Ruling out the need for antibiotics: are we sending the right message?

OBJECTIVES: To examine the relationships among physician-parent communication practices, physicians' perceptions of parental expectations for antibiotic treatment, and inappropriate antibiotic prescribing for viral upper respiratory tract infections. DESIGN: Cross-sectional study of pediatric encounters motivated by cold symptoms between October 1, 2000, and June 30, 2001. Each encounter was videotaped. Physicians completed a postvisit survey that measured whether they perceived the parent as expecting antibiotics. Coded communication variables were merged with survey variables. Multivariate analyses identified key predictors of parent-physician communication practices, physician perceptions of parents' expectations for antibiotics, and inappropriate antibiotic prescribing for viral conditions. SETTING: Twenty-seven pediatric practices in Los Angeles, Calif. PARTICIPANTS: Thirty-eight pediatricians and 522 consecutively approached parents of children with cold symptoms. MAIN OUTCOME MEASURES: Physicians' perceptions of parental expectations for antibiotics, inappropriate antibiotic prescribing, and parental questioning of nonantibiotic treatments. RESULTS: Physicians were 20.2% more likely to perceive parents as expecting antibiotics when they questioned the physician's treatment plan (P = .004; 95% confidence interval, 6.3%-34.0%). When physicians perceived parents as expecting antibiotics, they were 31.7% more likely to inappropriately prescribe them (P<.001; 95% confidence interval, 16.0%-47.3%). Parents were 24.0% more likely to question the treatment plan when the physician ruled out the need for antibiotics (P = .004; 95% confidence interval, 7.7%-40.3%). CONCLUSIONS: Parental questioning of the treatment plan increases physicians' perceptions that antibiotics are expected and thus increases inappropriate antibiotic prescribing. Treatment plans that focus on what can be done to make a child feel better, rather than on what is not needed, ie, antibiotics, may decrease inappropriate antibiotic prescribing.     

Incidence of acute otitis media and sinusitis complicating upper respiratory tract infection: the effect of age

Infants and young children are prone to developing upper respiratory tract infections, which often result in bacterial complications such as acute otitis media and sinusitis. We evaluated 623 upper respiratory tract infection episodes in 112 children (6-35 months of age) to determine the proportion of upper respiratory tract infection episodes that result in acute otitis media or sinusitis. Of all upper respiratory tract infections, 30% were complicated by acute otitis media and 8% were complicated by sinusitis. The rate of acute otitis media after upper respiratory tract infection declined with increasing age, whereas the rate of sinusitis after upper respiratory tract infection peaked in the second year of life. Risk for acute otitis media may be reduced substantially by avoiding frequent exposure to respiratory viruses (eg, avoidance of day care attendance) in the first year of life.     

Antibiotic prescribing for upper respiratory infections: European primary paediatricians' knowledge, attitudes and practice

Aim: Young children are the highest receivers of antibiotics in the European Union, with the majority of antibiotics given for children with minor upper respiratory infections (URIs). The study aims to examine paediatricians' reported views influencing community antibiotic prescribing. Methods: European primary care paediatricians and participants of the European Academy of Paediatrics Research in Ambulatory Setting Network were asked to complete a Web-based survey on knowledge, attitudes and practice of antibiotic prescribing for URIs. Results: The survey was completed by 685 respondents from 21 countries, 397 network participants (response rate 65%) and 288 paediatricians. Overall, 43.5% of respondents overestimated the risks associated with not prescribing antibiotics and the clinical benefit of antibiotics in otitis media and tonsillitis (strong believers in the benefits of antibiotics phenotype). Strong believers are also more likely to be high prescribers of antibiotics. Paediatricians from a low or medium European Surveillance of Antimicrobial Consumption country category prescribe less antibiotics than those from a higher category. Conclusion: There is a clear need for an educational intervention focused on European primary care paediatricians based on the risk-benefit analysis associated with the antibiotic prescribing for minor URIs, to reduce inappropriate prescribing.     

Effect of a conjugate pneumococcal vaccine on the occurrence of respiratory infections and antibiotic use in day-care center attendees

BACKGROUND: Incidence and severity of respiratory infections are increased in day-care center attendees. Streptococcus pneumoniae is an important contributor to these infections. OBJECTIVE: To examine whether the use of a pneumococcal conjugate vaccine could reduce the occurrence of respiratory infections and the ensuing antibiotic drug use in the day care. METHOD: In this double blind, randomized, controlled study performed in 8 day-care centers located in Beer-Sheva, Israel, 264 toddlers ages 12 to 35 months at enrollment were randomized to receive either a 9-valent conjugate pneumococcal vaccine (conjugated to CRM197) or a control vaccine [conjugate meningococcus C vaccine (conjugated to CRM197)] and were followed for an average of 22 months. The main outcome measures were respiratory morbidity and antibiotic use. RESULTS: An overall reduction of 7% in child months with > or = 1 reported illness episodes was observed among vaccinees (P = 0.008), and 85% of all episodes were related to the respiratory tract. Reductions of 15, 16 and 17% were observed in upper respiratory infections, lower respiratory problems and otitis media, respectively. An overall reduction of 17% in antibiotic days was observed [10% for upper respiratory infections, 20% for otitis and 47% for lower respiratory problems (P < or = 0.005 for each entity)]. The reduction in episodes and antibiotic use was greater for those <36 months of age than for the older children. CONCLUSION: The reduction of respiratory problems, including those not traditionally considered of pneumococcal origin and the ensuing lowered antibiotic use in day-care center attendees by pneumococcal conjugate vaccination suggest a broader benefit from the vaccine than preventing invasive disease only.     

Otitis media-related antibiotic prescribing patterns, outcomes, and expenditures in a pediatric medicaid population

BACKGROUND: Treatment of otitis media is the most frequent reason for administering antibiotics to children in the United States. However, only limited data are available on medical effectiveness of antibiotic prescribing patterns for otitis media and their associated expenditures or the factors that influence antibiotic prescribing. METHODS: The study population consisted of 131 169 children during 1991 and 157 065 children during 1992 who were 相似文献   

Cefprozil : A Review

Cefprozil is a novel third generation, broad-spectrum oral cephalosporin with activity against a spectrum of aerobic gram-negative and positive bacteria, as well as certain anaerobes. The beta-lactamase stability of cefprozil may exceed that of other oral cephalosporins for some important pathogens. Cefprozil may be a suitable alternative to several other commonly used beta-lactams and cephalosporins in the treatment of mild to moderate upper and lower respiratory tract infections including sinusitis, otitis media, pharyngitis/tonsillitis, secondary bacterial infection of acute bronchitis, and acute bacterial exacerbations of chronic bronchitis, and skin and skin structure infections in children. Available data indicate the safety of cefprozil in both pediatric and adult population.     

Upper respiratory tract infections

Acute respiratory infections accounts for 20–40% of outpatient and 12–35% of inpatient attendance in a general hospital. Upper respiratory tract infections including nasopharyngitis, pharyngitis, tonsillitis and otitis media constitute 87.5% of the total episodes of respiratory infections. The vast majority of acute upper respiratory tract infections are caused by viruses. Common cold is caused by viruses in most circumstances and does not require antimicrobial agent unless it is complicated by acute otitis media with effusion, tonsillitis, sinusitis, and lower respiratory tract infection. Sinusitis is commonly associated with common cold. Most instances of rhinosinusitis are viral and therefore, resolve spontaneously without antimicrobial therapy. The most common bacterial agents causing sinusitis areS. pneumoniae, H. influenzae, M. catarrhalis,S. aureus andS. pyogenes. Amoxycillin is antibacterial of choice. The alternative drugs are cefaclor or cephalexin. The latter becomes first line if sinusitis is recurrent or chronic. Acute pharyngitis is commonly caused by viruses and does not need antibiotics. About 15% of the episodes may be due to Group A beta hemolytic streptococcus (GABS). Early initiation of antibiotics in pharyngitis due to GABS can prevent complications such as acute rheumatic fever. The drug of choice is penicillin for 10–14 days. The alternative medications include oral cephalosporins (cefaclor, cephalexin), amoxicillin or macrolides.     

Correlates of parental antibiotic knowledge, demand, and reported use.

BACKGROUND: Clinicians cite parental misconceptions and requests for antibiotics as reasons for inappropriate prescribing. AIMS: To identify misconceptions regarding antibiotics and predictors of parental demand for antibiotics and to determine if parental knowledge and attitudes are associated with use. METHODS: Survey of parents in 16 Massachusetts communities. Domains included antibiotic-related knowledge, attitudes about antibiotics, antibiotic use during a 12-month period, demographics, and access to health information. Bivariate and multivariate analyses evaluated predictors of knowledge and proclivity to demand antibiotics. A multivariate model evaluated the associations of knowledge, demand, and demographic factors with parent-reported antibiotic use. RESULTS: A total of 1106 surveys were returned (response rates: 54% and 32% for commercially-insured and Medicaid-insured families). Misconceptions were common regarding bronchitis (92%) and green nasal discharge (78%). Two hundred sixty-five (24%) gave responses suggesting a proclivity to demand antibiotics. Antibiotic knowledge was associated with increased parental age and education, having more than 1 child, white race, and receipt of media information on resistance. Factors associated with a proclivity to demand antibiotics included decreased knowledge, pressure from day-care settings, lack of alternatives offered by clinicians, and lack of access to media information. Among all respondents, reported antibiotic use was associated with younger child age and day-care attendance. Among Medicaid-insured children only, less antibiotic knowledge and tendency to demand antibiotics were associated with higher rates of antibiotic use. CONCLUSIONS: Misconceptions regarding antibiotic use are widespread and potentially modifiable by clinicians and media sources. Particular attention should be paid to Medicaid-insured patients in whom such misconceptions may contribute to inappropriate prescribing.     

Upper respiratory tract infections in young children: duration of and frequency of complications

This study was performed to determine the usual duration of community-acquired viral upper respiratory tract infections and the incidence of complications (otitis media/sinusitis) of these respiratory tract infections in infancy and early childhood. Children in various forms of child-care arrangements (home care, group care, and day care) were enrolled at birth and observed for 3 years. Families were telephoned every 2 weeks to record on a standardized form the type and severity of illnesses experienced during the previous interval. Only children remaining in their original child-care group for the entire study period were compared. The mean duration of an upper respiratory tract infection varied between 6.6 days (for 1- to 2-year-old children in home care) and 8.9 days (for children younger than 1 year in day care). The percentage of apparently simple upper respiratory tract infections that lasted more than 15 days ranged from 6.5% (for 1- to 3-year-old children in home care) to 13.1% (for 2- to 3-year-old children in day care). Children in day care were more likely than children in home care to have protracted respiratory symptoms. Of 2741 respiratory tract infections recorded for the 3-year period, 801 (29.2%) were complicated by otitis media. During the first 2 years of life, children in any type of day care were more likely than children in home care to have otitis media as a complication of upper respiratory tract infection. In year 3, the risk of otitis media was similar in all types of child care.     

Measuring the quality of antibiotic prescribing for upper respiratory infections and bronchitis in 5 US health plans

OBJECTIVE: To develop and test the validity of a quality-of-care performance measure that examines antibiotic prescribing rates in children diagnosed as having upper respiratory infection (URI) or bronchitis. DESIGN AND METHODS: The measure developed examines the annual rate of antibiotic prescribing to children aged 3 months to 18 years with an episode of URI or bronchitis. Administrative data from 5 US health plans were used to identify episodes of URI or bronchitis using International Classification of Diseases, Ninth Revision, codes 460, 465, 466, and 490. Pharmacy data (National Drug Codes) were used to determine whether antibiotics were prescribed for the URI or bronchitis episode. Medical record abstractions were performed on a random sample of 465 cases to assess percentage agreement with pharmacy claims data for antibiotic prescribing. RESULTS: For the 84,166 children and adolescents aged 3 months to 18 years who had at least 1 episode of URI or bronchitis during the measurement year, 31% received antibiotics. Prescribing rates for URI and/or bronchitis varied widely among the 5 participating health plans (2%-75%; P < .001). Inappropriate antibiotic prescribing occurred most frequently for bronchitis episodes, with 4 of 5 health plans prescribing antibiotics in 60% of such cases (range, 60%-80%). Percentage agreement between administrative and medical records data for antibiotic prescribing was 88%. CONCLUSIONS: This quality measure is feasible to implement at the health plan level and validly assesses antibiotic prescribing rates using administrative data. Improvements in adhering to judicious use guidelines for antibiotic prescribing in children with URI and bronchitis are warranted.     

New cephalosporins

During the past 10 years, very few new cephalosporins have been introduced for pediatric use. Cefepime is a fourth-generation cephalosporin used for parenteral treatment of serious infections. Cefepime has enhanced activity against gram-negative enterics that often are resistant to multiple antibiotics, including those producing extended-spectrum β-lactamases or hyperproducing AmpC enzymes, and it retains good activity against gram-positive cocci. Cefepime is useful for treating nosocomial infections caused by multiresistant gram-negative enterics and has advantages over ceftazidime for empirical treatment of the febrile neutropenic child with cancer. Cefdinir is an extended-spectrum oral cephalosporin that has activity against organisms associated with upper respiratory tract infections comparable with that of cefuroxime or cefpodoxime. Cefdinir suspension is well tolerated by children and as a single daily dose is equivalent to amoxicillin-clavulanate for treating acute otitis media in children. Cefdinir is the oral cephalosporin to consider as second-line therapy for treatment of acute otitis media or acute bacterial sinusitis for children who are unresponsive to or intolerant of amoxicillin-clavulanate. Copyright © 2001 by W.B. Saunders Company