Use of diagnostic clusters to assess the economic consequences of rhinopharyngitis in children in Italy and France during the winter. Rhinitis Survey Group

Respiratory microorganisms in acute pharyngitis patients: Identification, antibiotic prescription patterns and appropriateness, and antibiotic resistance in private primary care, central Malaysia

Acute pharyngitis (AP) is a common reason for private primary care consultations, thus providing an avenue for widespread antibiotic intake among the community. However, there is limited data on the antibiotic prescription appropriateness and resistance information in the Malaysian private primary care setting, therefore, this study aimed to investigate the prevalence of isolated viruses and bacteria, antibiotic resistance patterns, antibiotic prescription patterns and appropriateness by general practitioners (GPs) and factors affecting antibiotic resistance and antibiotic prescription patterns. To investigate, a cross-sectional study was conducted among 205 patients presenting with AP symptoms at private primary care clinics in central Malaysia from 3rd January 2016 to 30th November 2016. Throat swabs were collected from 205 AP patients for two purposes: (i) the detection of four common respiratory viruses associated with AP via reverse-transcription real-time PCR (qRT-PCR); and (ii) bacterial identification using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS). Bacterial isolates were then subjected to antibiotic susceptibility screening and McIsaac scoring was calculated post-prescription based on GP selection of criteria. Generalized estimating equations analysis with multiple logistic regression was conducted to identify factors associated with presence of virus and antibiotic prescription. The results showed that 95.1% (195/205) of patients had at least one of the four viruses, with rhinovirus (88.5%) being the most prevalent, followed by adenovirus (74.9%), influenza A virus (4.6%) and enterovirus (2.1%). A total of 862 non-repetitive colonies were isolated from the culture of throat swabs from 205 patients who were positive for bacteria. From a total of 22 genera, Streptococcus constitutes the most prevalent bacteria genus (40.9%), followed by Neisseria (20%), Rothia (13.0%), Staphylococcus (11%) and Klebsiella (4.9%). Only 5 patients carried group A beta-hemolytic streptococci (GABHS). We also report the presence of vancomycin-resistant S. aureus or VRSA (n = 9, 10.1%) among which one isolate is a multidrug-resistant methicillin-resistant S. aureus (MDR-MRSA), while 54.1% (n = 111) were found to carry at least one antibiotic-resistant bacteria species. Application of the McIsaac scoring system indicated that 87.8% (n = 180) of patients should not be prescribed antibiotics as the majority of AP patients in this study had viral pharyngitis. The antibiotic prescription appropriateness by applying post-prescription McIsaac scoring was able to rule out GABHS pharyngitis in this sample with a GABHS culture-positive sensitivity of 40% (n = 2/5) and specificity of 90% (180/200). In conclusion, antibiotic-resistant throat isolates and over-prescription of antibiotics were observed and McIsaac scoring system is effective in guiding GPs to determine occurrences of viral pharyngitis to reduce unnecessary antibiotic prescription.

Fermented Milk Consumption and Common Infections in Children Attending Day-Care Centers: A Randomized Trial

OBJECTIVES

This multicenter, double-blind, randomized, placebo-controlled clinical trial investigated the effect of a fermented milk product containing the Lactobacillus casei National Collection of Microorganisms and Cell Cultures (CNCM) I-1518 strain on respiratory and gastrointestinal common infectious diseases (CIDs) in children attending day-care centers in Russia.

METHODS

Children ages 3 to 6 years received 100 g of a fermented milk product (n = 300) or a control product (n = 299) twice daily for 3 months, followed by a 1-month observation period. The primary outcome was the incidence of CIDs during the product consumption period.

RESULTS

There was no significant difference in the incidence of CIDs between the groups (N = 98 with fermented milk product vs N = 93 with control product). The overall number of CIDs (and no severe cases at all) in both study groups and in all 12 centers, however, was unexpectedly low resulting in underpowering of the study. No differences were found between the groups in the duration or severity of disease, duration of sick leave from day-care centers, parental missed working days, or in quality-of-life dimensions on the PedsQL questionnaire (P > 0.05).There was, however, a significantly lower incidence of the most frequently observed CID, rhinopharyngitis, in children consuming the fermented milk product compared with those consuming the control product (N = 81 vs N = 100, relative risk 0.82, 95% confidence interval 0.69-0.96, P = 0.017) when considering the entire study period.

CONCLUSIONS

Although no other significant differences were shown between the fermented milk and control product groups in this study, lower incidence of rhinopharyngitis may indicate a beneficial effect of this fermented milk product.

Public health and budget impact of probiotics on common respiratory tract infections: a modelling study

Objectives

Two recent meta-analyses by the York Health Economics Consortium (YHEC) and Cochrane demonstrated probiotic efficacy in reducing the duration and number of common respiratory tract infections (CRTI) and associated antibiotic prescriptions. A health-economic analysis was undertaken to estimate the public health and budget consequences of a generalized probiotic consumption in France.

Methods

A virtual age- and gender-standardized population was generated using a Markov microsimulation model. CRTI risk factors incorporated into this model were age, active/passive smoking and living in a community setting. Incidence rates and resource utilization were based on the 2011-2012 flu season and retrieved from the French GPs Sentinelles network. Results of both meta-analyses were independently applied to the French population to estimate CRTI events, assuming a generalized probiotic use compared to no probiotics during winter months: -0.77 days/CRTI episode (YHEC scenario) or odds-ratio 0.58 for ≥1 CRTI episode (Cochrane scenario) with vs. without probiotics. Economic perspectives were National Health System (NHS), society, family. Outcomes included cost savings related to the reduced numbers of CRTI episodes, days of illness, number of antibiotic courses, sick leave days, medical and indirect costs.

Results

For France, generalized probiotic use would save 2.4 million CRTI-days, 291,000 antibiotic courses and 581,000 sick leave days, based on YHEC data. Applying the Cochrane data, reductions were 6.6 million CRTI days, 473,000 antibiotic courses and 1.5 million sick days. From the NHS perspective, probiotics’ economic impact was about €14.6 million saved according to YHEC and €37.7 million according to Cochrane. Higher savings were observed in children, active smokers and people with more frequent human contacts.

Conclusions

Public health and budget impact of probiotics are substantial, whether they reduce CRTI episodes frequency or duration. Noteworthy, the 2011-12 winter CRTI incidence was low and this analysis focused on the fraction of CRTI patients consulting a practitioner.

Chinese medicinal herbs for sore throat

BACKGROUND

Chinese herbal medicines are commonly used to treat sore throat in China and are used worldwide by practitioners of traditional Chinese medicine (TCM). Their efficacy in treating sore throat has not previously been systematically reviewed.

OBJECTIVES

To assess the efficacy and safety of Chinese herbal medicines for patients with sore throat.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library Issue 4, 2011) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to week 3, November 2011); EMBASE (1980 to December 2011); AMED (1985 to December 2011); the Chinese Biomedical Database (CBM) (1975 to December 2011); and China National Knowledge Infrastructure (CNKI) (1994 to December 2011).

SELECTION CRITERIA

We included randomised controlled trial (RCTs) assessing Chinese herbal medicines for the treatment of sore throat, with the outcomes of recovery, inefficacy, and adverse events.

DATA COLLECTION AND ANALYSIS

The three review authors extracted and analysed the data. One review author contacted the study authors of potential RCTs.

MAIN RESULTS

We included 12 studies involving 1954 participants. We identified ten studies as being of methodologically poor quality and two studies as being of medium quality. We did not perform a meta-analysis but reported the results separately. Six formulations were shown to be superior to the control in improving recovery: Ertong Qingyan Jiere Koufuye was more effective than Fufang Shuanghua Koufuye for acute pharyngitis (odds ratio (OR) 2.52; 95% confidence interval (Cl) 1.11 to 5.74); Yanhouling mixture was more effective than gentamicin atomised inhalation for acute pharyngitis (OR 5.39; 95% CI 2.69 to 10.81); Qinganlan Liyan Hanpian was more effective than Fufang Caoshanhu Hanpian for acute pharyngitis (OR 2.25; 95% CI 1.08 to 4.67); sore throat capsules were more effective than antibiotics (intravenous cefalexin) for acute pharyngitis or acute tonsillitis (OR 2.36; 95% CI 1.01 to 5.51); compound dandelion soup was more effective than sodium penicillin for acute purulent tonsillitis (OR 5.06; 95% CI 1.70 to 15.05); and eliminating heat by nourishing yin and relieving sore-throat methods combined with Dikuiluqan Hanpian was more effective than Dikuiluqan Hanpian alone for children with chronic pharyngitis (OR 2.63; 95% CI 1.02 to 6.79). Another six formulations were shown to be equally efficacious as the control.

AUTHORS' CONCLUSIONS

Based on the existing evidence in this review, some Chinese herbal medicines for treating sore throat appeared efficacious. However, due to the lack of high quality clinical trials, the efficacy of Chinese herbal medicine for treating sore throat is controversial and questionable. Therefore we cannot recommend any kind of Chinese medical herbal formulation as an effective remedy for sore throat.

Meta-analysis of published clinical trials of a ribosomal vaccine (ribomunyl) in prevention of respiratory infections

OBJECTIVE

To perform a meta-analysis using data from all clinical trials and studies of a ribosomal vaccine (Ribomunyl((R))) in order to estimate its overall effect on the number of infections and antibacterial courses used per person.

DESIGN AND SETTING

Meta-analysis of studies performed between 1985 and 1999 in 7 European countries and also in Kazakhstan, Tunisia, Morocco and Argentina.

PATIENTS AND PARTICIPANTS

Information from 14 213 adults and children.

RESULTS

There were 9 randomised, double-blind, placebo-controlled studies, 3 randomised nonblind studies and 16 nonblind studies with no placebo arm in which the response to ribosomal vaccine was compared with historical information. The mean number of infections per person in a study period of 3 months using placebo was found to be 2.39 (standard error +/- 0.50), and in a study period of 6 months was 3.35 (+/-0.41) infections. In both study periods, ribosomal vaccine use was associated with a reduction in the number of infections per person of 1.43 (+/-0.26). In the study period, patients on placebo reported 3.02 (+/-0.44) antibacterial courses, whereas ribosomal vaccine was associated with a reduction of 1.32 (+/-0.42) antibacterial courses.

CONCLUSIONS

In spite of variability in data quality, and the small sample size in some of the studies, we conclude that in patients with recurrent respiratory infections ribosomal vaccine significantly reduces both the number of infections and the number of antibacterial courses compared with placebo. This study is a strong and objective demonstration of the efficacy of ribosomal vaccine in limiting the number of otorhinolaryngological infections in children and adults.

A single point acupuncture treatment at large intestine meridian: a randomized controlled trial in acute tonsillitis and pharyngitis

OBJECTIVES

One out of 4 patients visiting a general practitioner reports of a sore throat associated with pain on swallowing. This study was established to examine the immediate pain alleviating effect of a single point acupuncture treatment applied to the large intestine meridian of patients with sore throat.

PATIENTS AND METHODS

Sixty patients with acute tonsillitis and pharyngitis were enrolled in this randomized placebo-controlled trial. They either received acupuncture, or sham laser acupuncture, directed to the large intestine meridian section between acupuncture points LI 8 and LI 10. The main outcome measure was the change of pain intensity on swallowing a sip of water evaluated by a visual analog scale 15 minutes after treatment. A credibility assessment regarding the respective treatment was performed.

RESULTS

The pain intensity for the acupuncture group before and immediately after therapy was 5.6+/-2.8 and 3.0+/-3.0, and for the sham group 5.6+/-2.5 and 3.8+/-2.5, respectively. Despite the articulation of a more pronounced improvement among the acupuncture group, there was no significant difference between groups (Delta=0.9, confidence interval: -0.2-2.0; P=0.12; analysis of covariance). Patients' satisfaction was high in both treatment groups. The study was prematurely terminated due to a subsequent lack of suitable patients.

DISCUSSION

A single acupuncture treatment applied to a selected area of the large intestine meridian was no more effective in the alleviation of pain associated with clinical sore throat than sham laser acupuncture applied to the same area. Hence, clinically relevant improvement could be achieved. Pain alleviation might partly be due to the intense palpation of the large intestine meridian. The benefit of a comprehensive acupuncture treatment protocol in this condition should be subject to further trials.

Factors influencing parental decision to consult for children with upper respiratory tract infection

AIM

This study aimed to determine which factors could influence (i) parents' decision to seek medical consultatin and (ii) their preference for either public or private medical service in children with upper respiratory tract infection.

METHODS

This cross-sectional study was conducted at the Gombak district, which is an urban area in Malaysia. We randomly selected parents of kindergarten children aged 4-5 years to participate in this questionnaire survey. The main outcome measures were predictors of early medical consultation and type of service utilisation (public versus private).

RESULTS

We achieved a response rate of 84.5% (n = 1033/1223). 64.1% sought early medical consultation and 70.9% preferred to consult a private doctor. Early consultation was predicated by the parent gender being male (OR 1.50; 95% CI 1.09, 2.05), non-Chinese (OR 1.75%; 95% CI 1.10, 2.79), and those who preferred child specialists (OR 2.02; 95% CI 1.27, 3.23). Lower income group (OR 4.28; 95% CI 2.30, 7.95) and not having a regular doctor (OR 4.99%; 95% CI 3.19, 7.80) were predictors of using the public health services.

CONCLUSIONS

Parent's gender, ethnicity and income influenced their decision to seek early medical consultation for their children's respiratory illness while income and having a regular doctor could predict their choice of healthcare services.

Chinese medicinal herbs for sore throat

BACKGROUND

Chinese herbal medicines are commonly used to treat sore throat in China and among Chinese people worldwide. Their efficacy in treating sore throat has not previously been systematically reviewed.

OBJECTIVES

To assess the efficacy and safety of Chinese herbal medicines for patients with sore throat.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 3, 2006) which contains the Acute Respiratory Infections Group's specialised register; MEDLINE (1966 to August 2006); EMBASE (1980 to August 2006); AMED (1985 to August 2006); the Chinese Biomedical Database (CBM) (1975 to August 2006), and China National Knowledge Infrastructure (CNKI) (1994 to August 2006).

SELECTION CRITERIA

We only included randomised controlled trials (RCTs) assessing Chinese herbal medicines for the treatment of sore throat with the outcomes of recovery, inefficacy, and adverse events.

DATA COLLECTION AND ANALYSIS

One review author contacted the trial authors of claimed RCTs. Three review authors extracted and analysed the data.

MAIN RESULTS

Seven trials involving 1253 participants were included. All trials were identified as being of methodologically poor quality (C category). All of the Chinese herbal preparations in this review were inadequately characterised and were assessed in one trial only. It is highly likely that there was selection bias or detection bias, or both, in all of the included trials. Conflict of interest may have been another factor in producing a positive result in three studies as the prepared drugs were made in the trial author's hospital. We did not perform a meta-analysis and the results of the studies are reported separately. Three formulations were shown to be superior to the control in improving recovery: Ertong Qingyan Jiere Koufuye was more effective than Fufang Shuanghua Koufuye for acute pharyngitis (OR 1.54, 95% Cl 1.11 to 5.74); Yanhouling mixture was more effective than the gentamicin atomised inhalation for acute pharyngitis (OR 5.39, 95% CI 2.69 to 10.81) for acute pharyngitis; and Qinganlan Liyan Hanpian was more effective than Fufang Caoshanhu Hanpian for chronic pharyngitis (OR 2.25, 95% CI 1.08 to 4.67). Four four formulations were shown to be equal in efficacy to the control.

AUTHORS' CONCLUSIONS

Based on the existing evidence included in this review, the efficacy of Chinese herbal medicine for treating sore throat is controversial and questionable. We cannot recommend any kind of Chinese medical herbal formulation as an effective remedy for sore throat, due to the lack of high quality clinical trials.

Prevention of recurrent respiratory tract infections in children using a ribosomal immunotherapeutic agent: a clinical review

Recurrent respiratory tract infections (RRTIs) in children constitute a serious problem worldwide. Some children experience considerable morbidity as a result of RRTIs and receive repeated courses of antibacterials that are not effective against viral infectious agents and can increase bacterial resistance. Furthermore, the direct and indirect costs of RRTIs to the community are substantial. In this article, we review the available clinical evidence relating to use of the bacterial immunostimulant Ribomunyl for the prevention of RRTIs in children. The product is composed of ribosomal fractions from four bacteria involved in RRTIs as well as a membrane fraction from one of these bacteria (Klebsiella pneumoniae). Ribomunyl stimulates production of specific humoral and secretory antibodies against the four bacterial strains included in the compound. The product also stimulates non-specific immunity. Thus, Ribomunyl stimulates both the innate and acquired immune systems and offers preventive efficacy against both bacterial and viral infections. To perform this review, we searched the MEDLINE database for articles on Ribomunyl and then included only those publications that described placebo-controlled studies, complied with Good Clinical Practice standards, used the product in official registered indications, and administered it at the recommended dosages. In this way, we were able to generate a comprehensive profile of use of the product and draw valid conclusions about its clinical role. In clinical trials of children, Ribomunyl reduced the number of upper or lower RRTIs, the primary outcome measures. Other favorable results relating to efficacy parameters that served as secondary outcome measures in these studies included a reduction in antibacterial treatments, shorter duration of recurrent episodes, reduced need for other medications such as expectorants, smaller number of lost school days or parent absenteeism from work, less fever, and reduced hearing loss. Studies focusing on particular conditions, such as otitis media, or those that included specific patient groups, such as very young children, reported similar findings. Adverse events occurred very rarely and were mild. Their frequency was similar to that reported in placebo groups, and consisted mostly of fever, otorhinolaryngologic symptoms, and cutaneous events. In conclusion, this review clearly demonstrated that Ribomunyl is effective in preventing upper and lower RRTIs in children. Ribomunyl provided a reduction in the number, duration, and severity of infectious episodes and, thereby, reduced antibacterial use and the likelihood of consequent development of bacterial resistance. Ribomunyl also decreased absence from work or school, which has important economic consequences.

Cost-effectiveness of universal pneumococcal vaccination for infants in Italy

This study aimed at estimating the health and economic outcomes of universal infant vaccination with seven-valent pneumococcal conjugate vaccine (PCV-7) in Italy. A Markov model simulated lifetime evolution of a birth cohort (538,138 children): universal vaccination would avert 769 invasive infections, 18 deaths and 1323 life years. At base-case analysis, universal three-dose vaccination would cost euro 26,449 (95% CI: 1975-62,075) and euro 38,286 (95% CI: 22,164-70,801) per life year-saved in the societal and the NHS perspective, respectively. In the hypothesis of a 5-year long protection period, vaccination would cost euro 32,694 and euro 43,115 per life-year saved. Considering yearly incidence of invasive pneumococcal disease reported for Veneto and Sardinia regions, PCV-7 vaccination would result highly cost-effective determining a cost of euro 10,479 and euro 16,890 per life year-save in the NHS and the societal perspective, respectively.

Prevention of recurrent rhinopharyngitis in at-risk children in France: a cost-effectiveness model for a nonspecific immunostimulating bacterial extract (OM-85 BV)

OBJECTIVE

To estimate the pharmacoeconomic impact for the French Social Security System of preventing recurrent acute rhinopharyngitis (RARP) in at-risk children with OM-85 BV, an immunostimulating agent indicated for the prevention of recurrences.

DESIGN

A decision-analysis model. The probability of progression of the infection and of its associated care, the principal direct costs linked to them, and the effectiveness of OM-85 BV were established or calculated by reviewing the available literature (published between 1984 and 2000). Four experts validated the parameters and the model.

RESULTS

For the French Social Security System, the mean direct cost for an acute rhinopharyngitis (ARP) infection was 49.39 Euro(2000 values). By using OM-85 BV prevention, 1.52 infections were prevented in 6 months saving 67.83 Euro on the costs of care for the recurrently infected child. Sensitivity analyses confirmed the robustness of the model and indicated a saving of between 6.28 Euro and 303.64 Euro in direct costs for each individual treated preventively. Threshold analyses showed that OM-85 BV prophylaxis is economically profitable if more than 0.15 infections are prevented and if direct costs of care of an ARP are greater than 4.78 Euro.

CONCLUSION

Non-specific immunotherapy should be considered for the child at risk of RARP and administered in addition to other recommended measures. The economic savings for the community of using a medication for which the clinical effectiveness has been demonstrated should also be taken into account in assessing its usefulness.