Misconceptions about colds and predictors of health service utilization

Large-scale questionnaire survey of parents and guardians on antimicrobial resistance using group health checkups for infants and toddlers in Japan

BACKGROUND

It is important to improve the knowledge of antimicrobial resistance (AMR) among parents and guardians, to promote AMR stewardship in pediatrics. However, a large-scale survey on parents' knowledge and awareness of AMR has not yet been conducted in Japan. Furthermore, the current status of knowledge and awareness is unknown. Infant and toddler health checkups are large-scale administrative activities that approximately all children and their parents undergo in Japan. Therefore, we conducted a knowledge and awareness survey using a questionnaire during the group health checkups.

METHODS

All parents and guardians who participated in the group health checkups (4-month, 1.5-year, and 3-year) in Chiba City during the year were targeted. Parents' knowledge and awareness of AMR and their wishes for future information on AMR were surveyed using a one-choice questionnaire.

RESULTS

The questionnaire collection rate was 87.5% (16,663/19,047), and the valid response rate was 77.0% (14,674/19,047). Of the parents, 37.2% answered that "antibiotics are not effective for colds." However, 58.9% answered that they "had never heard of the drug-resistant bacteria." While 8.3% of parents answered that they "sometimes want my child to be prescribed antibiotics even if the doctor deemed it unnecessary," 46.1% of parents answered that "they were unaware of whether their children were prescribed antimicrobials."

CONCLUSIONS

Knowledge and awareness of AMR among parents in Japan are inadequate, and there is room for improvement. Continuous awareness-raising activities combining multiple methods are needed in the future.

Early Life Antibiotic Prescription for Upper Respiratory Tract Infection Is Associated With Higher Antibiotic Use in Childhood

BACKGROUND

Antibiotic prescription for uncomplicated upper respiratory tract infection (URTI) in children is not recommended but remains common. The primary objective was to evaluate the relationship between antibiotic prescription for URTI prior to age 2 and antibiotic prescription for URTI after age 2. It was hypothesized that antibiotic prescription for URTI in early childhood may increase the risk of antibiotic use for subsequent URTIs. The secondary objective was to investigate whether this relationship was different for acute otitis media (AOM), for which antibiotics may be indicated.

METHODS

A prospective cohort study was conducted between December 2008 and March 2016 at 9 primary care practices in Toronto, Canada. Healthy children aged 0-5 years that met TARGet Kids! cohort eligibility criteria were included if they had at least one sick visit prior to age 2 and least one sick visit after age 2. Generalized Estimating Equation (GEE) models were used to evaluate this relationship while considering within-subject correlation.

RESULTS

Of 2380 participants followed for a mean duration of 4.6 years, children who received an antibiotic prescription for URTI prior to age 2 had higher odds of receiving an antibiotic prescription for URTI in later childhood (adjusted odds ratio: 1.39; 95% confidence interval: 1.19 to 1.63; P < .001). This relationship did not appear to be different for AOM compared to non-AOM URTI.

CONCLUSION

Antibiotic prescription for URTI before age 2 was associated with antibiotic prescription for URTI in later childhood. Reducing early life antibiotic prescription for URTI may be associated with reduction in antibiotic prescription for subsequent URTIs.

A nationwide parent survey of antibiotic use in Australian children

BACKGROUND

Antimicrobial resistance is increasing globally, largely due to high rates of antibiotic use and misuse. Factors that influence frequent antibiotic use in children are poorly understood.

OBJECTIVES

This study describes rates of antibiotic use in Australian children and investigates parental factors including knowledge, attitudes and behaviours that influence antibiotic use.

METHODS

An online questionnaire relating to antibiotic use was administered as part of the Royal Children's Hospital National Child Health Poll to a randomly recruited nationwide sample of parents or guardians of children aged 0-17 years in Australia. Data on antibiotic use in children and parental knowledge of appropriate indications for antibiotics and behaviours were collected. Standard binary logistic regression was used to assess associations between parent demographics and behaviour with antibiotic administration.

RESULTS

The survey was completed by 2157 parents (64% completion rate), of which 1131 (52%) reported having given oral antibiotics to one or more of their children in the preceding 12 months. Of the 3971 children represented overall, 1719 (43%) had received at least one course of antibiotics. The average number of courses per child was 0.86 overall and 1.96 courses per child among those with reported antibiotic use. Notably, 194/1131 (17%) parents reported giving antibiotics to their child without a prescription. Poor parental knowledge of antibiotic indications was associated with antibiotic use.

CONCLUSIONS

Reducing excessive use of antibiotics in children is necessary in the global strategy for preventing antimicrobial resistance. This study identified areas for public health interventions to educate parents and increase regulation of access to antibiotics.

Influence of Dietary Advice Including Green Vegetables, Beef, and Whole Dairy Products on Recurrent Upper Respiratory Tract Infections in Children: A Randomized Controlled Trial

Background: Since no treatment exists for children suffering from upper respiratory tract infections (URTIs) without immunological disorders, we searched for a possible tool to improve the health of these children. Aim: We evaluated whether dietary advice (based on food matrix and food synergy), including standard supportive care, can decrease the number and duration of URTIs in children with recurrent URTIs. Design and Setting: This study was a multicenter randomized controlled trial in two pediatric outpatient clinics in the Netherlands, with 118 children aged one to four years with recurrent URTIs. The dietary advice group received dietary advice plus standard supportive care, while the control group received standard supportive care alone for six months. The dietary advice consisted of green vegetables five times per week, beef three times per week, 300 mL whole milk per day, and whole dairy butter on bread every day. Portion sizes were age-appropriate. Results and Conclusion: Children in the dietary advice group had 4.8 (1.6–9.5) days per month with symptoms of an URTI in the last three months of the study, compared to 7.7 (4.0–12.3) in the control group (p = 0.028). The total number of URTIs during the six-month study period was 5.7 (±0.55) versus 6.8 (±0.49), respectively (p = 0.068). The use of antibiotics was significantly reduced in the dietary advice group, as well as visits to a general practitioner, thereby possibly reducing healthcare costs. The results show a reduced number of days with symptoms of a URTI following dietary advice. The number of infections was not significantly reduced.

An informed public's views on reducing antibiotic overuse

OBJECTIVE

To understand public attitudes about and recommendations to address antibiotic overuse by employing public deliberation (a method for eliciting informed input on value-laden issues).

DATA SOURCES/STUDY SETTING

Participants in 24 Community Deliberation groups (CD; n = 263), four Citizens' Panel groups (CP; n = 96), and a control group (n = 348). Data were collected in 2012 in four U.S.

LOCATIONS

STUDY DESIGN

Using mixed methods, we analyzed quantitative and qualitative data from a randomized control trial.

DATA COLLECTION/EXTRACTION METHODS

Using pre/postdeliberation surveys, we compared CD and CP participant attitude changes regarding antibiotic use to the control group. We analyzed deliberation transcripts using qualitative techniques to provide context for survey results.

PRINCIPAL FINDINGS

Compared to control group participants, CD and CP participants had a larger postdeliberation shift in attitudes toward support of government limits on when doctors can prescribe antibiotics. Participants described unawareness about antibiotic overuse and called for education. When discussing prescription limits, participants debated tensions between preserving patient/doctor autonomy and protecting society from antibiotic-related harms. Participants saw patient, physician, and government roles in antibiotic stewardship policies/programs.

CONCLUSION

When informed about individual and social consequences of antibiotic overuse, patients may be more receptive to antibiotic prescription limits. Community-physician-government partnerships are needed to create solutions.

Antibiotics use for upper respiratory tract infections among children in rural Anhui: children's presentations, caregivers' management, and implications for public health policy

Children with upper respiratory tract infections (URTIs) are among the highest receivers of antibiotics. Using a retrospective cross-sectional study, we described clinical management in rural China of recent URTIs in children. We explored antibiotics using behaviors and associations of caregivers' variables and children's symptoms. Children with URTIs had a high consultation rate and a high prescription rate of antibiotics. For the children, some caregivers adopted, without rationale, 'self-medication' with antibiotics. Children with fever were more likely to be taken to a doctor; among those, children with particular symptoms were more likely to receive a prescription for antibiotics. Disseminating knowledge on antibiotics, and on interpretation and management of URTI symptoms will be important targets for caregiver and physician education and should become routine in training for physicians. Our findings also suggest the need to improve communication between doctors and caregivers, to strengthen regulation of drug sales, and to help caregivers learn when over-the-counter drug purchase without medical consultation is reasonable. These activities can help to improve health of a vast population of children in rural China.

Reducing Primary Care Attendance Intentions for Pediatric Respiratory Tract Infections

PURPOSE

The aim of this study was to evaluate a theory and evidence-based, parent-targeted online intervention, combining microbiological local syndromic surveillance data, symptom information, and home-care advice, to reduce primary care attendance for self-limiting, low-risk pediatric respiratory tract infections (RTIs).

METHODS

The effect of this novel intervention on primary care attendance intentions was evaluated in an online experimental study. A representative sample of mothers (n = 806) was randomly assigned to receive the intervention material before (intervention) or after (control) answering questions concerning attendance intentions for an RTI illness scenario and mediating factors. Both groups provided feedback on the material. Group comparisons, linear regression, and path analyses were conducted.

RESULTS

Intervention participants reported lower attendance intentions compared with control participants (d = 0.69, 95% CI, 0.55-0.83), an effect that remained when controlling for demographic and clinical characteristics (B = -1.62, 95% CI, -1.97 to -1.30). The path model highlighted that the intervention effect (B = -0.33, 95% CI, -0.40 to -0.26) was mostly indirect and mediated by infection and antibiotic knowledge, symptom severity concerns, and social norm perceptions concerning attendance. Information on when to attend was rated as the most important intervention component 227 times, followed by symptoms rated 186 times. Information on circulating viruses was rated as least important 274 times.

CONCLUSIONS

The intervention was effective in reducing primary care attendance intentions by increasing knowledge, lowering attendance motivation, and reducing the need for additional resources. The contribution of individual intervention components and effects on behavioral outcomes requires further testing.

Management of respiratory tract infections in young children-A qualitative study of primary care providers' perspectives

Respiratory tract infections in young children are the most common cause of general practice visits in Australia. Despite the availability of clinical practice guidelines, the treatment and management of respiratory tract infections in young children is inconsistent. The aim of the study was to explore the management of respiratory tract infections in young children from a multi-disciplinary perspective using across-sectional qualitative research design based on the theoretical domains framework and the Capability, Opportunity and Motivation-B model. In-depth interviews were conducted with 30 primary care providers to explore their knowledge, views and management of respiratory tract infections in young children. Interviews focused on symptomatic management, over-the-counter medications and antibiotic use, and data were thematically analysed. Our findings showed that factors such as primary care providers’ time constraints, parental anxiety, general practitioners’ perception of what parents want, perceived parental pressure, and fear of losing patients were some of the reasons why primary care providers did not always adhere to guideline recommendations. Primary care providers also provided conflicting advice to parents concerning over-the-counter medications and when children should resume normal activities. Overall, this study showed that complex interactions involving emotional and psychological factors influenced the decision making process of primary care providers’ management of respiratory tract infections in young children. A team care approach with consistent advice, and improved communication between primary care providers and parents is vital to overcome some of these barriers and improve guideline adherence. The findings of this research will inform the development of interventions to better manage respiratory tract infections in young children.

The emotions and psychology of both parents and clinicians influence how respiratory tract infections (RTIs) are managed in young children. Researchers in Australia, led by Ruby Biezen from Monash University, interviewed 30 primary care clinicians about their views on how to care for children with RTIs, such as the common cold. The interviews focused on symptomatic management, over-the-counter medications and antibiotic use. Despite the availability of best-practice guidelines, clinicians did not always follow the recommendations owing to factors such as time constraints, parental anxiety, perceived parental pressure, and fear of losing patients. These are some of the reasons why clinicians sometimes advise or prescribe unnecessary medications. The authors suggest that a team approach involving multiple healthcare professionals who deliver consistent advice could improve guideline adherence.

Antibiotic use in rural China: a cross-sectional survey of knowledge, attitudes and self-reported practices among caregivers in Shandong province

BACKGROUND

To improve antibiotic use globally, we must deepen our understanding of the public's knowledge, attitudes and practices (KAP) concerning antibiotics. Children are frequent users of antibiotics, and their caregivers play important roles in determining how antibiotics are used. The purpose of this study was to describe caregivers' KAP in a rural province in eastern China, and to identify socio-demographic factors associated with inappropriate antibiotic use.

METHODS

A cross-sectional questionnaire based survey was conducted in 12 villages in one county in Shandong Province. A total of 727 individuals who were the primary day-to-day caregiver for a child aged 0-7 years were randomly selected and invited to participate. All caregivers were surveyed face-to-face using a semi-structured questionnaire focusing on the use of antibiotics in children.

RESULTS

Almost all invited caregivers (99.3 %) completed the questionnaire in full. Caregivers expressed high levels of over-expectation for antibiotics for common childhood symptoms, stating that antibiotics were always or usually necessary when a child has a fever (46 %) or dry cough (42 %). Most caregivers (93 %) were aware that they should follow the doctor's advice when giving their children antibiotics. Many, however, reported that they had previously deviated from advice; this was most commonly through using antibiotics intermittently rather than regularly, but also by increasing and decreasing doses. Caregivers that were older and that had less formal education had higher levels of self-reported adherence (p < 0.01). A third of caregivers admitted to storing leftover antibiotics at home, and almost all of these caregivers (97 %) had used the antibiotics on a second occasion for their child.

CONCLUSION

We have identified important gaps in knowledge, attitudes and practices concerning antibiotics among this rural population of caregivers. There is a clear need for multifaceted interventions that target village doctors, to improve prescribing and communication, as well as the general public, to improve health-seeking behaviours and promote responsible individual use of antibiotics.

Prevalence of Parental Misconceptions About Antibiotic Use

BACKGROUND

Differences in antibiotic knowledge and attitudes between parents of Medicaid-insured and commercially insured children have been previously reported. It is unknown whether understanding has improved and whether previously identified differences persist.

METHODS

A total of 1500 Massachusetts parents with a child <6 years old insured by a Medicaid managed care or commercial health plan were surveyed in spring 2013. We examined antibiotic-related knowledge and attitudes by using χ(2) tests. Multivariable modeling was used to assess current sociodemographic predictors of knowledge and evaluate changes in predictors from a similar survey in 2000.

RESULTS

Medicaid-insured parents in 2013 (n = 345) were younger, were less likely to be white, and had less education than those commercially insured (n = 353), P < .01. Fewer Medicaid-insured parents answered questions correctly except for one related to bronchitis, for which there was no difference (15% Medicaid vs 16% commercial, P < .66). More parents understood that green nasal discharge did not require antibiotics in 2013 compared with 2000, but this increase was smaller among Medicaid-insured (32% vs 22% P = .02) than commercially insured (49% vs 23%, P < .01) parents. Medicaid-insured parents were more likely to request unnecessary antibiotics in 2013 (P < .01). Multivariable models for predictors of knowledge or attitudes demonstrated complex relationships between insurance status and sociodemographic variables.

CONCLUSIONS

Misconceptions about antibiotic use persist and continue to be more prevalent among parents of Medicaid-insured children. Improvement in understanding has been more pronounced in more advantaged populations. Tailored efforts for socioeconomically disadvantaged populations remain warranted to decrease parental drivers of unnecessary antibiotic prescribing.

Pediatric emergency department management benefits from appropriate early redirection of nonurgent visits

AIMS

Overcrowding at pediatric emergency departments (EDs) may result in delayed clinical management and higher risks of medical error. This study was designed to prospectively evaluate what parents of sick children seek emergency care for and how these patients are being assessed and managed.

METHODS

Patients aged 0 to 17 years seeking ED care at an urban Swedish university hospital, from 8 AM to 9 PM on 25 consecutive days, were included. Clinical urgency and further level of medical care were determined by experienced nurses based on individual clinical signs and vital parameters. Information on presenting problem, medical priority, gender, age, waiting time, day of week, time of day, and further management was recorded.

RESULTS

Among 1057 included children, two thirds were assessed by physicians, whereas one third were referred directly by nurses for other ED (n = 54) or primary care (n = 114), or sent home with medical advice (n = 176), more often during evenings and weekends. Of primarily referred patients, 7.6% returned within 72 hours, and three of them were admitted. Young infants, patients with respiratory or neurological problems, and sicker patients with fever or infections were mainly assessed by physicians, within desired priority time.

DISCUSSION

More than one fourth of pediatric ED patients might rapidly, appropriately, and safely be referred for primary care or sent home by experienced pediatric nurses soon after arrival, thereby facilitating management of urgent and more appropriate patients. Evaluations by physicians were primarily required in young infants and for urgent medical conditions demanding qualified pediatric skills.

Effect of a URI-related educational intervention in early head start on ED visits

OBJECTIVES

To evaluate the effectiveness of an educational intervention to decrease pediatric emergency department (PED) visits and adverse care practices for upper respiratory infections (URI) among predominantly Latino Early Head Start (EHS) families.

METHODS

Four EHS sites in New York City were randomized. Families at intervention sites received 3 1.5-hour education modules in their EHS parent-child group focusing on URIs, over-the-counter medications, and medication management. Standard curriculum families received the standard EHS curriculum, which did not include URI education. During weekly telephone calls for 5 months, families reported URI in family members, care sought, and medications given. Pre- and post-intervention knowledge-attitude surveys were also conducted. Outcomes were compared between groups.

RESULTS

There were 154 families who participated (76 intervention, 78 standard curriculum) including 197 children <4 years old. Families were primarily Latino and Spanish-speaking. Intervention families were significantly less likely to visit the PED when their young child (age 6 to <48 months) was ill (8.2% vs 15.7%; P = .025). The difference remained significant on the family level (P = .03). These families were also less likely to use an inappropriate over-the-counter medication for their <2-year-old child (odds ratio, 0.29; 95% confidence interval, 0.09-0.95; 12.2% vs 32.4%, P = .034) and/or incorrect dosing tool for their <4-year-old child (odds ratio, 0.24; 95% confidence interval, 0.08-0.74; 9.8% vs 31.1%; P < .01). The mean difference in Knowledge-Attitude scores for intervention families was higher.

CONCLUSIONS

A URI health literacy-related educational intervention embedded into EHS decreased PED visits and adverse care practices.

Can patients or clinicians predict the severity or duration of an acute upper respiratory infection?

PURPOSE

Acute upper respiratory infections (URI) are the second most common diagnosis in primary care offices. As treatments have limited effectiveness, patient counseling regarding expectations for the course of the URI is an important aspect of care. It is unknown how accurate patients, clinicians or questionnaires such as the Wisconsin Upper Respiratory Symptom Survey (WURSS) instrument are at predicting URI severity and duration, and whether these predictions should be used to counsel patients.

METHODS

Seven hundred and nineteen individuals with recent onset cold in community clinic settings participated. Participants and clinicians predicted the severity and duration of the URI and participants completed the WURSS instrument at initial visit. Subsequent URI global severity was calculated as area under the curve using an average of twice-daily WURSS-21 self-reports as the y-axis and illness duration as the x-axis. URI duration was determined by self-report of beginning and end of illness. Linear regression analysis was used to correlate baseline predictions with subsequent outcomes. Analyses by gender, age and income were also performed.

RESULTS

There was no significant association between participant and clinician predictions of severity or duration. Initial WURSS values explained 0.119 (95% CI: 0.074-0.163) of the variance in subsequent severity outcomes. There were no significant differences in associations by age, gender or income.

CONCLUSIONS

Clinicians should not use their predictive assessments or their patients' predictions when advising patients on the expected course of a URI. This study also suggests that the WURSS instrument could give some predictive information, but whether this is clinically useful is uncertain.

Over-prescribing of antibiotics and imaging in the management of uncomplicated URIs in emergency departments

BACKGROUND

Unnecessary use of resources for common illnesses has substantial effect on patient care and costs. Evidence-based guidelines do not recommend antibiotics or imaging for uncomplicated upper respiratory infections (URIs). The objective of the current study was to examine medical care providers' compliance with guidelines in treating uncomplicated URIs in emergency departments (EDs) in the US.

METHODS

Nationally representative data from the NHAMCS 2007 and 2008 were used. Uncomplicated URIs were identified through ICD-9 codes of nasopharyngitis, laryngitis, bronchitis, URI not otherwise specified and influenza involving upper respiratory tract. Exclusion criteria were concurrent comorbidities, follow-up visits, and age < 18 or >64 years. Most frequently prescribed classes of antibiotics were identified. Multivariate analyses were conducted to identify the factors associated with the prescribing of antibiotics and use of imaging studies.

RESULTS

In 2007 and 2008, there were 2.2 million adult uncomplicated URI visits without any other concurrent diagnoses in EDs in the US. Approximately 52% were given antibiotic prescriptions, over one-third of which were macrolides, and nearly half of the visits performed imaging studies. About 51% had a diagnosis of bronchitis, 35% URI NOS, 9% nasopharyngitis, laryngitis or influenza, and 4% multiple URI diagnoses. The diagnosis of bronchitis, fever at presentation, older ages, male gender, longer waiting time, and metropolitan areas were associated with a greater likelihood of prescribing antibiotics or imaging studies, controlling for confounding factors.

CONCLUSION

Despite the recommendations and campaign efforts by the CDC and many medical associations, the prescribing of antibiotics in treating uncomplicated URIs in the EDs remains prevalent. Furthermore, overutilization of imaging studies is prevalent. Changes at levels of health care system and hospitals are needed to avoid unnecessary resource utilization. In addition, further patient education about antibiotic use in the community may greatly facilitate the transition out of an antibiotic-dependent consumer culture.

Differences in antibiotic use and knowledge between adolescent and adult mothers in Ecuador

Objectives: To investigate the differences in antibiotic use and knowledge between adolescent and adult mothers of children under the age of 5 years in Ecuador.

Methods: A cross sectional study was performed in four health centers and hospitals. Mothers of children under five years, seeking medical attention their child's upper respiratory tract infection (URI), were included. The data was collected through interviews, using a structured questionnaire. The questionnaire covered the topics knowledge of antibiotic treatment, risk and resistance. 

Results: 777 mothers were included in the study, of which 15.8% were adolescent and 84.1% adult mothers. There were significant differences in the social and economic characteristics of the mothers (p ≤ 0.05), with adolescent mothers being more likely to have an incomplete high school education and lack of basic services in their home. Significant differences between these groups were found in adherence to treatment, knowledge about risks associated with antibiotic use, and having heard of antibiotic resistance. Among the adult mothers, 83.5% reported correct adherence, 28.5% were knowledgeable about risks associated with antibiotic use, and 29.3% had heard of antibiotic resistance. Among the adolescent mothers, these numbers were 75.4%, 15.0%, and 19.8%, respectively.

Conclusions: To develop successful interventions, it is crucial to understand the factors causing differences in antibiotic use and knowledge between mothers.

Representations of influenza and influenza-like illness in the community--a qualitative study

Background

There is little information regarding lay-people's representations of influenza and influenza-like illness in their day-to-day lives. An insight into these views may aid our understanding of community attitudes regarding official recommendations for its prevention.

Methods

This was a qualitative research. Semi-structured face-to-face interviews were conducted with 40 French participants from the community, and from five different locations. Questions elicited the participants' representations of onset of flu and influenza-like illness, as well as their views on what can/should be done to deal with symptoms and their personal experience with flu and flu-like symptoms.

Results

Thematic content analyses allowed us to identify five main themes: the presence of a clear continuum between influenza-like illness and flu; a description of flu as a very contagious disease; flu as being benign, except in "frail people", which the respondents never considered themselves to be; interruption of daily activities, which could be considered pathognomonic for influenza for most subjects; self-medication as the main current practice, and requests for healthcare mainly to confirm an auto-diagnosis.

Conclusions

There was a large homogeneity in the representation of flu. There was also a gap between people's representations (i.e., a continuum from having a "cold" to having "influenza") and scientific knowledge (i.e., a distinction between "true" influenza and influenza-like illnesses based on the existence of a confirmatory virological diagnosis). This gap raises issues for current campaigns for flu prevention, as these may not be congruent with the representation of flu being responsible for interrupting daily activities while also being seen as a non-severe disease, as well as the perception that flu is only a risk to "frail people" though no participants considered themselves to be "frail".

Rural parent behaviors and expectations when caring for children with acute respiratory infections

PURPOSE

To explore rural parents' behaviors and expectations regarding acute respiratory infections (ARIs) in children.

DATA SOURCES

A random digit dial telephone survey administered to 655 rural adults; 176 answered questions regarding care of their children.

CONCLUSIONS

Increasing fluid intake was the action most parents reported "always" taking when caring for a child with an ARI. Parents take their child to see a provider when they "just know" their child will not get better or when the child has discolored phlegm or discharge. Most reported reasons for not taking child to a provider were because the child got better on their own and they knew how to treat their child on their own. When seeing a provider for an ARI, parents considered it very important that the provider listen to the child's symptoms, examine their child for the cause of their symptoms, and provide symptom management advice. Parents expect providers to treat the ARI in one visit and allow for follow-up by phone or e-mail.

IMPLICATIONS FOR PRACTICE

Nurse practitioners (NPs) in rural communities should be aware of the behaviors and expectations of parents in their practice. Awareness of these potentially unique issues will allow NPs to work with rural patients more effectively.

Parental health literacy, knowledge and beliefs regarding upper respiratory infections (URI) in an urban Latino immigrant population

Parents who are recent immigrants and/or non-native English speakers are at increased risk for poor health literacy. For example, misconceptions regarding treatment for upper respiratory infections (URIs), including nonjudicious use of antibiotics, have been described among Latinos. We sought to assess the influence of health literacy on knowledge and beliefs surrounding URI care and to explore the correlation between two health literacy measures among Latino parents in northern Manhattan. A descriptive survey design was used, and a total of 154 Latino parents were enrolled from four early head start programs between September 2009 and December 2009. Health literacy was measured using the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and Newest Vital Sign (NVS); parental knowledge and beliefs regarding antibiotic treatment for URIs were also assessed. Analyses were conducted in 2010 with multivariable logistic regression performed to examine predictors of health literacy. Inadequate health literacy was observed in 83.8 % of respondents using NVS and 35.7 % with the S-TOFHLA. College education was significantly associated with adequate health literacy using either the NVS or S-TOFHLA; however, other results varied between measures. Using NVS, there was a greater likelihood of adequate health literacy with US birth status (AOR 13.8; 95 % CI, 1.99-95.1), >5 years US residency (AOR 7.6; 95 % CI, 1.3-43.1) and higher antibiotic knowledge scores (AOR 1.7; 95 % CI, 1.2-2.4). Using S-TOFHLA, the odds of adequate health literacy increased with access to a regular care provider (AOR 2.6; 95 % CI, 1.2-5.6). Scores consistent with adequate health literacy on the NVS, but not the S-TOFHLA, were associated with correct beliefs regarding antibiotic use for URIs in comparison to scores of participants with inadequate health literacy. Since health literacy levels were low in this population and the risk of viral URI was high during the first few years of life, targeted education to improve health literacy, knowledge, and beliefs about URI and related antibiotic treatment is needed.

Caregivers' baseline understanding and expectations of antibiotic use for their children

Although there is evidence that oral antibiotic prescriptions for children have decreased since the 1990s, antibiotic resistance continues to be a problem. This study evaluated the caregivers' understanding of antibiotic use for their children and identified demographic characteristics that may contribute to inappropriate antibiotic-seeking behavior. Caregivers were asked how often the child should receive antibiotics for common medical conditions and about factors to improve patient compliance. This study found that caregivers overexpected antibiotic use with upper respiratory infection, ear infection, and pneumonia. Caretakers with lower incomes and on Medicaid comprised the higher percentage of overusers. The most important factors to improve patient compliance were explanation of the name and indication for antibiotic use. This study showed that demographic variables play a role in caregivers' expectations of antibiotic use. Effective communication of physicians with caregivers on antibiotic use can be an important strategy to improve patient compliance.

[Prescription of systemic cold and cough drugs to children 0-13 years old. An unresolved problem]

INTRODUCTION AND OBJECTIVES

Upper respiratory tract infections are the most common cause of paediatric consultation, generating a high volume of prescriptions of drugs with unfavourable risk-benefit ratio. The aim of this study is to describe the prescription of systemic cough and cold medicines to children under 14 years of age in Castilla y León and analyse its variability.

POPULATION AND METHODS

A count was made of the prescriptions for the R05 therapeutic subgroup (antitussives and mucolytics) and the R01B pharmacological therapeutic subgroup (nasal decongestants for systemic use), prescribed for children under the age of 14 in the Public Health System between 2005-2010. The number of prescriptions was analysed as crude and age-adjusted rates, as well as a a multivariate analysis (Poisson regression) of the variability associated with health area, the urban/rural environment, age, and year of prescription.

RESULTS

There were 806,785 prescriptions for systemic cough and cold drugs given to an exposed population of 1,580,229 person-years. Prescription rates (per 100 person-years) were 20.7 (antitussives), 7.0 (sympathomimetic) and 23.4 (mucolytics). These drugs were employed more often in children <4 years. The prescription of mucolytics and sympathomimetics was highest at age of 1 year (rates=41.9 and 18.7, respectively) and of antitussives at 3 years (35.7). Multivariate analysis showed that in rural areas the prescription was higher than in urban areas, and that there were also significant differences between health areas.

CONCLUSIONS

Between 2005 and 2010 there was a high prescription of systemic cough and cold medicines, especially in children under 2 years old, and often outside the recommended conditions of use, and there was a high geographic variabilty.

A computerized education module improves patient knowledge and attitudes about appropriate antibiotic use for acute respiratory tract infections

BACKGROUND

Over-use of antibiotics for acute respiratory infections (ARIs) increases antimicrobial resistance, treatment costs, and side effects. Patient desire for antibiotics contributes to over-use.

OBJECTIVE

To explore whether a point-of-care interactive computerized education module increases patient knowledge and decreases desire for antibiotics.

METHODS

Bilingual (English/Spanish) interactive kiosks were available in 8 emergency departments as part of a multidimensional intervention to reduce antibiotic prescribing for ARIs. The symptom-tailored module included assessment of symptoms, knowledge about ARIs (3 items), and desire for antibiotics on a 10-point visual analog scale. Multivariable analysis assessed predictors of change in desire for antibiotics.

RESULTS

Of 686 adults with ARI symptoms, 63% initially thought antibiotics might help. The proportion of patients with low (1-3 on the scale) desire for antibiotics increased from 22% pre-module to 49% post-module (p<.001). Self-report of "learning something new" was associated with decreased desire for antibiotics, after adjusting for baseline characteristics (p=.001).

CONCLUSION

An interactive educational kiosk improved knowledge about antibiotics and ARIs. Learning correlated with changes in personal desire for antibiotics.

PRACTICE IMPLICATIONS

By reducing desire for antibiotics, point-of-care interactive educational computer technology may help decrease inappropriate use for antibiotics for ARIs.

Improving care of upper respiratory infections among Latino Early Head Start parents

Misconceptions about upper respiratory infections (URI) and their treatment are widely held, especially among Latino parents, and are associated with increased health care visits. The Centers for Disease Control and Prevention recommends community based interventions to educate families about URI. We designed a community-based, culturally competent health literacy intervention regarding URI, which was pilot tested with Latino Early Head Start (EHS) parents. In depth interviews were conducted to understand parents' perceptions. A paired-sample Wilcoxon signed rank test was used to assess change in pre-post knowledge/attitudes scores. Changes in care practices are described. Parents were very positive about this education, were open to non-antibiotic URI care, and reported that materials were helpful. Following the intervention, the mean composite knowledge/attitude score increased from 4.1 (total: 10) to 6.6 (P < .05). Families also reported improved care practices. EHS sites are promising locations for health literacy interventions regarding URI.

What do you tell parents when their child is sick with the common cold?

PURPOSE

To review research supporting the Food and Drug Administration's recommendation to relabel over-the-counter cough and cold medications (OTC CCMs), warning against use in young children.

CONCLUSIONS

Research has shown that the majority of OTC CCMs and antihistamines have little to no effect when used to treat the common cold and have a risky safety profile. Despite these findings, parents continue to use OTC CCMs for treatment of their children's colds.

PRACTICE IMPLICATIONS

Educating parents on the lack of scientific evidence supporting the use of OTC CCMs and the potential for harm is important in altering parental perception and decreasing the purchase of OTC CCMs.

Insurance status and the variable management of children presenting to the emergency department with bronchiolitis

OBJECTIVE

To determine if insurance type is associated with differences in the management of children presenting to the emergency department (ED) with bronchiolitis

METHODS

We analyzed data from a 30-center, prospective cohort study of children younger than 2 years with bronchiolitis presenting to the ED. Insurance status was defined as private, public, and no insurance.

RESULTS

Of 1450 patients, 473 (33%) had private, 928 (64%) had public, and 49 (3%) had no insurance. Multivariable analysis found that children with public insurance were less likely to receive inhaled β-agonists (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.50-0.92) or antibiotics (OR, 0.61; 95% CI, 0.42-0.89) the week before the ED visit. Children without insurance were less likely to have a primary care provider (OR, 0.15; 95% CI, 0.04-0.57) or receive laboratory testing in the ED (OR, 0.41; 95% CI, 0.19-0.88). The children's clinical presentation (eg, respiratory rate, oxygen saturation, and retractions) and ED treatments (eg, inhaled β-agonists, inhaled racemic epinephrine, systemic corticosteroids, and antibiotics) were similar. Likewise, hospital admission (multivariable OR 1.04; 95% CI, 0.45-2.42) was similar between insurance groups.

CONCLUSIONS

We noted some pre-ED and ED management differences across insurance types for children presenting to the ED with bronchiolitis. Although these variations may reflect treatments with unproven benefits, all children regardless of insurance should receive similar care. Despite these management variations, there were no differences in medications delivered in the ED or admission rate.

Predictors of flu vaccination among urban Hispanic children and adults

BACKGROUND

Flu vaccination is effective for preventing infection, but coverage levels in the USA remain low-especially among racial/ethnic minorities. This study examines factors associated with flu vaccination in a predominantly Hispanic community in Manhattan, New York.

METHODS

Households were recruited during the 2006-2007 and 2007-2008 flu seasons. Primary household respondents were interviewed to determine knowledge of flu transmission/treatment and vaccination status and demographic information for all household members.

RESULTS

Vaccination coverage was 47.3% among children <5, 39.3% among 5-17-year-olds, 15.3% among 18-49-year-olds, 31.0% among 50-64-year-olds and 37.1% among adults ≥65 in year 1; and 53.1% among children <5, 43.6% among 5-17-year-olds, 19.5% among 18-49-year-olds, 34.1% among 50-64-year-olds and 34.3% among adults ≥65 in year 2. For children, younger age, having a chronic respiratory condition (eg, asthma), and greater primary respondent knowledge of flu were positively associated with vaccination. Among adults, female gender, older age, higher education, greater primary respondent knowledge of flu, having been born in the USA and having a chronic respiratory condition were positively associated with vaccination. The most common reasons cited for not being vaccinated were the beliefs that flu vaccination was unnecessary or ineffective.

CONCLUSIONS

Possible methods for increasing vaccination levels in urban Hispanic communities include improving health literacy, making low-cost vaccination available and encouraging providers to use other office visits as opportunities to mention vaccination to patients.

REGISTRATION NUMBER

This study is registered at http://ClinicalTrials.gov (NCT00448981).

Impact of non-pharmaceutical interventions on URIs and influenza in crowded, urban households

OBJECTIVES

We compared the impact of three household interventions-education, education with alcohol-based hand sanitizer, and education with hand sanitizer and face masks-on incidence and secondary transmission of upper respiratory infections (URIs) and influenza, knowledge of transmission of URIs, and vaccination rates.

METHODS

A total of 509 primarily Hispanic households participated. Participants reported symptoms twice weekly, and nasal swabs were collected from those with an influenza-like illness (ILI). Households were followed for up to 19 months and home visits were made at least every two months.

RESULTS

We recorded 5034 URIs, of which 669 cases reported ILIs and 78 were laboratory-confirmed cases of influenza. Demographic factors significantly associated with infection rates included age, gender, birth location, education, and employment. The Hand Sanitizer group was significantly more likely to report that no household member had symptoms (p < 0.01), but there were no significant differences in rates of infection by intervention group in multivariate analyses. Knowledge improved significantly more in the Hand Sanitizer group (p < 0.0001). The proportion of households that reported > or = 50% of members receiving influenza vaccine increased during the study (p < 0.001). Despite the fact that compliance with mask wearing was poor, mask wearing as well as increased crowding, lower education levels of caretakers, and index cases 0-5 years of age (compared with adults) were associated with significantly lower secondary transmission rates (all p < 0.02).

CONCLUSIONS

In this population, there was no detectable additional benefit of hand sanitizer or face masks over targeted education on overall rates of URIs, but mask wearing was associated with reduced secondary transmission and should be encouraged during outbreak situations. During the study period, community concern about methicillin-resistant Staphylococcus aureus was occurring, perhaps contributing to the use of hand sanitizer in the Education control group, and diluting the intervention's measurable impact.

Stroke education: promising effects on the health beliefs of those at risk

BACKGROUND

The effect of patient education on reducing stroke has had mixed effects, raising questions about how to achieve optimal benefit. Because past evaluations have typically lacked an appropriate theoretical base, the design of past research may have missed important effects.

METHOD

This study used a social cognitive framework to identify variables that might change in response to education. A mixed design was used to evaluate two approaches to an intervention, both of which included education. Fifty seniors completed a measure of stroke knowledge and beliefs twice: before and after an intervention that was either standard (educational brochure plus activities that were not about stroke) or enhanced (educational brochure plus activities designed to enhance beliefs about stroke). Outcome measures were health beliefs, intention to exercise to reduce stroke, and stroke knowledge.

RESULTS

Selected beliefs changed significantly over time but not differentially across conditions. Beliefs that changed were (a) perceived susceptibility to stroke and (b) perceived benefit of exercise to reduce risk. Benefit beliefs, in particular, were strongly and positively associated with intention to exercise.

CONCLUSION

Findings suggest that basic approaches to patient education may influence health beliefs. More effective stroke prevention programs may result from continued consideration of the role of health beliefs in such programs.

Study on doctor shopping behavior: insight from patients with upper respiratory tract infection in Taiwan

OBJECTIVES

Based on the actual medical records of ambulatory care visits, this study analyzed patients' healthcare seeking behavior and doctor shopping behavior (DSB), and investigated the underlying factors and the impact on the depletion of the healthcare resources for health policy makers to build a better health delivery system.

METHODS

Among a cohort comprised of 200,000 patients randomly chosen from the National Health Insurance Research Database of Taiwan in 2004, only the patients seeking ambulatory care visits for upper respiratory tract infection (URI) were analyzed.

RESULTS

Among the 45,951 URI patients, 2875 of them exhibited DSB (prevalence 6.3%). The DSB showed a reverse U-shaped relationship with the patient age (the highest DSB in age 18-34 years). The episodes of the URI had a negative impact on the DSB. The odds ratios of gender and the frequency of consultation versus DSB were 1.10 and 4.72, respectively, and the depletion of days of medication and repeat prescription increased with doctor shopping.

CONCLUSIONS

Health education to raise DSB awareness is necessary, especially for female's age 18-34 years. Implementing a proper referral system with efficient data exchange, setting up control parameters in the IC cards, and strengthening the integrated care plan could reduce the unnecessary waste of the healthcare resources.

Impact of a health literacy intervention on pediatric emergency department use

OBJECTIVE

The aim of this study was to measure the impact of a simple parent health literacy intervention on emergency department and primary care clinic usage patterns.

METHODS

Study participants consisted of parents who brought their children to the Harbor-UCLA Medical Center pediatric emergency department for nonurgent complaints. Study participants filled out questionnaires regarding their management of children's mild health complaints and where respondents first seek help when their children become sick. After completing the questionnaires, participants were educated about how to use the health aid book What to Do When Your Child Gets Sick and provided a free copy. After 6 months, telephone follow-up interviews were conducted to assess whether the health literacy intervention had influenced the participants' management of their children's mild health complaints and their health care resource usage patterns.

RESULTS

One hundred thirteen parents were enrolled in the preintervention phase, and 61 were successfully interviewed at 6 months by telephone. Before and after comparisons demonstrated a 13% reduction in the percentage of respondents who stated they would go to the emergency department first if their child became sick. In addition, 30% fewer respondents reported actual visits to the emergency department in the previous 6 months. Regarding specific low-acuity scenarios, significantly fewer participants would take their child to the emergency department for a low-grade fever with a temperature of 99.5 degrees F and for vomiting for 1 day. There was no significant change in the proportion of parents who would take their child to the emergency department for earache or cough.

CONCLUSIONS

Health literacy interventions may reduce nonurgent emergency department visits and help mitigate emergency department overcrowding and the rising costs of health care.

Prospective study on antibiotics misuse among infants with upper respiratory infections

BACKGROUND

The judicious prescription of antibiotics has become a central focus of professional and public health measures to combat the spread of resistant organisms.

MATERIALS AND METHODS

A one-year multi-center prospective follow-up study of 1,320 healthy infants was conducted. The study aim was to determine the prevalence and identify the predictors of antibiotics misuse in viral respiratory illnesses among healthy infants in the first year of life. Infants born between August 2001 and February 2002 were recruited through the clinics and dispensaries of 117 pediatricians located in the Greater Beirut area of Lebanon. On each routine visit from birth until one year of life, pediatricians reported any episodes of upper respiratory tract infection (URTI; common cold) and bronchiolitis, as well as the treatment type, duration, and dose. Predictors that were considered included infant, maternal, and pediatrician characteristics.

RESULTS

Of the 1,320 recruited infants, 770 (58.3%) had common cold or acute bronchiolitis on at least one occasion during the study period. Pediatricians prescribed antibiotics at least once in 21.4% of cases diagnosed as the common cold and 45.5% of cases of acute bronchiolitis. Logistic regression analysis revealed that antibiotics misuse was more common among infants born to mothers with lower educational levels (odds ratio [OR] = 1.6; 95% confidence interval [CI]: 1.1-2.3). Furthermore, pediatricians tend to prescribe antibiotics in dispensaries more often than in private clinics (OR = 1.4; 95% CI: 1.0-2.3).

CONCLUSION

This study shows a substantial quantity of antibiotics prescriptions for common cold and acute bronchiolitis in our population. Our findings suggest that lower maternal education and pediatricians working in dispensaries (versus private clinics) are associated with increased antibiotics misuse.

Effect of intensive education on knowledge, attitudes, and practices regarding upper respiratory infections among urban Latinos

BACKGROUND

Although upper respiratory infections (URIs) take a major social and economic toll, little research has been conducted to assess the impact of educational interventions on knowledge, attitudes, and practices of community members regarding prevention and treatment of URIs, particularly among recently immigrated urban Latinos who may not be reached by the mainstream healthcare system.

OBJECTIVES

The objective of this study was to assess the impact of a culturally appropriate, home-based educational intervention on the knowledge, attitudes, and practices regarding prevention and treatment of URIs among urban Latinos.

METHODS

Using a pretest-posttest design, Spanish-language educational materials available from sources such as the Centers for Disease Control and Prevention were adapted based on feedback from community focus groups and provided to households during an in-person home visit every 2 months (generally three to four visits). Outcome data regarding knowledge, attitudes, and practices were collected in home-based interviews using an 85-item instrument adapted and pilot tested from three other validated instruments. Nonparametric and multiple linear regression analyses were used to summarize data and identify predictors of knowledge scores.

RESULTS

Four hundred twenty-two households had complete data at baseline and 6 months. Knowledge and attitude scores were improved significantly, and use of alcohol hand sanitizer and rates of influenza vaccine were increased significantly (all p <.01).

DISCUSSION

Although this home-based educational intervention was successful in improving knowledge, attitudes, and self-reported practices among urban Latinos regarding prevention and treatment of URIs, further research is needed to determine the cost-effectiveness of such a person-intensive intervention, the long-term outcomes, and whether less intensive interventions might be equally effective.

Recurrent respiratory infections

The child who has recurrent infections poses one of the most difficult diagnostic challenges in pediatrics. The clinician faces a two-fold challenge in determining first whether the child is normal or has a serious disease, and then, in the latter case, how to confirm or exclude the diagnosis with the minimum number of the least invasive tests. It is hoped that, in the absence of good-quality evidence for most clinical scenarios, the experience-based approach described in this article may prove a useful guide to the clinician.

Knowledge and reported use of antibiotics amongst immigrant ethnic groups in New Zealand

BACKGROUND

Over-use and misuse of antibiotics are major causes of antibiotic resistance. This study explored the understanding and reported use of antibiotics amongst three ethnic groups in New Zealand.

METHODS

Questionnaire survey of 300 Indian, Egyptian, and Korean people.

RESULTS

Most people (73.3%) knew that antibiotics killed bacteria, but other incorrect responses were also common. A range of medicines were mistakenly identified as antibiotics. Nearly half the sample (43.3%) believed colds and flu were caused by bacteria. Only 45.4% were sure that antibiotics were not useful for colds and flu. A minority of participants knew about antibiotic resistance. There were significant differences between groups, with Koreans having lower levels of understanding.

DISCUSSION

Interventions to improve use of antibiotics need to be pitched at a very basic level of knowledge, and need to be targeted towards particular ethnic groups, particularly those in whose home countries antibiotics are widely available without prescription.

Antibiotic use for emergency department patients with upper respiratory infections: prescribing practices, patient expectations, and patient satisfaction

STUDY OBJECTIVE

Physicians often prescribe antibiotics to patients even when there is no clear indication for their use. Previous studies examining antibiotic use in acute bronchitis and upper respiratory infections have been conducted in primary care settings. We evaluate the factors that physicians in the emergency department (ED) consider when prescribing antibiotics (eg, patient expectations) and the factors associated with patient satisfaction.

METHODS

Ten academic EDs enrolled adults and children presenting with symptoms consistent with upper respiratory infection. Enrolled patients were interviewed before their physician encounter and were reinterviewed before discharge and 2 weeks later. Physicians were interviewed about factors that influenced their management decisions, including their perceptions of patients' expectations. Patients with a single diagnosis of uncomplicated acute bronchitis or upper respiratory infection were included for analysis.

RESULTS

Of 272 patients enrolled, 68% of bronchitis patients and 9% of upper respiratory infection patients received antibiotics. Physicians were more likely to prescribe antibiotics when they believed that patients expected them (odds ratio [OR] 5.3; 95% confidence interval [CI] 2.9 to 9.6), although they were able to correctly identify only 27% of the patients who expected antibiotics. Satisfaction with the ED visit was reported by 87% of patients who received antibiotics and 89% of those not receiving antibiotics. Satisfaction with the visit was reported by 92% of patients who believed they had a better understanding of their illness but only by 72% of those who thought they had no better understanding (OR 4.4; 95% CI 2.0 to 8.4).

CONCLUSION

Physicians in our academic EDs prescribed antibiotics to 68% of acute bronchitis patients and to fewer than 10% of upper respiratory infection patients. Physicians were more likely to prescribe antibiotics to patients who they believed expected them, although they correctly identified only about 1 in 4 of those patients. Patient satisfaction was not related to receipt of antibiotics but was related to the belief they had a better understanding of their illness.

Warned, but not well armed: preventing viral upper respiratory infections in households

ABSTRACT The purpose of this state‐of‐the‐science review was to identify strategies and household‐level interventions for public health nurses to help prevent the acquisition and spread of viral upper respiratory infections (URI) in the community. Even though viral URI are a major global economic and social problem, surprisingly little research has been conducted to attempt to prevent them or reduce their transmission, probably because URI (with the exception of epidemic influenza) are generally considered to be mild and self‐limited. Based on the research to date, public health nurses can use several promising strategies for prevention: (a) provide more tailored educational messages regarding preventive strategies such as vaccination, hand hygiene, spatial separation of infected household members, avoidance of antibiotics to treat viral URI, and environmental cleaning (e.g., for toys or other shared items), which are delivered personally rather than passively (e.g., pamphlets placed in a waiting room); (b) use each patient encounter in any setting to encourage influenza vaccination for relevant risk groups; (c) encourage use of alcohol hand sanitizers by household members during the cold and flu season; and (d) provide opportunities for skill development for adult and child household members (e.g., cover your cough, when to seek care or an antibiotic).

Parental knowledge about antibiotic use: results of a cluster-randomized, multicommunity intervention

OBJECTIVE

The goal was to determine the impact of a community-wide educational intervention on parental misconceptions likely contributing to pediatric antibiotic overprescribing.

METHODS

We conducted a cluster-randomized trial of a 3-year, community-wide, educational intervention directed at parents of children < 6 years of age in 16 Massachusetts communities to improve parental antibiotic knowledge and attitudes and to decrease unnecessary prescribing. Parents in 8 intervention communities were mailed educational newsletters and exposed to educational materials during visits to local pediatric providers, pharmacies, and child care centers. We compared responses from mailed surveys in 2000 (before the intervention) and 2003 (after the intervention) for parents in intervention and control communities. Analyses were performed on the individual level, clustered according to community.

RESULTS

There were 1106 (46%) and 2071 (40%) respondents to the 2000 and 2003 surveys, respectively. Between 2000 and 2003, the proportion of parents who answered > or = 7 of 10 knowledge questions correctly increased significantly in both intervention (from 52% to 64%) and control (from 54% to 61%) communities. We did not detect a significant intervention impact on knowledge regarding appropriate antibiotic use in the population overall. In a subanalysis, we did observe a significant intervention effect among parents of Medicaid-insured children, who began with lower baseline knowledge scores.

CONCLUSIONS

Although knowledge regarding appropriate use of antibiotics is improving without additional targeted intervention among more socially advantaged populations, parents of Medicaid-insured children may benefit from educational interventions to promote judicious antibiotic use. These findings may have implications for other health education campaigns.

Minimal use of antibiotics for acute respiratory tract infections: validity and patient satisfaction

BACKGROUND

Antibiotics have been overused for acute respiratory tract infections (ARTIs) and the recent guidelines have emphasized limiting their use.

OBJECTIVE

To clarify the exact rate of antibiotic use and patient outcomes and satisfaction, under strict adherence to the guideline proposed by the American College of Physicians.

DESIGN

Prospective cohort observational study.

SETTING

Primary care clinics in Japan.

PATIENTS

783 patients diagnosed with ARTIs from October 2004 to April 2005, aged 15-64 and without any underlying disease.

MEASUREMENTS

Scores of symptoms and patient satisfaction at the 5th, 8th and 15th day of their initial visit, when treatment had been initiated according to that strategy.

RESULTS

In 691 non-influenza patients, comprising 554 (80%) cases of nonspecific upper respiratory tract infection (A), 11 (2%) of acute rhinosinusitis (B), 90 (13%) of acute pharyngitis (C) and 36 (5%) of acute bronchitis (D); the rates of antibiotic use were 5% [0.2%; (A), 9%; (B), 36%; (C), 3%; (D)] initially and 2% [2%; (A), 0%; (B), 1%; (C), 3%; (D)] subsequently. For the remaining 92 influenza patients, no antibiotics were prescribed, though oseltamivir was prescribed in 89 (97%). Within 7 days, more than 90% of all patients felt improved and expressed their satisfaction with the treatment. Furthermore, no patients needed emergency room visits or hospital admission.

LIMITATIONS

Only patients who gave informed consent were enrolled.

CONCLUSIONS

Adhering to the guideline, antibiotic use could be limited to only 5-7% of non-influenza ARTIs-mainly acute pharyngitis-without any problems and with a high degree of patient satisfaction.

A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home

OBJECTIVE

Good hand hygiene may reduce the spread of infections in families with children who are in out-of-home child care. Alcohol-based hand sanitizers rapidly kill viruses that are commonly associated with respiratory and gastrointestinal (GI) infections. The objective of this study was to determine whether a multifactorial campaign centered on increasing alcohol-based hand sanitizer use and hand-hygiene education reduces illness transmission in the home.

METHODS

A cluster randomized, controlled trial was conducted of homes of 292 families with children who were enrolled in out-of-home child care in 26 child care centers. Eligible families had > or =1 child who was 6 months to 5 years of age and in child care for > or =10 hours/week. Intervention families received a supply of hand sanitizer and biweekly hand-hygiene educational materials for 5 months; control families received only materials promoting good nutrition. Primary caregivers were phoned biweekly and reported respiratory and GI illnesses in family members. Respiratory and GI-illness-transmission rates (measured as secondary illnesses per susceptible person-month) were compared between groups, adjusting for demographic variables, hand-hygiene practices, and previous experience using hand sanitizers.

RESULTS

Baseline demographics were similar in the 2 groups. A total of 1802 respiratory illnesses occurred during the study; 443 (25%) were secondary illnesses. A total of 252 GI illnesses occurred during the study; 28 (11%) were secondary illnesses. The secondary GI-illness rate was significantly lower in intervention families compared with control families (incidence rate ratio [IRR]: 0.41; 95% confidence interval [CI]: 0.19-0.90). The overall rate of secondary respiratory illness was not significantly different between groups (IRR: 0.97; 95% CI: 0.72-1.30). However, families with higher sanitizer usage had a marginally lower secondary respiratory illness rate than those with less usage (IRR: 0.81; 95% CI: 0.65-1.09).

CONCLUSIONS

A multifactorial intervention emphasizing alcohol-based hand sanitizer use in the home reduced transmission of GI illnesses within families with children in child care. Hand sanitizers and multifaceted educational messages may have a role in improving hand-hygiene practices within the home setting.