Belgium;
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
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10
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Mortazhejri S, Hong PJ, Yu AM, Hong BY, Stacey D, Bhatia RS, Grimshaw JM. Systematic review of patient-oriented interventions to reduce unnecessary use of antibiotics for upper respiratory tract infections. Syst Rev 2020; 9:106. [PMID: 32384919 PMCID: PMC7210679 DOI: 10.1186/s13643-020-01359-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/14/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Antibiotics are prescribed frequently for upper respiratory tract infections (URTIs) even though most URTIs do not require antibiotics. This over-prescription contributes to antibiotic resistance which is a major health problem globally. As physicians' prescribing behaviour is influenced by patients' expectations, there may be some opportunities to reduce antibiotic prescribing using patient-oriented interventions. We aimed to identify these interventions and to understand which ones are more effective in reducing unnecessary use of antibiotics for URTIs. METHODS We conducted a systematic review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), CINAHL, and the Web of Science. We included English language randomized controlled trials (RCTs), quasi-RCTs, controlled before and after studies, and interrupted time series (ITS) studies. Two authors screened the abstract/titles and full texts, extracted data, and assessed study risk of bias. Where pooling was appropriate, a meta-analysis was performed by using a random-effects model. Where pooling of the data was not possible, a narrative synthesis of results was conducted. RESULTS We included 13 studies (one ITS, one cluster RCTs, and eleven RCTs). All interventions could be classified into two major categories: delayed prescriptions (seven studies) and patient/public information and education interventions (six studies). Our meta-analysis of delayed prescription studies observed significant reductions in the use of antibiotics for URTIs (OR = 0.09, CI 0.03 to 0.23; six studies). A subgroup analysis showed that prescriptions that were given at a later time and prescriptions that were given at the index consultation had similar effects. The studies in the patient/public information and education group varied according to their methods of delivery. Since only one or two studies were included for each method, we could not make a definite conclusion on their effectiveness. In general, booklets or pamphlets demonstrated promising effects on antibiotic prescription, if discussed by a practitioner. CONCLUSIONS Patient-oriented interventions (especially delayed prescriptions) may be effective in reducing antibiotic prescription for URTIs. Further research is needed to investigate the costs and feasibility of implementing these interventions as part of routine clinical practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016048007.
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Affiliation(s)
- Sameh Mortazhejri
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Patrick Jiho Hong
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Ashley M. Yu
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Brian Younho Hong
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Canada
| | - Dawn Stacey
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - R. Sacha Bhatia
- Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Canada
- Insitute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
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11
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Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg 2019; 160:S1-S42. [PMID: 30798778 DOI: 10.1177/0194599818801757] [Citation(s) in RCA: 272] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.
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Affiliation(s)
| | | | - Stacey L Ishman
- 3 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Sarah Coles
- 5 University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Sandra A Finestone
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | | | - Terri Giordano
- 8 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Tae W Kim
- 10 University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Robin M Lloyd
- 11 Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota, USA
| | | | - Stanford T Shulman
- 13 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David L Walner
- 14 Advocate Children's Hospital, Park Ridge, Illinois, USA
| | - Sandra A Walsh
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Lorraine C Nnacheta
- 15 Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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12
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Al-Qahtani SM, Baffoe-Bonnie H, El-Saed A, Alshamrani M, Algwizani A, Alaklabi A, AlJoudi K, Albaalharith N, Mohammed A, Hussain S, Balkhy HH. Appropriateness of antimicrobial use among septic patients managed by the critical care response team: an opportunity for improvement through de-escalation. Antimicrob Resist Infect Control 2019; 8:186. [PMID: 31832186 PMCID: PMC6869254 DOI: 10.1186/s13756-019-0609-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/21/2019] [Indexed: 01/09/2023] Open
Abstract
Background Most septic patients managed by critical care response teams (CCRT) are prescribed antimicrobials. Nevertheless, data evaluating their appropriateness are lacking both locally and internationally. The objective was to assess antimicrobial use among septic and non-septic patients managed by CCRT. Setting Case-control design was used to compare septic (cases) and non-septic (controls) CCRT patients at tertiary care setting. The frequency of antimicrobial use was assessed before and after CCRT activation. The appropriateness of antimicrobial use was assessed at day four post-CCRT, based on standard recommendations, clinical assessment, and culture results. Main results A total of 157 cases and 158 controls were included. The average age was 61.1 ± 20.4 years, and 54.6% were males, with minor differences between groups. The use of any antimicrobial was 100.0% in cases and 87.3% in controls (p < 0.001). The use of meropenem (68.2% versus 34.8%, p < 0.001) and vancomycin (56.7% versus 25.9%, p < 0.001) were markedly higher in cases than controls. The overall appropriateness was significantly lower in cases than controls (50.7% versus 59.6%, p = 0.047). Individual appropriateness was lowest with meropenem (16.7%) and imipenem (25.0%), and highest with piperacillin/tazobactam (87.1%) and colistin (78.3%). Only 48.5% of antimicrobials prescribed by CCRT were de-escalated by a primary team within four days. Individual appropriateness and de-escalations were not different between groups. Conclusions Empiric use and inadequate de-escalation of broad-spectrum antimicrobials were major causes for inappropriate antimicrobial use in CCRT patients. Our findings highlight the necessity of urgent implementation of an antimicrobial stewardship program, including training and auditing of antimicrobial prescriptions.
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Affiliation(s)
- Saad M Al-Qahtani
- 1Intensive Care Medicine Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Henry Baffoe-Bonnie
- 3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Aiman El-Saed
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Majid Alshamrani
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Ali Alaklabi
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,5Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Khuloud AlJoudi
- 6Pharmacy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Nahlah Albaalharith
- 1Intensive Care Medicine Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Azzam Mohammed
- 3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Sajid Hussain
- 1Intensive Care Medicine Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hanan H Balkhy
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,7King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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13
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Ciofi degli Atti ML, D’Amore C, Ceradini J, Paolini V, Ciliento G, Chessa G, Raponi M. Prevalence of antibiotic use in a tertiary care hospital in Italy, 2008-2016. Ital J Pediatr 2019; 45:63. [PMID: 31109362 PMCID: PMC6528368 DOI: 10.1186/s13052-019-0645-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 04/12/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Few data are available about temporal trends of antibiotic use in hospitalized children. The aim of the current study was to investigate the pattern and trends of antibiotic use over the years 2008-2016 in the largest children's hospital in Italy. METHODS Annual point prevalence surveys of antibiotic use were conducted by reviewing medical charts of 0-17 year-old children hospitalized for ≥48 h. Prevalence of antibiotic use was computed by year, type of ward and indication. Trends in prevalence over time were evaluated using the Cochrane-Armitage test. Possibile determinants of antibiotic use were assessed at univariate analysis and through a logistic regression model. RESULTS Out of 3015 children, 1516 (50.3%) received antibiotics, 58.1% of which for medical/surgical prophylaxis. Prevalence of antibiotic use increased from 42.0% in 2008 to 56.2% in 2016 (p = 0.001). The prevalence of patients receiving antibiotics for medical prophylaxis increased from 6.1% in 2008 to 24.2% in 2016 (p < 0.001), whereas the prevalence of patients receiving antibiotics for surgical prophylaxis significantly decreased (from 13.7 to 11.8%; p = 0.04); no significant temporal trends were found in antibiotic use for treating infections. The administration of third-generation cephalosporins for surgical and medical prophylaxis significantly decreased over time, while the proportion of antibiotics prescribed to treat infections after microbiological investigations significantly increased. Year (ORadj: 1.8 in 2016 compared to 2008, p < 0.001), age (ORadj ≥1.5 in children ≥1 year, compared to infants ≤2 months, p < 0.001), length of stay (LOS) (ORadj: 1.4 in case of LOS between 8 and 30 days compared to LOS ≤ 7 days, p < 0.001), and type of ward (ORadj: ≥1.3 in intensive-care, surgical and medical-subspecialty units compared to medical units, p < 0.001) were significantly and independently associated with antibiotic use. CONCLUSIONS Comparing prevalence rates of antibiotic use among hospitals and over time should consider differences in patient characteristics, such as age, ward of hospitalization and length of stay. Over the years, we documented an improvement in the choice of antibiotics prescribed for medical and surgical prophylaxis. However, further efforts are needed to avoid antibiotic misuse for medical prophylaxis, and to reduce the empirical use of broad spectrum antibiotics.
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Affiliation(s)
| | - Carmen D’Amore
- Unit of Clinical Epidemiology, Bambino Gesù Children’s Hospital, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - Jacopo Ceradini
- Medical Direction, Bambino Gesù Children’s Hospital, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - Valerio Paolini
- Medical Direction, Bambino Gesù Children’s Hospital, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - Gaetano Ciliento
- Medical Direction, Bambino Gesù Children’s Hospital, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - Giuseppe Chessa
- Medical Direction, Bambino Gesù Children’s Hospital, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - Massimiliano Raponi
- Medical Direction, Bambino Gesù Children’s Hospital, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
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14
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Balkhy HH, El-Saed A, El-Metwally A, Arabi YM, Aljohany SM, Al Zaibag M, Baharoon S, Alothman AF. Antimicrobial consumption in five adult intensive care units: a 33-month surveillance study. Antimicrob Resist Infect Control 2018; 7:156. [PMID: 30598819 PMCID: PMC6302414 DOI: 10.1186/s13756-018-0451-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 12/11/2018] [Indexed: 12/16/2022] Open
Abstract
Background Estimating the baseline antimicrobial consumption is extremely important to monitor the impact of antimicrobial stewardship activities that aim to reduce the burden and cost of antimicrobial consumption. Objectives To quantify service-specific antimicrobial consumption using different metrics. Methods A surveillance study was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between October 2012 and June 2015 in five adult intensive care units (ICUs). Consumption data were collected manually on a daily basis by infection control practitioners. Data were presented as defined daily dose (DDD), days of therapy (DOT) per 1000 patient days, and frequency of daily consumption. Results A total of 43,970 DDDs and 46,940 DOTs were monitored during 54,116 patient-days. For the most frequently consumed antimicrobials, the consumption of carbapenems, piperacillin/tazobactam, vancomycin, and colistin (respectively) in all ICUs combined were 255.9, 134.3, 98.2, and 13.6 DDDs per 1000 patient-days and 235.7, 145.9, 129.5, and 117.5 DOTs per 1000 patient-days. For the frequency of daily consumption, carbapenems were the most frequently consumed antimicrobial group in medical/surgical, burn, and step-down ICUs while piperacillin/tazobactam was the most frequently consumed antimicrobial in neuro-surgical and cardio-thoracic ICUs. Conclusion High consumption of broad-spectrum antimicrobial agents such as meropenem and piperacillin/tazobactam is observed in multiple ICUs in a tertiary care hospital. Meropenem consumption is considerably higher than similar ICUs internationally. Future studies focusing on concurrent monitoring of antimicrobial resistance and identifying patient and physician characteristics associated with specific prescription patterns may help in improving judicious antimicrobial consumption.
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Affiliation(s)
- Hanan H Balkhy
- 1King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.,2Infectious Diseases, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.,3Infection Prevention and Control Department, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs (MNGHA), P.O. Box 22490, Riyadh, 11426 Kingdom of Saudi Arabia
| | - Aiman El-Saed
- 1King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.,3Infection Prevention and Control Department, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs (MNGHA), P.O. Box 22490, Riyadh, 11426 Kingdom of Saudi Arabia.,4Community Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ashraf El-Metwally
- 1King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Yaseen M Arabi
- 1King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.,2Infectious Diseases, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.,Intensive Care Department, KAMC, MNGHA, Riyadh, Saudi Arabia
| | - Sameera M Aljohany
- 1King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.,Pathology and Laboratory Medicine Department, KAMC, MNGHA, Riyadh, Saudi Arabia
| | - Muayed Al Zaibag
- Cardiac Center & Cardiac Sciences, KAMC, MNGHA, Riyadh, Saudi Arabia
| | - Salim Baharoon
- 1King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.,Internal Medicine Department, Infectious Disease Division, KAMC, MNGHA, Riyadh, Saudi Arabia
| | - Adel F Alothman
- 1King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.,Internal Medicine Department, Infectious Disease Division, KAMC, MNGHA, Riyadh, Saudi Arabia
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15
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Abstract
AbstractInappropriate antibiotic use is associated with increased antimicrobial resistance and adverse events that can lead to further downstream patient harm. Preventative strategies must be employed to improve antibiotic use while reducing avoidable harm. We use the term “antibiotic never events” to globally recognize and define the most inappropriate antibiotic use.
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16
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Llor C, Moragas A, Cordoba G. [Twenty-five myths in infectious diseases in primary care associated with overdiagnosis and overtreatment]. Aten Primaria 2018; 50 Suppl 2:57-64. [PMID: 30270191 PMCID: PMC6836970 DOI: 10.1016/j.aprim.2018.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 11/17/2022] Open
Abstract
Overdiagnosis and overprescribing is common in current clinical practice of infectious diseases in primary care. On the basis of studies published in the medical literature we identify my means of a non-systematic review a total of 25 myths associated with the diagnosis and treatment and present the literature pertaining to each myth. These myths result in extraneous testing (overdiagnosis) and excessive antimicrobial treatment (overtreatment). Most of these myths are ingrained among general practitioners in our country. Not only should these myths be debunked from our clinical practice, but they should also be reversed, and we encourage our readers to critically appraise their practice when it comes down to the misconceptions treated in this manuscript. We attempt to give guidance to clinicians facing these frequent clinical scenarios.
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Affiliation(s)
- Carles Llor
- Centro de Salud Via Roma, Barcelona, España; Grupo de Trabajo de Enfermedades Infecciosas de la semFYC.
| | - Ana Moragas
- Universitat Rovira i Virgili. Centro de Salud Jaume I, Tarragona, España
| | - Gloria Cordoba
- Centro de Investigación y Educación en Medicina Familiar, Instituto de Salud Pública, Universidad de Copenhague, Copenhague, Dinamarca
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Antibacterial and Antibiotic-Potentiating Activities of Thirteen Cameroonian Edible Plants against Gram-Negative Resistant Phenotypes. ScientificWorldJournal 2018; 2018:4020294. [PMID: 30275799 PMCID: PMC6151687 DOI: 10.1155/2018/4020294] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/24/2018] [Accepted: 07/17/2018] [Indexed: 12/12/2022] Open
Abstract
This work was designed to investigate the antibacterial activities of methanol extracts from thirteen Cameroonian edible plants and their antibiotic-potentiating effects against Gram-negative multidrug-resistant (MDR) phenotypes. The broth microdilution method was used to evaluate the minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) of the extracts, as well as their antibiotic-potentiating activities. The phytochemical screening of the extracts was carried out according to the standard methods. The results of phytochemical tests revealed the presence of sterols, polyphenols, and tannins in most of the tested extracts, with the other classes of secondary metabolites being selectively distributed. Tested extracts showed variable antibacterial activities with MIC values ranging from 64 to 1024 μg/mL. However, some extracts were significantly active against certain bacterial strains: seeds extract of Theobroma cacao (64 μg/mL) against Escherichia coli AG100Atet and Klebsiella pneumoniae K24, and the bark extract of Uapaca guineensis against E. coli ATCC 8739. The leaves extract of T. cacao displayed the best MBC values (256 μg/mL) against E. aerogenes EA27. Some tested extracts included extracts from the leaves of T. cacao and P. vulgaris, and the seeds of D. edulis and barks A. indica has selectively improved (2- to 64-fold) the antibacterial activities of some of the tested antibiotics, chloramphenicol (CHL), tetracycline (TET), kanamycin (KAN), streptomycin (STR), and erythromycin (ERY), against more than 70% of tested MDR bacteria. The findings of this work showed that tested plant extracts and particularly those from T. cacao and Phaseolus vulgaris can be used alone or in combination with conventional antibiotics in the treatment of infections involving multiresistant bacteria.
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Chowdhury F, Sturm-Ramirez K, Mamun AA, Iuliano AD, Chisti MJ, Ahmed M, Bhuiyan MU, Hossain K, Haider MS, Aziz SA, Rahman M, Azziz-Baumgartner E. Effectiveness of an educational intervention to improve antibiotic dispensing practices for acute respiratory illness among drug sellers in pharmacies, a pilot study in Bangladesh. BMC Health Serv Res 2018; 18:676. [PMID: 30170573 PMCID: PMC6119333 DOI: 10.1186/s12913-018-3486-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inappropriate dispensing of antibiotics for acute respiratory illness (ARI) is common among drug sellers in Bangladesh. In this study, we evaluated the impact of an educational intervention to promote guidelines for better ARI management among drug sellers. METHODS From June 2012 to December 2013, we conducted baseline and post-intervention surveys on dispensing practices in 100 pharmacies within Dhaka city. In these surveys, drug sellers participated in 6 standardized role-playing scenarios led by study staffs acting as caregivers of ARI patients and drug sellers were blinded to these surveys. After the baseline survey, we developed ARI guidelines and facilitated a one-day educational intervention about ARI management for drug sellers. Our guidelines only recommended antibiotics for children with complicated ARI. Finally, we conducted the six month post-intervention survey using the same scenarios to record changes in drug dispensing practices. RESULTS Only 2/3 of participating pharmacies were licensed and few (11%) of drug sellers had pharmacy training. All the drug sellers were male, had a median age of 34 years (IQR 28-41). For children, dispensing of antibiotics for uncomplicated ARI decreased (30% baseline vs. 21% post-intervention; p = 0.04), but drug sellers were equally likely to dispense antibiotics for complicated ARI (15% baseline vs. 17% post-intervention; p = 0.6) and referrals to physicians for complicated ARIs decreased (70% baseline vs. 58% post-intervention; p = 0.03). For adults, antibiotic dispensing remained similar for uncomplicated ARI (48% baseline vs. 40% post-intervention; p = 0.1) but increased among those with complicated ARI (44% baseline vs. 78% post-intervention; p < 0.001). Although our evidence-based guidelines recommended against prescribing antihistamines for children, drug sellers continued to sell similar amounts for uncomplicated ARI (33% baseline vs. 32% post-intervention; p = 0.9). CONCLUSIONS Despite the intervention, drug sellers continued to frequently dispense antibiotics for ARI, except for children with uncomplicated ARI. Pairing educational interventions among drug sellers with raising awareness about proper antibiotic use among general population should be further explored. In addition, annual licensing and an reaccreditation system with comprehensive monitoring should be enforced, using penalties for non-compliant pharmacies as possible incentives for appropriate dispensing practices.
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Affiliation(s)
- Fahmida Chowdhury
- International Centre for Diarrhoeal Disease Research, (icddr,b), Bangladesh, Dhaka, Bangladesh
| | - Katharine Sturm-Ramirez
- International Centre for Diarrhoeal Disease Research, (icddr,b), Bangladesh, Dhaka, Bangladesh
- Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - Abdullah Al Mamun
- International Centre for Diarrhoeal Disease Research, (icddr,b), Bangladesh, Dhaka, Bangladesh
| | | | - Mohammod Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, (icddr,b), Bangladesh, Dhaka, Bangladesh
| | - Makhdum Ahmed
- International Centre for Diarrhoeal Disease Research, (icddr,b), Bangladesh, Dhaka, Bangladesh
| | - Mejbah Uddin Bhuiyan
- International Centre for Diarrhoeal Disease Research, (icddr,b), Bangladesh, Dhaka, Bangladesh
| | - Kamal Hossain
- International Centre for Diarrhoeal Disease Research, (icddr,b), Bangladesh, Dhaka, Bangladesh
| | | | - Shaikh Abdul Aziz
- International Centre for Diarrhoeal Disease Research, (icddr,b), Bangladesh, Dhaka, Bangladesh
| | - Mahmudur Rahman
- Institute of Epidemiology, Disease Control and Research, (IEDCR), Dhaka, Bangladesh
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Results from a Patient-Based Health Education Intervention in Reducing Antibiotic Use for Acute Upper Respiratory Tract Infections in the Private Sector Primary Care Setting in Singapore. Antimicrob Agents Chemother 2017; 61:AAC.02257-16. [PMID: 28193663 PMCID: PMC5404603 DOI: 10.1128/aac.02257-16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 02/05/2017] [Indexed: 11/20/2022] Open
Abstract
We investigated the efficacy of patient-targeted education in reducing antibiotic prescriptions for upper respiratory tract infections (URTIs) among adults in the private primary care setting in Singapore. Our randomized controlled trial enrolled patients aged 21 years and above presenting at general practitioner (GP) clinics with URTI symptoms for 7 days or less. Intervention arm patients were verbally educated via pamphlets about the etiology of URTIs, the role of antibiotics in treating URTIs, and the consequences of inappropriate antibiotic use. Control arm patients were educated on influenza vaccinations. Both arms were compared regarding the proportions prescribed antibiotics and the patients' postconsultation views. A total of 914 patients consulting 35 doctors from 24 clinics completed the study (457 in each arm). The demographics of patients in both arms were similar, and 19.1% were prescribed an antibiotic, but this varied from 0% to 70% for individual GPs. The intervention did not significantly reduce antibiotic prescriptions (odds ratio [OR], 1.20; 95% confidence interval [CI], 0.83–1.73) except in patients of Indian ethnicity (OR, 0.28; 95% CI, 0.09–0.93). Positive associations between the intervention and the view that antibiotics were not needed most of the time for URTIs (P = 0.047) and on being worried about the side effects of antibiotics (P = 0.018) were restricted to the Indian subgroup. GPs in limited liability partnerships or clinic chains prescribed less (OR, 0.36; 95% CI, 0.14 to 0.92), while certain inappropriate patient responses were associated with the receipt of antibiotics. Follow-up studies to investigate differences in responses to educational programs between ethnicities and to explore GP-targeted interventions are recommended.
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Mehta N, Schilder A, Fragaszy E, E R Evans H, Dukes O, Manikam L, Little P, Smith SC, Hayward A. Antibiotic prescribing in patients with self-reported sore throat. J Antimicrob Chemother 2017; 72:914-922. [PMID: 27999063 PMCID: PMC5400092 DOI: 10.1093/jac/dkw497] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 10/19/2016] [Indexed: 01/21/2023] Open
Abstract
Objectives To investigate the predictors of general practitioner (GP) consultation and antibiotic use in those developing sore throat. Methods We conducted a prospective population-based cohort study on 4461 participants in two rounds (2010-11) from 1897 households. Results Participants reported 2193 sore throat illnesses, giving a community sore throat incidence of 1.57/ person-year. 13% of sore throat illnesses led to a GP consultation and 56% of these consultations led to antibiotic use. Participants most likely to have sore throats included women and children (e.g. school compared with retirement age); adjusted incidence rate ratio (aIRR) of 1.33 and 1.52, respectively. Participants with sore throat were more likely to consult their GP if they were preschool compared with retirement age [adjusted OR (aOR) 3.22], had more days of sore throat (aOR 1.11), reported more severe pain (aOR 4.24) or reported fever (aOR 3.82). Antibiotics were more often used by chronically ill individuals (aOR 1.78), those reporting severe pain (aOR 4.14), those reporting fever (aOR 2.58) or children with earache (aOR 1.85). Among those who consulted, males and adults who reported feeling anxious were more likely to use antibiotics; aOR 1.87 and 5.36, respectively. Conclusions Only 1 in 10 people who have a sore throat see a doctor and more than half of those attending get antibiotics. Further efforts to curb antibiotic use should focus on reducing initial GP consultations through public information promoting safe self-management, targeted at groups identified above as most likely to attend with sore throats.
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Affiliation(s)
- Nishchay Mehta
- Farr Institute of Health Informatics Research, UCL, 222 Euston Road, London NW1 2DA, UK
- evidENT, Ear Institute, UCL, 330 Gray's Inn Road, London WC1X 8DA, UK
| | - Anne Schilder
- evidENT, Ear Institute, UCL, 330 Gray's Inn Road, London WC1X 8DA, UK
| | - Ellen Fragaszy
- Farr Institute of Health Informatics Research, UCL, 222 Euston Road, London NW1 2DA, UK
- London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Hannah E R Evans
- Farr Institute of Health Informatics Research, UCL, 222 Euston Road, London NW1 2DA, UK
- evidENT, Ear Institute, UCL, 330 Gray's Inn Road, London WC1X 8DA, UK
| | - Oliver Dukes
- Farr Institute of Health Informatics Research, UCL, 222 Euston Road, London NW1 2DA, UK
| | - Logan Manikam
- evidENT, Ear Institute, UCL, 330 Gray's Inn Road, London WC1X 8DA, UK
- Population, Policy and Practice, UCL Great Ormond Street, Institute of Child Health, London, UK
| | - Paul Little
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton, Aldermoor Close, Southampton SO16 5ST, UK
| | - Sarah C Smith
- London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Andrew Hayward
- Farr Institute of Health Informatics Research, UCL, 222 Euston Road, London NW1 2DA, UK
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Bielicki JA, Barker CIS, van der Velden AW, Sharland M, van Esso D, Hadjipanayis A, Del Torso S, Grossman Z. Antibiotic preferences for childhood pneumonia vary by physician type and European region. ERJ Open Res 2016; 2:00001-2016. [PMID: 27730183 PMCID: PMC5005166 DOI: 10.1183/23120541.00001-2016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 04/02/2016] [Indexed: 11/30/2022] Open
Abstract
Antibiotics are the most commonly prescribed medicines for acutely unwell children worldwide [1]. Many of these antibiotic prescriptions are issued in a primary care setting [2–4]. Despite this, a robust evidence base for agent selection in primary care is lacking for many childhood indications, including community-acquired pneumonia (CAP). In an era of increasing antibiotic resistance, with optimal antibiotic use being paramount to preserve this precious resource, trials involving ambulatory patients representative of those seen in primary care are needed to address this gap. Survey of EAPRASnet and @PREPARE_EUROPE members reveals heterogeneity of antibiotic choice for childhood pneumoniahttp://ow.ly/4mIS2P
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Affiliation(s)
- Julia A Bielicki
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK; Paediatric Pharmacology, University of Basel Children's Hospital, Basel, Switzerland
| | - Charlotte I S Barker
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Diego van Esso
- Primary Care Center "Pare Claret", Catalan Institute of Health, Barcelona, Spain
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Fisher JD, Freeman K, Clarke A, Spurgeon P, Smyth M, Perkins GD, Sujan MA, Cooke MW. Patient safety in ambulance services: a scoping review. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03210] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BackgroundThe role of ambulance services has changed dramatically over the last few decades with the introduction of paramedics able to provide life-saving interventions, thanks to sophisticated equipment and treatments available. The number of 999 calls continues to increase, with adverse events theoretically possible with each one. Most patient safety research is based on hospital data, but little is known concerning patient safety when using ambulance services, when things can be very different. There is an urgent need to characterise the evidence base for patient safety in NHS ambulance services.ObjectiveTo identify and map available evidence relating to patient safety when using ambulance services.DesignMixed-methods design including systematic review and review of ambulance service documentation, with areas for future research prioritised using a Delphi process.Setting and participantsAmbulance services, their staff and service users in UK.Data sourcesA wide range of data sources were explored. Multiple databases, reference lists from key papers and citations, Google and the NHS Confederation website were searched, and experts contacted to ensure that new data were included in the review. The databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts, Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium (HMIC), NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED),Health Technology Assessment, the FADE library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE) and Zetoc (The British Library's Electronic Table of Contents) were searched from 1 January 1980 to 12 October 2011. Publicly available documents and issues identified by National Patient Safety Agency (NPSA), NHS Litigation Authority (NHSLA) and coroners’ reports were considered. Opinions and perceptions of senior managers, ambulance staff and service users were solicited.Review methodsData were extracted from annual reports using two-stage thematic analysis, data from quality accounts were collated with safety priorities tabulated and considered using thematic analysis, NPSA incident report data were collated and displayed comparatively using descriptive statistics, claims reported to NHSLA were analysed to identify number and cost of claims from mistakes and/or poor service, and summaries of coroners’ reports were assessed using thematic analysis to identify underlying safety issues. The depth of analysis is limited by the remit of a scoping exercise and availability of data.ResultsWe identified studies exploring different aspects of safety, which were of variable quality and with little evidence to support activities currently undertaken by ambulance services. Adequately powered studies are required to address issues of patient safety in this service, and it appeared that national priorities were what determined safety activities, rather than patient need. There was inconsistency of information on attitudes and approaches to patient safety, exacerbated by a lack of common terminology.ConclusionPatient safety needs to become a more prominent consideration for ambulance services, rather than operational pressures, including targets and driving the service. Development of new models of working must include adequate training and monitoring of clinical risks. Providers and commissioners need a full understanding of the safety implications of introducing new models of care, particularly to a mobile workforce often isolated from colleagues, which requires a body of supportive evidence and an inherent critical evaluation culture. It is difficult to extrapolate findings of clinical studies undertaken in secondary care to ambulance service practice and current national guidelines often rely on consensus opinion regarding applicability to the pre-hospital environment. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Joanne D Fisher
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Karoline Freeman
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Aileen Clarke
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Peter Spurgeon
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Mike Smyth
- West Midlands Ambulance Service, Millennium Point, Waterfront Business Park, Brierley Hill, West Midlands, UK
| | - Gavin D Perkins
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | | | - Matthew W Cooke
- Department of Health Sciences, Warwick Medical School, Coventry, UK
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Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf 2014; 5:229-41. [PMID: 25436105 DOI: 10.1177/2042098614554919] [Citation(s) in RCA: 855] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Antimicrobial resistance is a global public health challenge, which has accelerated by the overuse of antibiotics worldwide. Increased antimicrobial resistance is the cause of severe infections, complications, longer hospital stays and increased mortality. Overprescribing of antibiotics is associated with an increased risk of adverse effects, more frequent re-attendance and increased medicalization of self-limiting conditions. Antibiotic overprescribing is a particular problem in primary care, where viruses cause most infections. About 90% of all antibiotic prescriptions are issued by general practitioners, and respiratory tract infections are the leading reason for prescribing. Multifaceted interventions to reduce overuse of antibiotics have been found to be effective and better than single initiatives. Interventions should encompass the enforcement of the policy of prohibiting the over-the-counter sale of antibiotics, the use of antimicrobial stewardship programmes, the active participation of clinicians in audits, the utilization of valid rapid point-of-care tests, the promotion of delayed antibiotic prescribing strategies, the enhancement of communication skills with patients with the aid of information brochures and the performance of more pragmatic studies in primary care with outcomes that are of clinicians' interest, such as complications and clinical outcomes.
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Affiliation(s)
- Carl Llor
- School of Medicine, Cardiff University, Department of Primary Care and Public Health, 5th Floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4XN, UK
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Macy E, Contreras R. Adverse reactions associated with oral and parenteral use of cephalosporins: A retrospective population-based analysis. J Allergy Clin Immunol 2014; 135:745-52.e5. [PMID: 25262461 DOI: 10.1016/j.jaci.2014.07.062] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 07/07/2014] [Accepted: 07/09/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Few studies have provided population-based, route-specific data on allergy to cephalosporin or incidence of serious adverse drug reactions (ADRs). OBJECTIVE We investigated the incidence of new reports of cephalosporin-associated "allergy" and serious ADRs. METHODS We identified all members of the Kaiser Permanente Southern California health plan given cephalosporins (from January 1, 2010, through December 31, 2012), all new reports of cephalosporin-associated allergy, and all serious ADRs. RESULTS There were 622,456 health plan members exposed to 901,908 courses of oral cephalosporins and 326,867 members exposed to 487,630 courses of parenteral cephalosporins over the 3-year study period. New reports of allergy to cephalosporin were more frequent among women (0.56%; 95% CI, 0.54% to 0.57%) than among men (0.43%; 95% CI, 0.41% to 0.44%) per course (P < .0001). The most frequent serious cephalosporin-associated ADRs were Clostridium difficile infection within 90 days (0.91%), nephropathy within 30 days (0.15%), and all-cause death within 1 day (0.10%). None correlated with history of drug allergy. Physician-documented cephalosporin-associated anaphylaxis occurred with 5 oral exposures (95% CI, 1/1,428,571-1/96,154) and 8 parenteral exposures (95% CI, 1/200,000-1/35,971) (P = .0761). There were 3 documented cephalosporin-associated serious cutaneous adverse reactions (95% CI, 0-1 in 217,291). All were associated with the use of another antibiotic at the same time as cephalosporin. CONCLUSIONS Cephalosporins are widely and safely used, even in individuals with a history of penicillin allergy. Physician-documented cephalosporin-associated anaphylaxis and serious cutaneous adverse reactions are rare compared with C difficile infection within 90 days, nephropathy within 30 days, and all-cause death within 1 day.
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Affiliation(s)
- Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, Calif.
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Health Care Program, Pasadena, Calif
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Abstract
Iatrogenic disease is one of the most frequent causes of hospital admissions and constitutes a growing public health problem. The most common type of iatrogenic neurologic disease is pharmacologic, and the central and peripheral nervous systems are particularly vulnerable. Despite this, iatrogenic disease is generally overlooked as a differential diagnosis among neurologic patients. The clinical picture of pharmacologically mediated iatrogenic neurologic disease can range from mild to fatal. Common and uncommon forms of drug toxicity are comprehensively addressed in this chapter. While the majority of neurologic adverse effects are listed and referenced in the tables, the most relevant issues are further discussed in the text.
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Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Osvaldo Fustinoni
- INEBA Institute of Neurosciences, Buenos Aires, Argentina; Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina.
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Stahlmann R, Lode HM. Risks associated with the therapeutic use of fluoroquinolones. Expert Opin Drug Saf 2013; 12:497-505. [DOI: 10.1517/14740338.2013.796362] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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In vitro, in vivo, and clinical studies of tedizolid to assess the potential for peripheral or central monoamine oxidase interactions. Antimicrob Agents Chemother 2013; 57:3060-6. [PMID: 23612197 DOI: 10.1128/aac.00431-13] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Tedizolid phosphate is a novel oxazolidinone prodrug whose active moiety, tedizolid, has improved potency against Gram-positive pathogens and pharmacokinetics, allowing once-daily administration. Given linezolid warnings for drug-drug and drug-food interactions mediated by monoamine oxidase (MAO) inhibition, including sporadic serotonergic toxicity, these studies evaluated tedizolid for potential MAO interactions. In vitro, tedizolid and linezolid were reversible inhibitors of human MAO-A and MAO-B; the 50% inhibitory concentration (IC50) for tedizolid was 8.7 μM for MAO-A and 5.7 μM for MAO-B and 46.0 and 2.1 μM, respectively, with linezolid. Tedizolid phosphate was negative in the mouse head twitch model of serotonergic activity. Two randomized placebo-controlled crossover clinical studies assessed the potential of 200 mg/day tedizolid phosphate (at steady state) to enhance pressor responses to coadministered oral tyramine or pseudoephedrine. Sensitivity to tyramine was determined by comparing the concentration of tyramine required to elicit a ≥ 30-mmHg increase in systolic blood pressure (TYR30) when administered with placebo versus tedizolid phosphate. The geometric mean tyramine sensitivity ratio (placebo TYR30/tedizolid phosphate TYR30) was 1.33; a ratio of ≥ 2 is considered clinically relevant. In the pseudoephedrine study, mean maximum systolic blood pressure was not significantly different when pseudoephedrine was coadministered with tedizolid phosphate versus placebo. In summary, tedizolid is a weak, reversible inhibitor of MAO-A and MAO-B in vitro. Provocative testing in humans and animal models failed to uncover significant signals that would suggest potential for hypertensive or serotonergic adverse consequences at the therapeutic dose of tedizolid phosphate. Clinical studies are registered at www.clinicaltrials.gov as NCT01539473 (tyramine interaction study conducted at Covance Clinical Research Center, Evansville, IN) and NCT01577459 (pseudoephedrine interaction study conducted at Vince and Associates Clinical Research, Overland Park, KS).
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Bianciotto M, Chiappini E, Raffaldi I, Gabiano C, Tovo PA, Sollai S, de Martino M, Mannelli F, Tipo V, Da Cas R, Traversa G, Menniti-Ippolito F. Drug use and upper gastrointestinal complications in children: a case-control study. Arch Dis Child 2013; 98:218-21. [PMID: 23264432 PMCID: PMC3582087 DOI: 10.1136/archdischild-2012-302100] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the risk of upper gastrointestinal complications (UGIC) associated with drug use in the paediatric population. METHODS This study is part of a large Italian prospective multicentre study. The study population included children hospitalised for acute conditions through the emergency departments of eight clinical centres. Patients admitted for UGIC (defined as endoscopically confirmed gastroduodenal lesions or clinically defined haematemesis or melena) comprised the case series; children hospitalised for neurological disorders formed the control group. Information on drug and vaccine exposure was collected through parental interview during the children's hospitalisation. Logistic regression was used to estimate ORs for the occurrence of UGIC associated with drug use adjusted for age, clinical centre and concomitant use of any drug. RESULTS 486 children hospitalised for UGIC and 1930 for neurological disorders were enrolled between November 1999 and November 2010. Drug use was higher in cases than in controls (73% vs 54%; p<0.001). UGICs were associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) (adjusted OR 2.9, 95% CI 2.1 to 4.0), oral steroids (adjusted OR 2.9, 95% CI 1.7 to 4.8) and antibiotics (adjusted OR 2.3, 95% CI 1.8 to 3.1). The duration of use of these drug categories was short (range 1-8 days). Paracetamol showed a lower risk (adjusted OR 2.0, 95% CI 1.5 to 2.6) compared to ibuprofen (adjusted OR 3.7, 95% CI 2.3 to 5.9), although with partially overlapping CIs. CONCLUSIONS NSAIDs, oral steroids and antibiotics, even when administered for a short period, were associated with an increased risk of UGIC.
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Affiliation(s)
| | | | | | | | | | - Sara Sollai
- Anna Meyer Children's University Hospital, Florence, Italy
| | | | | | | | - Roberto Da Cas
- National Centre for Epidemiology, Italian National Institute of Health, Rome, Italy
| | - Giuseppe Traversa
- National Centre for Epidemiology, Italian National Institute of Health, Rome, Italy
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Blasi F, Tarsia P, Mantero M, Morlacchi LC, Piffer F. Cefditoren versus levofloxacin in patients with exacerbations of chronic bronchitis: serum inflammatory biomarkers, clinical efficacy, and microbiological eradication. Ther Clin Risk Manag 2013; 9:55-64. [PMID: 23430960 PMCID: PMC3575210 DOI: 10.2147/tcrm.s41131] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background The aim of this open-label, randomized, parallel-group pilot study was to evaluate the efficacy of cefditoren pivoxil and levofloxacin in terms of speed of reduction in inflammatory parameters, clinical recovery, and microbiological eradication. Methods Forty eligible patients with acute exacerbation of chronic bronchitis (AECB) were randomized to receive cefditoren 200 mg twice a day for 5 days (n = 20) or levofloxacin 500 mg once daily for 7 days (n = 20). Results The inflammatory parameters which were significantly reduced at test-of-cure with respect to visit 1 were Krebs von den Lundgen-6 (KL-6) and interleukin-6. KL-6 decreased both in the overall study population (from 19 ± 11 UI/mL to 6 ± 8 UI/mL, P = 0.000) and in the cefditoren (from 19 ± 13 UI/mL to 8 ± 10 UI/mL, P = 0.006) and levofloxacin (from 19 ± 10 UI/mL to 5 ± 5 UI/mL, P = 0.000) arms. Similarly, interleukin-6 decreased both in the overall study population (from 13.35 ± 16.41 pg/mL to 3 ± 4.7 pg/mL, P = 0.000) and in the cefditoren (from 15.90 ± 19.54 pg/mL to 4.13 ± 6.42 pg/mL, P = 0.015) and levofloxacin (from 10.80 ± 12.55 pg/mL to 1.87 ± 1.16 pg/mL, P = 0.003) arms. At the end of treatment (test-of-cure, 6–9 days after drug initiation), the clinical success rate in the overall study population was 78%; the clinical cure rate was 80% in the cefditoren arm and 75% in the levofloxacin arm. Globally, bacteriological eradication at test-of-cure was obtained in 85% of the overall study population. Both treatments were well tolerated. Conclusion Cefditoren represents a valid option in the treatment of mild to moderately severe cases of AECB in the outpatient care setting. Moreover, the use of this cephalosporin is associated with a significant reduction of interleukin-6 and KL-6, two key mediators of lung inflammation and epithelial damage.
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Affiliation(s)
- Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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English ML, Fredericks CE, Milanesio NA, Rohowsky N, Xu ZQ, Jenta TRJ, Flavin MT, Eiznhamer DA. Cethromycin versus clarithromycin for community-acquired pneumonia: comparative efficacy and safety outcomes from two double-blinded, randomized, parallel-group, multicenter, multinational noninferiority studies. Antimicrob Agents Chemother 2012; 56:2037-47. [PMID: 22290969 PMCID: PMC3318370 DOI: 10.1128/aac.05596-11] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 12/30/2011] [Indexed: 11/20/2022] Open
Abstract
Community-acquired pneumonia (CAP) continues to be a major health challenge in the United States and globally. Factors such as overprescribing of antibiotics and noncompliance with dosing regimens have added to the growing antibacterial resistance problem. In addition, several agents available for the treatment of CAP have been associated with serious side effects. Cethromycin is a new ketolide antibiotic that may provide prescribing physicians with an additional agent to supplement a continually limited armamentarium. Two global phase III noninferiority studies (CL05-001 and CL06-001) to evaluate cethromycin safety and efficacy were designed and conducted in patients with mild to moderate CAP. Study CL05-001 demonstrated an 83.1% clinical cure rate in the cethromycin group compared with 81.1% in the clarithromycin group (95% confidence interval [CI], -4.8%, +8.9%) in the intent to treat (ITT) population and a 94.0% cethromycin clinical cure rate compared with a 93.8% clarithromycin cure rate (95% CI, -4.5%, +5.1%) in the per protocol clinical (PPc) population. Study CL06-001 achieved an 82.9% cethromycin clinical cure rate in the ITT population compared with an 88.5% clarithromycin cure rate (95% CI, -11.9%, +0.6%), whereas the clinical cure rate in the PPc population was 91.5% in cethromycin group compared with 95.9% in clarithromycin group (95% CI, -9.1%, +0.3%). Both studies met the primary endpoints for clinical cure rate based on predefined, sliding-scale noninferiority design. Therefore, in comparison with clarithromycin, these two noninferiority studies demonstrated the efficacy and safety of cethromycin, with encouraging findings of efficacy in subjects with Streptococcus pneumoniae bacteremia. No clinically significant adverse events were observed during the studies. Cethromycin may be a potential oral therapy for the outpatient treatment of CAP.
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Pugi A, Longo L, Bartoloni A, Rossolini GM, Mugelli A, Vannacci A, Lapi F. Cardiovascular and metabolic safety profiles of the fluoroquinolones. Expert Opin Drug Saf 2011; 11:53-69. [PMID: 21958023 DOI: 10.1517/14740338.2011.624512] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Certain fluoroquinolones share similar indications of use. A comparison among Cardiovascular and metabolic (i.e., dysglycemia) safety profiles of the fluoroquinolones might be particularly useful for the prescribers' decision-making process as well as to hypothesize future researcher purposes. AREAS COVERED A literature search was conducted using keywords apt to identify information on safety profile of the fluoroquinolones. Publications concerned with descriptive and etiological surveys were manually reviewed. EXPERT OPINION Cardiac alterations and blood glucose impairments might be associated with any fluoroquinolone. However, the benefit/risk profile of these agents could be stratified for the single compounds. Several predisposing factors, such as diabetes, heart illnesses and their related pharmacotherapies, might exacerbate the risk of potentially serious adverse events. In this context, the opportunity of the more appropriate choice among different fluoroquinolones could be applicable.
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Affiliation(s)
- Alessandra Pugi
- University of Florence, Department of Pharmacology, Viale Pieraccini 6, 50139, Florence, Italy.
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Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, Darrow DH, Giordano T, Litman RS, Li KK, Mannix ME, Schwartz RH, Setzen G, Wald ER, Wall E, Sandberg G, Patel MM. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 2011; 144:S1-30. [PMID: 21493257 DOI: 10.1177/0194599810389949] [Citation(s) in RCA: 602] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Tonsillectomy is one of the most common surgical procedures in the United States, with more than 530,000 procedures performed annually in children younger than 15 years. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil including its capsule by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Depending on the context in which it is used, it may indicate tonsillectomy with adenoidectomy, especially in relation to sleep-disordered breathing. This guideline provides evidence-based recommendations on the preoperative, intraoperative, and postoperative care and management of children 1 to 18 years old under consideration for tonsillectomy. In addition, this guideline is intended for all clinicians in any setting who interact with children 1 to 18 years of age who may be candidates for tonsillectomy. PURPOSE The primary purpose of this guideline is to provide clinicians with evidence-based guidance in identifying children who are the best candidates for tonsillectomy. Secondary objectives are to optimize the perioperative management of children undergoing tonsillectomy, emphasize the need for evaluation and intervention in special populations, improve counseling and education of families of children who are considering tonsillectomy for their child, highlight the management options for patients with modifying factors, and reduce inappropriate or unnecessary variations in care. RESULTS The panel made a strong recommendation that clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. The panel made a strong recommendation against clinicians routinely administering or prescribing perioperative antibiotics to children undergoing tonsillectomy. The panel made recommendations for (1) watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years; (2) assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess; (3) asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems; (4) counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing; (5) counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management; (6) advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain; and (7) clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually. The panel offered options to recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and 1 or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A β-hemolytic streptococcus.
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Affiliation(s)
- Reginald F Baugh
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA.
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Rouzaud F, Robledo J. Cutting costs on mono-resistant tuberculosis diagnosis could eventually end up being more expensive. Indian J Med Microbiol 2010; 28:412-3. [PMID: 20966587 DOI: 10.4103/0255-0857.71808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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