Treatment of undifferentiated respiratory infections in infants

Antibiotics for preventing suppurative complications from undifferentiated acute respiratory infections in children under five years of age

BACKGROUND

Undifferentiated acute respiratory infections (ARIs) are a large and heterogeneous group of infections not clearly restricted to one specific part of the upper respiratory tract, which last for up to seven days. They are more common in pre-school children in low-income countries and are responsible for 75% of the total amount of prescribed antibiotics in high-income countries. One possible rationale for prescribing antibiotics is the wish to prevent bacterial complications.

OBJECTIVES

To assess the effectiveness and safety of antibiotics in preventing bacterial complications in children aged two months to 59 months with undifferentiated ARIs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 7), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to August week 1, 2015) and EMBASE (1974 to August 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing antibiotic prescriptions with placebo or no treatment in children aged two months to 59 months with an undifferentiated ARI for up to seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted and analysed data using the standard Cochrane methodological procedures.

MAIN RESULTS

We identified four trials involving 1314 children. Three trials investigated the use of amoxicillin/clavulanic acid to prevent otitis and one investigated ampicillin to prevent pneumonia.The use of amoxicillin/clavulanic acid compared to placebo to prevent otitis showed a risk ratio (RR) of 0.70 (95% confidence interval (CI) 0.45 to 1.11, three trials, 414 selected children, moderate-quality evidence). Methods of random sequence generation and allocation concealment were not clearly stated in two trials. Performance, detection and reporting bias could not be ruled out in three trials.Ampicillin compared to supportive care (continuation of breastfeeding, clearing of the nose and paracetamol for fever control) to prevent pneumonia showed a RR of 1.05 (95% CI 0.74 to 1.49, one trial, 889 selected children, moderate-quality evidence). The trial was non-blinded. Random sequence generation and allocation concealment methods were not clearly stated, so the possibility of reporting bias could not be ruled out.Harm outcomes could not be analysed as they were expressed only in percentages.We found no studies assessing mastoiditis, quinsy, abscess, meningitis, hospital admission or death.

AUTHORS' CONCLUSIONS

There is insufficient evidence for antibiotic use as a means of reducing the risk of otitis or pneumonia in children up to five years of age with undifferentiated ARIs. Further high-quality research is needed to provide more definitive evidence of the effectiveness of antibiotics in this population.

Antibiotics for preventing suppurative complications from undifferentiated acute respiratory infections in children under five years of age

BACKGROUND

Undifferentiated acute respiratory infections (ARIs) are a large and heterogeneous group of infections not clearly restricted to one specific part of the upper respiratory tract, which last for up to seven days. They are more common in pre-school children in low-income countries and are responsible for 75% of the total amount of prescribed antibiotics in high-income countries. One possible rationale for prescribing antibiotics is the wish to prevent bacterial complications.

OBJECTIVES

To assess the effectiveness and safety of antibiotics in preventing complications in children aged two to 59 months with undifferentiated ARIs.

SEARCH METHODS

We searched CENTRAL 2013, Issue 4, MEDLINE (1950 to May week 2, 2013) and EMBASE (1974 to May 2013).

SELECTION CRITERIA

Randomised controlled trials (RCT) or quasi-RCTs comparing antibiotic prescriptions with placebo or non-treatment in children up to 59 months with an undifferentiated ARI for up to seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted and analysed data using the standard Cochrane methodological procedures.

MAIN RESULTS

We identified four trials involving 1314 children. Three trials investigated the use of amoxicillin/clavulanic acid to prevent otitis and one investigated ampicillin to prevent pneumonia.The use of amoxicillin/clavulanic acid compared to placebo to prevent otitis showed a risk ratio (RR) of 0.70 (95% confidence interval (CI) 0.45 to 1.11, three trials, 414 selected children, moderate-quality evidence). Methods of random sequence generation and allocation concealment were not clearly stated in two trials. Performance, detection and reporting bias could not be ruled out in three trials.Ampicillin compared to supportive care (continuation of breastfeeding, clearing of the nose and paracetamol for fever control) to prevent pneumonia showed a RR of 1.05 (95% CI 0.74 to 1.49, one trial, 889 selected children, moderate-quality evidence). The trial was non-blinded. Random sequence generation and allocation concealment methods were not clearly stated so the possibility of reporting bias could not be ruled out.Harm outcomes could not be analysed as they were expressed only in percentages.No studies were found assessing mastoiditis, quinsy, abscess, meningitis, hospital admission or death.

AUTHORS' CONCLUSIONS

The quality of evidence currently available does not provide strong support for antibiotic use as a means of reducing the risk of otitis or pneumonia in children up to five years of age with undifferentiated ARIs. Further high-quality research is needed to provide more definitive evidence of the effectiveness of antibiotics in this population.

Antibiotics for the common cold and acute purulent rhinitis

BACKGROUND

It has long been believed that antibiotics have no role in the treatment of common colds yet they are often prescribed in the belief that they may prevent secondary bacterial infections.

OBJECTIVES

To determine the efficacy of antibiotics compared with placebo for reducing general and specific nasopharyngeal symptoms of acute upper respiratory tract infections (URTIs) (common colds).To determine if antibiotics have any influence on the outcomes for acute purulent rhinitis and acute clear rhinitis lasting less than 10 days before the intervention.To determine whether there are significant adverse outcomes associated with antibiotic therapy for participants with a clinical diagnosis of acute URTI or acute purulent rhinitis.

SEARCH METHODS

For this 2013 update we searched CENTRAL 2013, Issue 1, MEDLINE (March 2005 to February week 2, 2013), EMBASE (January 2010 to February 2013), CINAHL (2005 to February 2013), LILACS (2005 to February 2013) and Biosis Previews (2005 to February 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antibiotic therapy against placebo in people with symptoms of acute upper respiratory tract infection for less than seven days, or acute purulent rhinitis less than 10 days in duration.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed trial quality and extracted data.

MAIN RESULTS

This updated review included 11 studies. Six studies contributed to one or more analyses related to the common cold, with up to 1047 participants. Five studies contributed to one or more analyses relating to purulent rhinitis, with up to 791 participants. One study contributed only to data on adverse events and one met the inclusion criteria but reported only summary statistics without providing any numerical data that could be included in the meta-analyses. Interpretation of the combined data is limited because some studies included only children, or only adults, or only males; a wide range of antibiotics were used and outcomes were measured in different ways. There was a moderate risk of bias because of unreported methods details or because an unknown number of participants were likely to have chest or sinus infections.Participants receiving antibiotics for the common cold did no better in terms of lack of cure or persistence of symptoms than those on placebo (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.59 to 1.51, (random-effects)), based on a pooled analysis of six trials with a total of 1047 participants. The RR of adverse effects in the antibiotic group was 1.8, 95% CI 1.01 to 3.21, (random-effects). Adult participants had a significantly greater risk of adverse effects with antibiotics than with placebo (RR 2.62, 95% CI 1.32 to 5.18) (random-effects) while there was no greater risk in children (RR 0.91, 95% CI 0.51 to 1.63).The pooled RR for persisting acute purulent rhinitis with antibiotics compared to placebo was 0.73 (95% CI 0.47 to 1.13) (random-effects), based on four studies with 723 participants. There was an increase in adverse effects in the studies of antibiotics for acute purulent rhinitis (RR 1.46, 95% CI 1.10 to 1.94).

AUTHORS' CONCLUSIONS

There is no evidence of benefit from antibiotics for the common cold or for persisting acute purulent rhinitis in children or adults. There is evidence that antibiotics cause significant adverse effects in adults when given for the common cold and in all ages when given for acute purulent rhinitis. Routine use of antibiotics for these conditions is not recommended.

Antibiotics for nasopharyngitis are associated with a lower risk of office-based physician visit for acute otitis media within 14 days for 3- to 6-year-old children

OBJECTIVES

This study was designed to analyse factors potentially influencing children's return visits to physicians for symptoms of acute otitis media (AOM) within 14 days after being diagnosed with nasopharyngitis (NP), and the impact of recent antibiotic use.

DESIGN

A controlled population-based pharmaco-epidemiological trial in 3- to 6-year-old children conducted from January to May 2000.

SETTING

Three different geographical regions in France.

PARTICIPANTS

Among 2507 eligible children, 2456 could be analysed and 505 children had 634 office-based physician visits (OBPV) for NP symptoms.

INTERVENTIONS

The statistical associations between antibiotics prescribed for NP and an OBPV for AOM within 14 days in a population-based study were analysed along with risk factors of AOM.

MAIN OUTCOMES MEASURE

Clinical events and antibiotic use.

RESULTS

During the 2 weeks following physician-diagnosed NP, antibiotic use, especially a beta-lactam, significantly decreased the risk of OBPV for AOM in children (odds ratio=0.2; 95% confidence interval=0.09-0.7; P=0.002).

CONCLUSION

Antibiotics prescribed to children for NP seem to protect during the following 2 weeks against the risk of OBPV for AOM. It remains to be determined whether a subgroup at high risk of developing AOM after a viral infection exists and what might be the best strategy to adopt for NP in a national programme of optimal antibiotic use.

Antibiotics for the common cold and acute purulent rhinitis

BACKGROUND

It has long been believed that antibiotics have no role in treating common colds yet they are often prescribed in the belief that they may prevent secondary bacterial infections. Given the increasing concerns about antibiotic resistance it is important to examine the evidence for the benefit of antibiotics for the common cold.

OBJECTIVES

To determine:(1) the efficacy of antibiotics, in comparison with placebo, for reducing general symptoms and specific nasopharyngeal symptoms of acute upper respiratory tract infections; (2) if antibiotics have any influence on acute purulent rhinitis; (3) whether antibiotics cause significant adverse outcomes in patients with acute upper respiratory tract infections.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005); MEDLINE (January 1966 to March, Week 1, 2005); EMBASE (1980 to December 2004), the Family Medicine Database (1908, volume 1 to 1993, volume 13; this database was discontinued in 1993), and reference lists of articles, and we contacted principal investigators.

SELECTION CRITERIA

Randomised trials comparing any antibiotic therapy against placebo in people with acute upper respiratory tract infections and with less than seven days of symptoms, or acute purulent rhinitis less than ten days in duration.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed trial quality and extracted data.

MAIN RESULTS

All analyses used the fixed-effect model unless otherwise stated. The overall quality of the included trials was variable. People receiving antibiotics did no better in terms of lack of cure or persistence of symptoms than those on placebo (relative risk (RR) 0.89, 95% confidence interval (CI) 0.77 to 1.04), based on a pooled analysis of six trials with a total of 1147 patients. Overall, the relative risk of adverse effects in the antibiotic group was RR 1.8 (95% CI 1.01 to 3.21), using a random-effects model. Adult patients had a significantly greater risk of adverse effects with antibiotics than with placebo (RR 2.62, 95% CI 1.32 to 5.18) (random-effects model) while there was no greater risk in children (RR 0.91, 95% CI 0.51 to 1.63). The pooled relative risk for persisting acute purulent rhinitis with antibiotics compared to placebo was 0.57 (95% CI 0.37 to 0.87) (random-effects model), based on 6 studies with 772 participants.

AUTHORS' CONCLUSIONS

There is insufficient evidence of benefit to warrant the use of antibiotics for upper respiratory tract infections in children or adults. Antibiotics cause significant adverse effects in adults. The evidence on acute purulent rhinitis and acute clear rhinitis suggests a benefit for antibiotics for these conditions but their routine use is not recommended.

Rhinopharyngites de l’enfant

La rhinopharyngite désigne une inflammation modérée des voies aériennes supérieures d’origine infectieuse. Les signes habituels en sont l’obstruction nasale, la rhinorrhée, l’éternuement, la douleur pharyngée et la toux. Le terme de rhinopharyngite est spécifiquement français. Les auteurs anglo-saxons parlent de rhume (common cold) ou de upper respiratory tract infection (URI) pour décrire une inflammation aiguë des voies aériennes supérieures, et d’adénoïdite chronique (chronic adenoiditis) pour désigner une infection chronique des végétations adénoïdes responsable de rhinorrhées fébriles itératives ou d’obstruction des voies aériennes supérieures. Les rhinopharyngites aiguës non compliquées sont d’origine virale. Leur évolution spontanée est habituellement rapide et non compliquée. Elles ne nécessitent donc ni prélèvement bactériologique ni antibiothérapie systématique. En première intention, elles relèvent exclusivement d’un traitement antalgique et antipyrétique associé à des lavages des fosses nasales au sérum salé iso- ou hypertonique. Les complications des rhinopharyngites sont infectieuses, essentiellement représentées par les otites et les sinusites, et respiratoires obstructives. Le caractère fréquemment itératif des rhinopharyngites à partir de l’âge de 6 mois reflète un processus physiologique de maturation du système immunitaire. En présence de rhinopharyngites fréquentes et invalidantes, les principaux facteurs de risque devant être recherchés et si possible éradiqués sont le tabagisme passif et la fréquentation d’une collectivité d’enfants. L’adénoïdectomie n’est pas indiquée en l’absence de complications. Le développement d’antiviraux efficaces dans la prévention et dans le traitement des rhinopharyngites fait l’objet d’intenses recherches cliniques et expérimentales.

Rinofaringitis infantiles

La rinofaringitis designa una inflamación moderada de las vías respiratorias superiores de origen infeccioso. Sus signos habituales son obstrucción nasal, rinorrea, estornudos, dolor faríngeo y tos. Los autores anglosajones hablan de catarro (common cold) o de infección de vías respiratorias altas para describir una inflamación de las vías respiratorias superiores, y de adenoiditis crónica (chronic adenoiditis) para designar una infección crónica de las vegetaciones adenoides que produce rinorrea febril recidivante u obstrucción de las vías respiratorias altas. Las rinofaringitis agudas no complicadas son de origen vírico. Habitualmente su evolución espontánea es rápida y sin complicaciones. Por tanto, no hay que obtener muestras bacteriológicas ni hacer un tratamiento antibiótico sistemático. Como tratamiento de primera línea, sólo precisan analgésicos y antipiréticos asociados a lavados de las fosas nasales con suero salino isotónico o hipertónico. Las complicaciones de las rinofaringitis son infecciosas –representadas esencialmente por las otitis y las sinusitis– y respiratorias obstructivas. El carácter a menudo repetitivo de las rinofaringitis a partir de los 6 meses de edad refleja un proceso fisiológico de maduración del sistema inmunitario. Cuando existen rinofaringitis frecuentes e invalidantes, los principales factores de riesgo que se deben buscar, y de ser posible erradicar, son el tabaquismo pasivo y los contactos con una población infantil. La adenoidectomía ya no está indicada si no existen complicaciones. Se están realizando investigaciones clínicas y experimentales sobre el desarrollo de fármacos antivíricos eficaces para la prevención y el tratamiento de las rinofaringitis.

No advantage of treating acute respiratory tract infections with azithromycin in a placebo-controlled study

Acute respiratory tract infection (ARTI) is the commonest reason for which antibiotics are prescribed, despite the fact that ARTI is mostly of viral origin. The effectiveness of antibiotics in these illnesses is, at best, questionable. Jordan is a developing country where bacterial infections are thought to be more common than in developed countries and initially viral illnesses are frequently superimposed by bacterial infections. The present study represents an attempt to assess whether routine antibiotic treatment of ARTI has any beneficial effect on the course of the illness. The study was conducted in northern Jordan between 1 June and December 14, 2000. Patients > or =8 y of age visiting either of 2 health centers and diagnosed by the physician with ARTI above the level of the bronchioles were assigned on an alternating basis to receive either azithromycin or placebo. Patients were assessed at their initial visit and were subsequently followed up after 3 d, 1 week and 2 weeks. A total of 185 patients were included in the study. Patients administered azithromycin or placebo did similarly in terms of the proportions improved or cured and the duration of illness. We conclude that routine use of antibiotics (azithromycin) in ARTI is unlikely to alter the course of the illness.

Antibiotics for the common cold

BACKGROUND

The common cold is considered to be caused by viruses and it has long been believed that antibiotics have no role in treating this condition. In many countries doctors will often prescribe antibiotics for the common cold in the belief that they may prevent secondary bacterial infection and in some cases to respond to patient demand. There is also increasing concern over the resistance of common bacteria to commonly used antibiotics. A crucial step in reducing the use of antibiotics for the common cold is to examine the evidence to see if there is any benefit or if there is benefit for some subgroups or symptom constellations.

OBJECTIVES

(1) To determine the efficacy of antibiotics in comparison with placebo in the treatment of acute upper respiratory tract infections (common colds) in terms of the proportion of patients in whom the clinical outcome was considered to be a reduction in general symptoms and specific nasopharyngeal symptoms. (2) To determine whether there are significant adverse outcomes associated with antibiotic therapy for patients with a clinical diagnosis of acute upper respiratory tract infection.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, the Family Medicine Database, and reference lists of articles, and we contacted principal investigators. The most recent search was in May 2001 SELECTION CRITERIA: Randomised trials comparing any antibiotic therapy with placebo in acute upper respiratory tract infections with less than 7 days of symptoms

DATA COLLECTION AND ANALYSIS

Both reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

All analyses used fixed effects unless otherwise stated Main results: Nine trials involving 2249 (2157 analysed) people aged between two months and 79 years (and adults with no upper age limit) years were included. The overall quality of the included trials was variable. People receiving antibiotics did not do better in terms of lack of cure or persistence of symptoms than those on placebo (odds ratio 0.8, 95% confidence interval (95% CI) 0.59 to 1.08). Only one study Taylor et al (1977) specifically reported persistence of clear rhinitis with a small benefit to those on antibiotics. Two studies found a significant benefit for antibiotics compared with placebo for runny nose (clear) odds ratio 0.42 (0.22-0.78). Two studies also found a significant benefit in patients with sore throat odds ratio 0.27 95% CI (0.10-0.74). Only one study reported work time lost with 22% of those on antibiotic treatment and 25% of those on placebo but this was not significant. Adult patients treated with antibiotics had a significant increase in adverse effects (odds ratio 3.6 95% CI 2.21 to 5.89) while there was no significant increase in children odds ratio 0.90 95% CI (0.44-1.82).

REVIEWERS' CONCLUSIONS

There is not enough evidence of important benefits from the treatment of upper respiratory tract infections with antibiotics to warrant their routine use in children or adults and there is a significant increase in adverse effects associated with antibiotic use in adult patients.

Antibiotics and return visits for respiratory illness: a comparison of pooled versus hierarchical statistical methods

BACKGROUND

Antibiotic prescribing for respiratory illness has been associated with small reductions in return visits in an analysis of a large practice-based network. In this study, we apply hierarchical analytical methods that account for the clustering of patients by practices to identify whether antibiotic prescribing by primary care physicians reduces subsequent visits for 6 acute respiratory illnesses-upper respiratory infection, pharyngitis, bronchitis, otitis media, sinusitis, and cough.

METHODS

The study data came from 318 family physicians and internists in 45 practices in the Practice Partner Research Network from January 1995 through December 1996, with 255,564 active patients. Patients treated with antibiotics were compared with those who were not on the frequency of revisit within the next 14 days. A simple pooling model and 3 hierarchical statistical models (fixed-effects, random-effects, and Bayesian) were used to compare the odds-ratios for return visits.

RESULTS

Statistically significant results were found only for bronchitis and sinusitis by the hierarchical models, but the simple pooling model produced statistically significant results for all study conditions.

CONCLUSION

We conclude that antibiotics may reduce return visits for patients with bronchitis and sinusitis, but not for patients with other respiratory illness (upper respiratory infection, pharyngitis, otitis media, or cough). Studies of large clinical databases should use methods of analysis that account for the grouping of patients by practice to avoid false positive associations (type I errors.)

Survey of clinical pharmacists' knowledge of appropriateness of antimicrobial therapy for upper respiratory infections and acute bronchitis

We conducted a survey to assess clinical pharmacists' recommendation of antibiotics for upper respiratory infections (URIs) and acute bronchitis. A random sample of 752 members of the American College of Clinical Pharmacy were mailed a multiple-choice survey that presented four examples consistent with clinical symptoms of the two disorders. Respondents were asked what treatment they would recommend for each example. The response rate was 59%. Pharmacists recommended antibiotics for the treatment of both URIs and acute bronchitis significantly more if patients' symptoms included discolored discharge or sputum as opposed to clear discharge. Those who were board certified were less likely than nonboard-certified pharmacists to recommend antibiotics for URIs with discolored discharge. Pharmacists who specialized in either ambulatory care or infectious disease were less likely than those in other specialties to recommend antibiotics for acute bronchitis with discolored sputum. Clinical pharmacists are similar to patients and physicians in their belief that antibiotics are appropriate for URIs and acute bronchitis with discolored discharge. Considering the role that pharmacists play as clinical consultants to physicians, greater efforts should be made to educate them regarding appropriate prescription of antibiotics.

Systematic review of the treatment of upper respiratory tract infection

OBJECTIVES

To assess the risks and benefits of antibiotic treatment in children with symptoms of upper respiratory tract infection (URTI).

DESIGN

Quantitative systematic review of randomised trials that compare antibiotic treatment with placebo.

DATA SOURCES

Twelve trials retrieved from a systematic search (electronic databases, contact with authors, contact with drug manufacturers, reference lists); no restriction on language.

MAIN OUTCOME MEASURES

The proportion of children in whom the clinical outcome was worse or unchanged; the proportion of children who suffered complications or progression of illness; the proportion of children who had side effects.

RESULTS

1699 children were randomised in six trials that contributed to the meta-analysis. Six trials were not used in the meta-analysis because of different outcomes or incomplete data. Clinical outcome was not improved by antibiotic treatment (relative risk 1.01, 95% confidence interval (CI) 0.90 to 1.13), neither was the proportion of children suffering from complications or progression of illness (relative risk 0.71, 95% CI 0.45 to 1.12). Complications from URTI in the five trials that reported this outcome was low (range 2-15%). Antibiotic treatment was not associated with an increase in side effects compared with placebo (relative risk 0.8, 95% CI 0.54 to 1.21).

CONCLUSIONS

In view of the lack of efficacy and low complication rates, antibiotic treatment of children with URTI is not supported by current evidence from randomised trials.