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States failing at tobacco control
When it comes to tobacco control, state and the federal governments are falling far short of what is needed to oversee and enact tobacco prevention policies and programs, for the third year in a row, according to the American Lung Association’s 11th annual State of Tobacco Control report.
"We are faced with a deep-pocketed, ever-evolving tobacco industry that’s determined to maintain its market share at the expense of our kids and current smokers," according to Paul G. Billings, American Lung Association senior vice president for advocacy and education. "State and federal policymakers must battle a changing Big Tobacco and step up to fund programs and enact policies proven to reduce tobacco use," according to the 158-page report, which is presented on an interactive Web page, with infographics and easy to browse drop-down menus.
The report, which tracks annual progress on tobacco control policies at the federal and state level, criticizes the Food and Drug Administration for not exercising its authority, and for not regulating various tobacco products, allowing for proliferation of a new generation of tobacco products aimed at youth.
The states’ inaction includes failure to invest the money from taxes and tobacco settlement payments into tobacco prevention programs, according to the report. The payments totaled close to $26 billion in 2012. The Centers for Disease Control and Prevention recommends that states spend a total of $3.7 billion to control tobacco use each year, but the states spent only $460 million, according to the American Lung Association analysis. Delaware, North Dakota, and Wyoming were the only states that did not receive a D or F (D for spending 50-59% of the CDC level, and F for less than 50%).
The only major tobacco prevention effort in 2012, according to the report, was the CDC’s "Tips From Former Smokers" advertising campaign, which cost $54 million. "We need more campaigns like this from the federal government," said Mr. Billings.
The report also followed the money, showing that during the 2011-2012 election cycle, candidates for state offices accepted $53.4 million from the tobacco industry. The industry also contributed more than $3.7 million to congressional and presidential candidates.
"It’s no wonder we’re losing ground in the fight to end tobacco-caused death and disease," said Mr. Billings. "Elected officials are getting cozy with Big Tobacco."
Smoking costs Americans $200 billion each year in health care costs and lost productivity.
On Twitter @NaseemSMiller
When it comes to tobacco control, state and the federal governments are falling far short of what is needed to oversee and enact tobacco prevention policies and programs, for the third year in a row, according to the American Lung Association’s 11th annual State of Tobacco Control report.
"We are faced with a deep-pocketed, ever-evolving tobacco industry that’s determined to maintain its market share at the expense of our kids and current smokers," according to Paul G. Billings, American Lung Association senior vice president for advocacy and education. "State and federal policymakers must battle a changing Big Tobacco and step up to fund programs and enact policies proven to reduce tobacco use," according to the 158-page report, which is presented on an interactive Web page, with infographics and easy to browse drop-down menus.
The report, which tracks annual progress on tobacco control policies at the federal and state level, criticizes the Food and Drug Administration for not exercising its authority, and for not regulating various tobacco products, allowing for proliferation of a new generation of tobacco products aimed at youth.
The states’ inaction includes failure to invest the money from taxes and tobacco settlement payments into tobacco prevention programs, according to the report. The payments totaled close to $26 billion in 2012. The Centers for Disease Control and Prevention recommends that states spend a total of $3.7 billion to control tobacco use each year, but the states spent only $460 million, according to the American Lung Association analysis. Delaware, North Dakota, and Wyoming were the only states that did not receive a D or F (D for spending 50-59% of the CDC level, and F for less than 50%).
The only major tobacco prevention effort in 2012, according to the report, was the CDC’s "Tips From Former Smokers" advertising campaign, which cost $54 million. "We need more campaigns like this from the federal government," said Mr. Billings.
The report also followed the money, showing that during the 2011-2012 election cycle, candidates for state offices accepted $53.4 million from the tobacco industry. The industry also contributed more than $3.7 million to congressional and presidential candidates.
"It’s no wonder we’re losing ground in the fight to end tobacco-caused death and disease," said Mr. Billings. "Elected officials are getting cozy with Big Tobacco."
Smoking costs Americans $200 billion each year in health care costs and lost productivity.
On Twitter @NaseemSMiller
When it comes to tobacco control, state and the federal governments are falling far short of what is needed to oversee and enact tobacco prevention policies and programs, for the third year in a row, according to the American Lung Association’s 11th annual State of Tobacco Control report.
"We are faced with a deep-pocketed, ever-evolving tobacco industry that’s determined to maintain its market share at the expense of our kids and current smokers," according to Paul G. Billings, American Lung Association senior vice president for advocacy and education. "State and federal policymakers must battle a changing Big Tobacco and step up to fund programs and enact policies proven to reduce tobacco use," according to the 158-page report, which is presented on an interactive Web page, with infographics and easy to browse drop-down menus.
The report, which tracks annual progress on tobacco control policies at the federal and state level, criticizes the Food and Drug Administration for not exercising its authority, and for not regulating various tobacco products, allowing for proliferation of a new generation of tobacco products aimed at youth.
The states’ inaction includes failure to invest the money from taxes and tobacco settlement payments into tobacco prevention programs, according to the report. The payments totaled close to $26 billion in 2012. The Centers for Disease Control and Prevention recommends that states spend a total of $3.7 billion to control tobacco use each year, but the states spent only $460 million, according to the American Lung Association analysis. Delaware, North Dakota, and Wyoming were the only states that did not receive a D or F (D for spending 50-59% of the CDC level, and F for less than 50%).
The only major tobacco prevention effort in 2012, according to the report, was the CDC’s "Tips From Former Smokers" advertising campaign, which cost $54 million. "We need more campaigns like this from the federal government," said Mr. Billings.
The report also followed the money, showing that during the 2011-2012 election cycle, candidates for state offices accepted $53.4 million from the tobacco industry. The industry also contributed more than $3.7 million to congressional and presidential candidates.
"It’s no wonder we’re losing ground in the fight to end tobacco-caused death and disease," said Mr. Billings. "Elected officials are getting cozy with Big Tobacco."
Smoking costs Americans $200 billion each year in health care costs and lost productivity.
On Twitter @NaseemSMiller
ACS weighs in on CT screens for lung cancer
Low-dose CT scans were endorsed for lung cancer screening in select high-risk individuals in guidelines from the American Cancer Society.
"Clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with patients aged 55 years to 74 years who have at least a 30–pack-year smoking history, currently smoke, or have quit within the past 15 years, and who are in relatively good health," wrote Dr. Richard Wender and the members of the guidelines committee in an article published online in CA: A Cancer Journal for Clinicians (doi: 10.3322/caac.21172).
The recommendations are centered on the eligibility criteria used in the NLST (National Lung Screening Trial). Because of the uncertainty regarding the balance of benefits and harms, low-dose CT screening is not recommended for individuals at younger or older ages, with less lifetime exposure to tobacco smoke, and with sufficiently severe lung damage to require oxygen. The guideline writers acknowledge that clinicians will need to rely on their best judgment in cases when risk seems to approximate or exceed the NLST eligibility criteria in one category but not in another.
Since few government or private insurance programs provide coverage for the initial low-dose CT for lung cancer screening, "clinicians who decide to offer screening bear the responsibility of helping patients determine if they will have to pay for the initial test themselves and to help the patient know how much they will have to pay," according to the guideline writers. "In light of the firm evidence that screening high-risk individuals can substantially reduce death rates from lung cancer, both private and public health care insurers should expand coverage to include the cost of annual (low-dose CT) screening for lung cancer in appropriate high-risk individuals."
The "meaningful use" criteria for electronic health records under the recent HITECH (Health Information Technology for Economic and Clinical Health) Act are likely to improve identification of patients eligible for this screening as clinicians are required to determine the smoking status of more than 50% of their patients who are aged 13 years or older and to track the percentage of patients aged 10 years and older who are current smokers, according to Dr. Wender, chair of the department of family and community medicine, Jefferson Medical College, Philadelphia, and the other guideline writers.
While low-dose CT screening has been shown to substantially reduce the risk of dying of lung cancer, the technology will not detect all lung cancers or all lung cancers in early enough stages to avoid death from lung cancer. Further, a false-positive finding runs the risk of prompting an invasive procedure for incidental findings. The guidelines also warn that current smokers should not view screening as a substitute for smoking cessation. Counseling is recommended for current smokers, and all patients eligible for annual screening should make the decision only if they are willing to accept the risks and costs of annual screening until they reach age 74 years.
The guidelines also note that chest x-rays should not be used for lung cancer screening.
Wherever possible, screening should be performed as part of an organized program at an institution with expertise in low-dose CT screening and a multidisciplinary team skilled in the evaluation, diagnosis, and treatment of abnormal lung lesions. When those options are available but patients strongly wish to be screened, they should be referred to a center that performs a reasonably high volume of lung CT scans, diagnostic tests, and lung cancer surgeries. Otherwise, "the risks of cancer screening may be substantially higher than the observed risks associated with screening in the NLST, and screening is not recommended."
Multiple members of the guideline committee had financial disclosures related to drug manufacturers. The single committee member with ties to a device manufacturer declared his work was not directly related to the article.
On Twitter @maryjodales
Low-dose CT scans were endorsed for lung cancer screening in select high-risk individuals in guidelines from the American Cancer Society.
"Clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with patients aged 55 years to 74 years who have at least a 30–pack-year smoking history, currently smoke, or have quit within the past 15 years, and who are in relatively good health," wrote Dr. Richard Wender and the members of the guidelines committee in an article published online in CA: A Cancer Journal for Clinicians (doi: 10.3322/caac.21172).
The recommendations are centered on the eligibility criteria used in the NLST (National Lung Screening Trial). Because of the uncertainty regarding the balance of benefits and harms, low-dose CT screening is not recommended for individuals at younger or older ages, with less lifetime exposure to tobacco smoke, and with sufficiently severe lung damage to require oxygen. The guideline writers acknowledge that clinicians will need to rely on their best judgment in cases when risk seems to approximate or exceed the NLST eligibility criteria in one category but not in another.
Since few government or private insurance programs provide coverage for the initial low-dose CT for lung cancer screening, "clinicians who decide to offer screening bear the responsibility of helping patients determine if they will have to pay for the initial test themselves and to help the patient know how much they will have to pay," according to the guideline writers. "In light of the firm evidence that screening high-risk individuals can substantially reduce death rates from lung cancer, both private and public health care insurers should expand coverage to include the cost of annual (low-dose CT) screening for lung cancer in appropriate high-risk individuals."
The "meaningful use" criteria for electronic health records under the recent HITECH (Health Information Technology for Economic and Clinical Health) Act are likely to improve identification of patients eligible for this screening as clinicians are required to determine the smoking status of more than 50% of their patients who are aged 13 years or older and to track the percentage of patients aged 10 years and older who are current smokers, according to Dr. Wender, chair of the department of family and community medicine, Jefferson Medical College, Philadelphia, and the other guideline writers.
While low-dose CT screening has been shown to substantially reduce the risk of dying of lung cancer, the technology will not detect all lung cancers or all lung cancers in early enough stages to avoid death from lung cancer. Further, a false-positive finding runs the risk of prompting an invasive procedure for incidental findings. The guidelines also warn that current smokers should not view screening as a substitute for smoking cessation. Counseling is recommended for current smokers, and all patients eligible for annual screening should make the decision only if they are willing to accept the risks and costs of annual screening until they reach age 74 years.
The guidelines also note that chest x-rays should not be used for lung cancer screening.
Wherever possible, screening should be performed as part of an organized program at an institution with expertise in low-dose CT screening and a multidisciplinary team skilled in the evaluation, diagnosis, and treatment of abnormal lung lesions. When those options are available but patients strongly wish to be screened, they should be referred to a center that performs a reasonably high volume of lung CT scans, diagnostic tests, and lung cancer surgeries. Otherwise, "the risks of cancer screening may be substantially higher than the observed risks associated with screening in the NLST, and screening is not recommended."
Multiple members of the guideline committee had financial disclosures related to drug manufacturers. The single committee member with ties to a device manufacturer declared his work was not directly related to the article.
On Twitter @maryjodales
Low-dose CT scans were endorsed for lung cancer screening in select high-risk individuals in guidelines from the American Cancer Society.
"Clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with patients aged 55 years to 74 years who have at least a 30–pack-year smoking history, currently smoke, or have quit within the past 15 years, and who are in relatively good health," wrote Dr. Richard Wender and the members of the guidelines committee in an article published online in CA: A Cancer Journal for Clinicians (doi: 10.3322/caac.21172).
The recommendations are centered on the eligibility criteria used in the NLST (National Lung Screening Trial). Because of the uncertainty regarding the balance of benefits and harms, low-dose CT screening is not recommended for individuals at younger or older ages, with less lifetime exposure to tobacco smoke, and with sufficiently severe lung damage to require oxygen. The guideline writers acknowledge that clinicians will need to rely on their best judgment in cases when risk seems to approximate or exceed the NLST eligibility criteria in one category but not in another.
Since few government or private insurance programs provide coverage for the initial low-dose CT for lung cancer screening, "clinicians who decide to offer screening bear the responsibility of helping patients determine if they will have to pay for the initial test themselves and to help the patient know how much they will have to pay," according to the guideline writers. "In light of the firm evidence that screening high-risk individuals can substantially reduce death rates from lung cancer, both private and public health care insurers should expand coverage to include the cost of annual (low-dose CT) screening for lung cancer in appropriate high-risk individuals."
The "meaningful use" criteria for electronic health records under the recent HITECH (Health Information Technology for Economic and Clinical Health) Act are likely to improve identification of patients eligible for this screening as clinicians are required to determine the smoking status of more than 50% of their patients who are aged 13 years or older and to track the percentage of patients aged 10 years and older who are current smokers, according to Dr. Wender, chair of the department of family and community medicine, Jefferson Medical College, Philadelphia, and the other guideline writers.
While low-dose CT screening has been shown to substantially reduce the risk of dying of lung cancer, the technology will not detect all lung cancers or all lung cancers in early enough stages to avoid death from lung cancer. Further, a false-positive finding runs the risk of prompting an invasive procedure for incidental findings. The guidelines also warn that current smokers should not view screening as a substitute for smoking cessation. Counseling is recommended for current smokers, and all patients eligible for annual screening should make the decision only if they are willing to accept the risks and costs of annual screening until they reach age 74 years.
The guidelines also note that chest x-rays should not be used for lung cancer screening.
Wherever possible, screening should be performed as part of an organized program at an institution with expertise in low-dose CT screening and a multidisciplinary team skilled in the evaluation, diagnosis, and treatment of abnormal lung lesions. When those options are available but patients strongly wish to be screened, they should be referred to a center that performs a reasonably high volume of lung CT scans, diagnostic tests, and lung cancer surgeries. Otherwise, "the risks of cancer screening may be substantially higher than the observed risks associated with screening in the NLST, and screening is not recommended."
Multiple members of the guideline committee had financial disclosures related to drug manufacturers. The single committee member with ties to a device manufacturer declared his work was not directly related to the article.
On Twitter @maryjodales
FROM CA, A CANCER JOURNAL FOR CLINICIANS
FDA approves first flu shot made without eggs
A new trivalent influenza vaccine approved by the Food and Drug Administration Jan. 16 is the first to be made without eggs.
Instead, Flublok’s manufacturer, Protein Sciences Corp. of Meriden, Conn., uses the expression system of baculovirus (an insect virus) and recombinant DNA.
"The new technology offers the potential for faster start-up of the vaccine manufacturing process in the event of a pandemic, because it is not dependent on an egg supply or on availability of the influenza virus," Dr. Karen Midthun, director of the FDA’s Center for Biologics Evaluation and Research, said in a statement.
The vaccine is indicated for the prevention of seasonal influenza in people aged 18-49 years. It proved 44.6% effective against all circulating influenza strains, not just the three it contains, when tested in about 2,300 people against placebo shots in about the same number.
Side effects were similar to those for egg-based flu vaccines and included injection-site pain, headache, fatigue, and muscle aches. Flublok has a shelf life of 16 weeks, the agency noted, and its manufacturing technique is already in use for other approved vaccines.
Flublok contains full-length, recombinant hemagglutinin proteins against H1N1 and H3N2 influenza A strains and one influenza B strain.
A new trivalent influenza vaccine approved by the Food and Drug Administration Jan. 16 is the first to be made without eggs.
Instead, Flublok’s manufacturer, Protein Sciences Corp. of Meriden, Conn., uses the expression system of baculovirus (an insect virus) and recombinant DNA.
"The new technology offers the potential for faster start-up of the vaccine manufacturing process in the event of a pandemic, because it is not dependent on an egg supply or on availability of the influenza virus," Dr. Karen Midthun, director of the FDA’s Center for Biologics Evaluation and Research, said in a statement.
The vaccine is indicated for the prevention of seasonal influenza in people aged 18-49 years. It proved 44.6% effective against all circulating influenza strains, not just the three it contains, when tested in about 2,300 people against placebo shots in about the same number.
Side effects were similar to those for egg-based flu vaccines and included injection-site pain, headache, fatigue, and muscle aches. Flublok has a shelf life of 16 weeks, the agency noted, and its manufacturing technique is already in use for other approved vaccines.
Flublok contains full-length, recombinant hemagglutinin proteins against H1N1 and H3N2 influenza A strains and one influenza B strain.
A new trivalent influenza vaccine approved by the Food and Drug Administration Jan. 16 is the first to be made without eggs.
Instead, Flublok’s manufacturer, Protein Sciences Corp. of Meriden, Conn., uses the expression system of baculovirus (an insect virus) and recombinant DNA.
"The new technology offers the potential for faster start-up of the vaccine manufacturing process in the event of a pandemic, because it is not dependent on an egg supply or on availability of the influenza virus," Dr. Karen Midthun, director of the FDA’s Center for Biologics Evaluation and Research, said in a statement.
The vaccine is indicated for the prevention of seasonal influenza in people aged 18-49 years. It proved 44.6% effective against all circulating influenza strains, not just the three it contains, when tested in about 2,300 people against placebo shots in about the same number.
Side effects were similar to those for egg-based flu vaccines and included injection-site pain, headache, fatigue, and muscle aches. Flublok has a shelf life of 16 weeks, the agency noted, and its manufacturing technique is already in use for other approved vaccines.
Flublok contains full-length, recombinant hemagglutinin proteins against H1N1 and H3N2 influenza A strains and one influenza B strain.
Algorithm sliced antibiotics Rx in acute bronchitis
A decision-support algorithm to help primary care physicians assess adolescents and adults with uncomplicated acute bronchitis reduced unnecessary antibiotic use by about 10%, according to a report published online Jan. 14 in JAMA Internal Medicine.
Plus, printed and computer-assisted approaches alike decreased the overuse of antibiotic treatment in primary care practices, said Dr. Ralph Gonzales of the departments of medicine and epidemiology and biostatistics, University of California, San Francisco, and his associates (JAMA Intern. Med. 2013 Jan. 14 [doi:10.1001/jamainternmed.2013.1589]).
Reduced antibiotic use did not result in a significant increase in return visits to either the study’s primary care practices or a hospital, the researchers noted. So it appears that there was no appreciable increase in the adverse clinical consequences of withholding antibiotics, such as a rise in the incidence of pneumonia.
"In aggregate, these findings support the wider dissemination and use of this clinical algorithm to help reduce the overuse of antibiotics for acute bronchitis in primary care," the investigators said.
Dr. Gonzales and his colleagues tested the algorithm in a randomized, controlled trial involving 33 primary care practices from Geisinger Health System in rural and semirural central and northeastern Pennsylvania.
In addition to patient education materials, the decision-support algorithm included clinician education materials, such as:
– Prompts for taking an appropriate history and physical examination of all patients presenting with cough illness.
– A way to calculate a patient’s probability of having pneumonia.
– A list of relevant testing and treatment options for bronchitis.
– Feedback on the clinicians’ performance in appropriately prescribing antibiotics.
Eleven primary care practices were randomly assigned to use a printed version of the decision-support algorithm, 11 to use a computerized version, and 11 to serve as control practices where no decision-support algorithm was implemented.
The study included all of the practices’ board-certified internal medicine and family practice physicians, nurse practitioners, physician assistants, and registered nurses. The patient population comprised all adolescents and adults aged 13-64 years who presented with uncomplicated acute bronchitis during a single winter-season intervention period.
The data from these 6,242 patient cases were compared with those of 9,808 cases that occurred during the three winter seasons preceding implementation of the decision-support algorithm.
The number of visits for acute respiratory infections and the proportion diagnosed as uncomplicated acute bronchitis remained stable over time and across the study sites.
Compared with the preintervention period, the percentage of patients who were prescribed antibiotics during the intervention period decreased by 11.7% (from 80.0% to 68.3%) in practices using the print algorithm, and by 13.3% (from 74.0% to 60.7%) in practices using the computerized algorithm.
Those declines were significantly greater than the change in antibiotic prescribing seen in the control practices, where clinicians actually increased the use of antibiotics by 1.8%, from 72.5% to 74.3%, Dr. Gonzales and his associates said.
The percentage of patients who were not given antibiotics and who subsequently developed pneumonia requiring return visits remained "low" in all practices at all time periods, ranging from 0.5% to 1.5%.
The study results indicate that both conventional (printed) and computerized strategies for decision support are effective at reducing unwarranted use of antibiotics in uncomplicated acute bronchitis, the investigators said.
However, the findings may not be applicable in all settings, the researchers cautioned, because the study included only small- to medium-sized primary care practices within an integrated health care system in a rural and semirural region.
In addition, the study could not establish whether the declines in inappropriate prescription of antibiotics were due to the patient education component, the clinician education component, some other component, or simply to all clinicians’ knowledge that they were being monitored, the researchers said.
The Centers for Disease Control and Prevention supported the study. Dr. Gonzales reported ties to Phreesia, and an associate reported ties to Merck.
The antibiotic prescribing rate declined in this study, but only by 10%. The rate should have been zero, but it remained at 60%-70% – hardly a success, said Dr. Jeffrey A. Linder.
"We should not be satisfied with interventions that reduce the acute bronchitis prescribing rate to 60%. We should demand better for our patients," he said. "Success is not reducing the antibiotic prescribing rate by 10%; success is reducing the antibiotic prescribing rate to 10%."
Dr. Linder is with the division of general medicine and primary care at Brigham and Women’s Hospital and Harvard Medical School, Boston. His work on acute respiratory infection is supported by the National Institutes of Health, the National Institute of Allergy and Infectious Diseases, and the Agency for Healthcare Research and Quality. He reported no financial conflicts of interest. These remarks were taken from his invited commentary accompanying Dr. Gonzales’ report (JAMA Intern. Med. 2013 Jan. 14 [doi:10.1001;jamainternmed.2013.1984]).
Plus, printed and computer-assisted approaches alike decreased the overuse of antibiotic treatment in primary care practices, said Dr. Ralph Gonzales of the departments of medicine and epidemiology and biostatistics, University of California, San Francisco, and his associates (JAMA Intern. Med. 2013 Jan. 14 [doi:10.1001/jamainternmed.2013.1589]).
Reduced antibiotic use did not result in a significant increase in return visits to either the study’s primary care practices or a hospital, the researchers noted. So it appears that there was no appreciable increase in the adverse clinical consequences of withholding antibiotics, such as a rise in the incidence of pneumonia.
"In aggregate, these findings support the wider dissemination and use of this clinical algorithm to help reduce the overuse of antibiotics for acute bronchitis in primary care," the investigators said.
Dr. Gonzales and his colleagues tested the algorithm in a randomized, controlled trial involving 33 primary care practices from Geisinger Health System in rural and semirural central and northeastern Pennsylvania.
In addition to patient education materials, the decision-support algorithm included clinician education materials, such as:
– Prompts for taking an appropriate history and physical examination of all patients presenting with cough illness.
– A way to calculate a patient’s probability of having pneumonia.
– A list of relevant testing and treatment options for bronch
The antibiotic prescribing rate declined in this study, but only by 10%. The rate should have been zero, but it remained at 60%-70% – hardly a success, said Dr. Jeffrey A. Linder.
"We should not be satisfied with interventions that reduce the acute bronchitis prescribing rate to 60%. We should demand better for our patients," he said. "Success is not reducing the antibiotic prescribing rate by 10%; success is reducing the antibiotic prescribing rate to 10%."
Dr. Linder is with the division of general medicine and primary care at Brigham and Women’s Hospital and Harvard Medical School, Boston. His work on acute respiratory infection is supported by the National Institutes of Health, the National Institute of Allergy and Infectious Diseases, and the Agency for Healthcare Research and Quality. He reported no financial conflicts of interest. These remarks were taken from his invited commentary accompanying Dr. Gonzales’ report (JAMA Intern. Med. 2013 Jan. 14 [doi:10.1001;jamainternmed.2013.1984]).
The antibiotic prescribing rate declined in this study, but only by 10%. The rate should have been zero, but it remained at 60%-70% – hardly a success, said Dr. Jeffrey A. Linder.
"We should not be satisfied with interventions that reduce the acute bronchitis prescribing rate to 60%. We should demand better for our patients," he said. "Success is not reducing the antibiotic prescribing rate by 10%; success is reducing the antibiotic prescribing rate to 10%."
Dr. Linder is with the division of general medicine and primary care at Brigham and Women’s Hospital and Harvard Medical School, Boston. His work on acute respiratory infection is supported by the National Institutes of Health, the National Institute of Allergy and Infectious Diseases, and the Agency for Healthcare Research and Quality. He reported no financial conflicts of interest. These remarks were taken from his invited commentary accompanying Dr. Gonzales’ report (JAMA Intern. Med. 2013 Jan. 14 [doi:10.1001;jamainternmed.2013.1984]).
A decision-support algorithm to help primary care physicians assess adolescents and adults with uncomplicated acute bronchitis reduced unnecessary antibiotic use by about 10%, according to a report published online Jan. 14 in JAMA Internal Medicine.
Plus, printed and computer-assisted approaches alike decreased the overuse of antibiotic treatment in primary care practices, said Dr. Ralph Gonzales of the departments of medicine and epidemiology and biostatistics, University of California, San Francisco, and his associates (JAMA Intern. Med. 2013 Jan. 14 [doi:10.1001/jamainternmed.2013.1589]).
Reduced antibiotic use did not result in a significant increase in return visits to either the study’s primary care practices or a hospital, the researchers noted. So it appears that there was no appreciable increase in the adverse clinical consequences of withholding antibiotics, such as a rise in the incidence of pneumonia.
"In aggregate, these findings support the wider dissemination and use of this clinical algorithm to help reduce the overuse of antibiotics for acute bronchitis in primary care," the investigators said.
Dr. Gonzales and his colleagues tested the algorithm in a randomized, controlled trial involving 33 primary care practices from Geisinger Health System in rural and semirural central and northeastern Pennsylvania.
In addition to patient education materials, the decision-support algorithm included clinician education materials, such as:
– Prompts for taking an appropriate history and physical examination of all patients presenting with cough illness.
– A way to calculate a patient’s probability of having pneumonia.
– A list of relevant testing and treatment options for bronchitis.
– Feedback on the clinicians’ performance in appropriately prescribing antibiotics.
Eleven primary care practices were randomly assigned to use a printed version of the decision-support algorithm, 11 to use a computerized version, and 11 to serve as control practices where no decision-support algorithm was implemented.
The study included all of the practices’ board-certified internal medicine and family practice physicians, nurse practitioners, physician assistants, and registered nurses. The patient population comprised all adolescents and adults aged 13-64 years who presented with uncomplicated acute bronchitis during a single winter-season intervention period.
The data from these 6,242 patient cases were compared with those of 9,808 cases that occurred during the three winter seasons preceding implementation of the decision-support algorithm.
The number of visits for acute respiratory infections and the proportion diagnosed as uncomplicated acute bronchitis remained stable over time and across the study sites.
Compared with the preintervention period, the percentage of patients who were prescribed antibiotics during the intervention period decreased by 11.7% (from 80.0% to 68.3%) in practices using the print algorithm, and by 13.3% (from 74.0% to 60.7%) in practices using the computerized algorithm.
Those declines were significantly greater than the change in antibiotic prescribing seen in the control practices, where clinicians actually increased the use of antibiotics by 1.8%, from 72.5% to 74.3%, Dr. Gonzales and his associates said.
The percentage of patients who were not given antibiotics and who subsequently developed pneumonia requiring return visits remained "low" in all practices at all time periods, ranging from 0.5% to 1.5%.
The study results indicate that both conventional (printed) and computerized strategies for decision support are effective at reducing unwarranted use of antibiotics in uncomplicated acute bronchitis, the investigators said.
However, the findings may not be applicable in all settings, the researchers cautioned, because the study included only small- to medium-sized primary care practices within an integrated health care system in a rural and semirural region.
In addition, the study could not establish whether the declines in inappropriate prescription of antibiotics were due to the patient education component, the clinician education component, some other component, or simply to all clinicians’ knowledge that they were being monitored, the researchers said.
The Centers for Disease Control and Prevention supported the study. Dr. Gonzales reported ties to Phreesia, and an associate reported ties to Merck.
A decision-support algorithm to help primary care physicians assess adolescents and adults with uncomplicated acute bronchitis reduced unnecessary antibiotic use by about 10%, according to a report published online Jan. 14 in JAMA Internal Medicine.
Plus, printed and computer-assisted approaches alike decreased the overuse of antibiotic treatment in primary care practices, said Dr. Ralph Gonzales of the departments of medicine and epidemiology and biostatistics, University of California, San Francisco, and his associates (JAMA Intern. Med. 2013 Jan. 14 [doi:10.1001/jamainternmed.2013.1589]).
Reduced antibiotic use did not result in a significant increase in return visits to either the study’s primary care practices or a hospital, the researchers noted. So it appears that there was no appreciable increase in the adverse clinical consequences of withholding antibiotics, such as a rise in the incidence of pneumonia.
"In aggregate, these findings support the wider dissemination and use of this clinical algorithm to help reduce the overuse of antibiotics for acute bronchitis in primary care," the investigators said.
Dr. Gonzales and his colleagues tested the algorithm in a randomized, controlled trial involving 33 primary care practices from Geisinger Health System in rural and semirural central and northeastern Pennsylvania.
In addition to patient education materials, the decision-support algorithm included clinician education materials, such as:
– Prompts for taking an appropriate history and physical examination of all patients presenting with cough illness.
– A way to calculate a patient’s probability of having pneumonia.
– A list of relevant testing and treatment options for bronchitis.
– Feedback on the clinicians’ performance in appropriately prescribing antibiotics.
Eleven primary care practices were randomly assigned to use a printed version of the decision-support algorithm, 11 to use a computerized version, and 11 to serve as control practices where no decision-support algorithm was implemented.
The study included all of the practices’ board-certified internal medicine and family practice physicians, nurse practitioners, physician assistants, and registered nurses. The patient population comprised all adolescents and adults aged 13-64 years who presented with uncomplicated acute bronchitis during a single winter-season intervention period.
The data from these 6,242 patient cases were compared with those of 9,808 cases that occurred during the three winter seasons preceding implementation of the decision-support algorithm.
The number of visits for acute respiratory infections and the proportion diagnosed as uncomplicated acute bronchitis remained stable over time and across the study sites.
Compared with the preintervention period, the percentage of patients who were prescribed antibiotics during the intervention period decreased by 11.7% (from 80.0% to 68.3%) in practices using the print algorithm, and by 13.3% (from 74.0% to 60.7%) in practices using the computerized algorithm.
Those declines were significantly greater than the change in antibiotic prescribing seen in the control practices, where clinicians actually increased the use of antibiotics by 1.8%, from 72.5% to 74.3%, Dr. Gonzales and his associates said.
The percentage of patients who were not given antibiotics and who subsequently developed pneumonia requiring return visits remained "low" in all practices at all time periods, ranging from 0.5% to 1.5%.
The study results indicate that both conventional (printed) and computerized strategies for decision support are effective at reducing unwarranted use of antibiotics in uncomplicated acute bronchitis, the investigators said.
However, the findings may not be applicable in all settings, the researchers cautioned, because the study included only small- to medium-sized primary care practices within an integrated health care system in a rural and semirural region.
In addition, the study could not establish whether the declines in inappropriate prescription of antibiotics were due to the patient education component, the clinician education component, some other component, or simply to all clinicians’ knowledge that they were being monitored, the researchers said.
The Centers for Disease Control and Prevention supported the study. Dr. Gonzales reported ties to Phreesia, and an associate reported ties to Merck.
Plus, printed and computer-assisted approaches alike decreased the overuse of antibiotic treatment in primary care practices, said Dr. Ralph Gonzales of the departments of medicine and epidemiology and biostatistics, University of California, San Francisco, and his associates (JAMA Intern. Med. 2013 Jan. 14 [doi:10.1001/jamainternmed.2013.1589]).
Reduced antibiotic use did not result in a significant increase in return visits to either the study’s primary care practices or a hospital, the researchers noted. So it appears that there was no appreciable increase in the adverse clinical consequences of withholding antibiotics, such as a rise in the incidence of pneumonia.
"In aggregate, these findings support the wider dissemination and use of this clinical algorithm to help reduce the overuse of antibiotics for acute bronchitis in primary care," the investigators said.
Dr. Gonzales and his colleagues tested the algorithm in a randomized, controlled trial involving 33 primary care practices from Geisinger Health System in rural and semirural central and northeastern Pennsylvania.
In addition to patient education materials, the decision-support algorithm included clinician education materials, such as:
– Prompts for taking an appropriate history and physical examination of all patients presenting with cough illness.
– A way to calculate a patient’s probability of having pneumonia.
– A list of relevant testing and treatment options for bronch
Plus, printed and computer-assisted approaches alike decreased the overuse of antibiotic treatment in primary care practices, said Dr. Ralph Gonzales of the departments of medicine and epidemiology and biostatistics, University of California, San Francisco, and his associates (JAMA Intern. Med. 2013 Jan. 14 [doi:10.1001/jamainternmed.2013.1589]).
Reduced antibiotic use did not result in a significant increase in return visits to either the study’s primary care practices or a hospital, the researchers noted. So it appears that there was no appreciable increase in the adverse clinical consequences of withholding antibiotics, such as a rise in the incidence of pneumonia.
"In aggregate, these findings support the wider dissemination and use of this clinical algorithm to help reduce the overuse of antibiotics for acute bronchitis in primary care," the investigators said.
Dr. Gonzales and his colleagues tested the algorithm in a randomized, controlled trial involving 33 primary care practices from Geisinger Health System in rural and semirural central and northeastern Pennsylvania.
In addition to patient education materials, the decision-support algorithm included clinician education materials, such as:
– Prompts for taking an appropriate history and physical examination of all patients presenting with cough illness.
– A way to calculate a patient’s probability of having pneumonia.
– A list of relevant testing and treatment options for bronch
FROM JAMA INTERNAL MEDICINE
Major Finding: The percentage of patients with uncomplicated acute bronchitis who were prescribed antibiotics decreased by 11.7% (from 80.0% to 68.3%) in practices using a printed algorithm and by 13.3% (from 74.0% to 60.7%) in practices using a computerized algorithm, while it increased by 1.8% (from 72.5% to 74.3%) in practices using no algorithm.
Data Source: A three-arm randomized, controlled trial comparing antibiotic prescribing practices before and after implementation of printed or computerized decision-support algorithms for choosing treatment for adolescents and adults presenting with uncomplicated acute bronchitis.
Disclosures: This study was supported by the Centers for Disease Control and Prevention. Dr. Gonzales reported ties to Phreesia, and an associate reported ties to Merck.
FDA requires lower recommended doses for certain sleep drugs
The U.S. Food and Drug Administration announced Jan. 10 new, lower dosing requirements for certain sleep drugs that contain zolpidem, including Ambien, Ambien CR, Edluar, and ZolpiMist. Ambien and Ambien CR are also available as generics. The move comes on the heels of new data from driving simulation and laboratory studies showing that zolpidem blood levels in some individuals may be high enough the morning after use to impair activities that require alertness, including driving.
"After analyzing these new data we felt it necessary to add new drug safety information to the labeling, including lowering of the recommended dose," Dr. Ellis Unger, director of the Office of Drug Evaluation in the FDA’s Center for Drug Evaluation and Research, said during a Jan. 10 teleconference. "We hope that use of lower doses of zolpidem will mean that less drug will be in the bloodstream in the morning hours. We urge health care professionals to caution all patients who use these products about the risks of next morning impairment for activities that require complete mental alertness."
For women, the FDA now recommends that the dose of zolpidem should be lowered from 10 mg to 5 mg for immediate-release products and from 12.5 mg to 6.25 mg for extended-release products. (Ambien and Ambien CR are also available as generics.) "We have learned rather recently that women appear to be more susceptible to the risk of next morning impairment, because they eliminate zolpidem more slowly from their bodies than men," Dr. Unger said, noting that reasons for this association remain unclear. The supposition that women are smaller in size, compared with men, "is the first thing that one would think of," he said. "But if you correct the drug level data for patient size, that doesn’t account for the difference between men and women [in how the drug is eliminated]." For men, the FDA advises health care professionals to consider these same lower doses (5 mg for immediate-release products and 6.25 mg for extended release products).
More details about the development can be found in a Drug Safety Communication that was issued concomitantly. Despite the new recommendations, Dr. Unger emphasized that patients who are currently taking the higher doses of these sleep drugs "should continue to take the drug as it’s been prescribed until they discuss their situation with their health care provider and figure out how to continue to take the medication safely. We know that each patient is unique. The appropriate dose should be discussed with their health care professional."
Dr. Unger also explained that next morning impairment is not limited to sleep drugs that contain zolpidem. "All sleep drugs have the potential to cause this," he said. "So for all sleep medications all health care professionals should prescribe the lowest dose that is capable of preventing insomnia. The lower doses will decrease the potential for next morning impairment. Patients who must drive the next morning or perform other activities requiring full alertness should talk to their health care professional about whether sleep medicine is appropriate for them."
He concluded his remarks by noting that the FDA is continuing to evaluate the risk of impaired mental alertness with other insomnia drugs, including those sold over the counter.
The U.S. Food and Drug Administration announced Jan. 10 new, lower dosing requirements for certain sleep drugs that contain zolpidem, including Ambien, Ambien CR, Edluar, and ZolpiMist. Ambien and Ambien CR are also available as generics. The move comes on the heels of new data from driving simulation and laboratory studies showing that zolpidem blood levels in some individuals may be high enough the morning after use to impair activities that require alertness, including driving.
"After analyzing these new data we felt it necessary to add new drug safety information to the labeling, including lowering of the recommended dose," Dr. Ellis Unger, director of the Office of Drug Evaluation in the FDA’s Center for Drug Evaluation and Research, said during a Jan. 10 teleconference. "We hope that use of lower doses of zolpidem will mean that less drug will be in the bloodstream in the morning hours. We urge health care professionals to caution all patients who use these products about the risks of next morning impairment for activities that require complete mental alertness."
For women, the FDA now recommends that the dose of zolpidem should be lowered from 10 mg to 5 mg for immediate-release products and from 12.5 mg to 6.25 mg for extended-release products. (Ambien and Ambien CR are also available as generics.) "We have learned rather recently that women appear to be more susceptible to the risk of next morning impairment, because they eliminate zolpidem more slowly from their bodies than men," Dr. Unger said, noting that reasons for this association remain unclear. The supposition that women are smaller in size, compared with men, "is the first thing that one would think of," he said. "But if you correct the drug level data for patient size, that doesn’t account for the difference between men and women [in how the drug is eliminated]." For men, the FDA advises health care professionals to consider these same lower doses (5 mg for immediate-release products and 6.25 mg for extended release products).
More details about the development can be found in a Drug Safety Communication that was issued concomitantly. Despite the new recommendations, Dr. Unger emphasized that patients who are currently taking the higher doses of these sleep drugs "should continue to take the drug as it’s been prescribed until they discuss their situation with their health care provider and figure out how to continue to take the medication safely. We know that each patient is unique. The appropriate dose should be discussed with their health care professional."
Dr. Unger also explained that next morning impairment is not limited to sleep drugs that contain zolpidem. "All sleep drugs have the potential to cause this," he said. "So for all sleep medications all health care professionals should prescribe the lowest dose that is capable of preventing insomnia. The lower doses will decrease the potential for next morning impairment. Patients who must drive the next morning or perform other activities requiring full alertness should talk to their health care professional about whether sleep medicine is appropriate for them."
He concluded his remarks by noting that the FDA is continuing to evaluate the risk of impaired mental alertness with other insomnia drugs, including those sold over the counter.
The U.S. Food and Drug Administration announced Jan. 10 new, lower dosing requirements for certain sleep drugs that contain zolpidem, including Ambien, Ambien CR, Edluar, and ZolpiMist. Ambien and Ambien CR are also available as generics. The move comes on the heels of new data from driving simulation and laboratory studies showing that zolpidem blood levels in some individuals may be high enough the morning after use to impair activities that require alertness, including driving.
"After analyzing these new data we felt it necessary to add new drug safety information to the labeling, including lowering of the recommended dose," Dr. Ellis Unger, director of the Office of Drug Evaluation in the FDA’s Center for Drug Evaluation and Research, said during a Jan. 10 teleconference. "We hope that use of lower doses of zolpidem will mean that less drug will be in the bloodstream in the morning hours. We urge health care professionals to caution all patients who use these products about the risks of next morning impairment for activities that require complete mental alertness."
For women, the FDA now recommends that the dose of zolpidem should be lowered from 10 mg to 5 mg for immediate-release products and from 12.5 mg to 6.25 mg for extended-release products. (Ambien and Ambien CR are also available as generics.) "We have learned rather recently that women appear to be more susceptible to the risk of next morning impairment, because they eliminate zolpidem more slowly from their bodies than men," Dr. Unger said, noting that reasons for this association remain unclear. The supposition that women are smaller in size, compared with men, "is the first thing that one would think of," he said. "But if you correct the drug level data for patient size, that doesn’t account for the difference between men and women [in how the drug is eliminated]." For men, the FDA advises health care professionals to consider these same lower doses (5 mg for immediate-release products and 6.25 mg for extended release products).
More details about the development can be found in a Drug Safety Communication that was issued concomitantly. Despite the new recommendations, Dr. Unger emphasized that patients who are currently taking the higher doses of these sleep drugs "should continue to take the drug as it’s been prescribed until they discuss their situation with their health care provider and figure out how to continue to take the medication safely. We know that each patient is unique. The appropriate dose should be discussed with their health care professional."
Dr. Unger also explained that next morning impairment is not limited to sleep drugs that contain zolpidem. "All sleep drugs have the potential to cause this," he said. "So for all sleep medications all health care professionals should prescribe the lowest dose that is capable of preventing insomnia. The lower doses will decrease the potential for next morning impairment. Patients who must drive the next morning or perform other activities requiring full alertness should talk to their health care professional about whether sleep medicine is appropriate for them."
He concluded his remarks by noting that the FDA is continuing to evaluate the risk of impaired mental alertness with other insomnia drugs, including those sold over the counter.
Community-acquired pneumonia in children: A look at the IDSA guidelines
• Chest x-rays and lab testing may be optional for children with community-acquired pneumonia (CAP) who are not seriously ill. A
• Start amoxicillin empirically for any child with mild-to-moderate CAP. B
• If an atypical bacterial pneumonia is suspected, azithromycin is the first-line treatment. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
What are the recommended antibiotic choices for children with mild-to-moderate bacterial community-acquired pneumonia (CAP) in the outpatient setting? How much diagnostic testing is required? When might hospitalization and combination antibiotic therapy be warranted?
Evidence-based answers to these and other questions relevant to the management of CAP in infants and children older than 3 months are provided in a set of guidelines jointly published by the Infectious Diseases Society of America (IDSA) and the Pediatric Infectious Diseases Society (PIDS) in 2011.1 We summarize them here.
What the guidelines do, and don’t, address
The IDSA/PIDS guidelines, which focus on the care of otherwise healthy children with CAP in both outpatient and inpatient settings, seek to decrease morbidity and mortality rates associated with this respiratory infection. The guidelines do not apply to children younger than 3 months, immunocompromised patients, children receiving home mechanical ventilation, or children with chronic conditions or underlying lung disease, such as cystic fibrosis.
The need for evidence-based guidance. Globally each year, 1.5 million children 5 years of age and younger suffer a pneumonia-related death, particularly in developing countries.2-5 This is more than the number of deaths associated with any other disease in the world, including acquired immune deficiency syndrome (AIDS), tuberculosis (TB), or malaria.2 In 2010, pneumonia was ranked in the United States as the sixth leading cause of death for children one to 4 years of age and the 10th leading cause of death in adolescents.5 It is estimated that out of every 1000 infants and children in North America and Europe, 35 to 40 will be affected by CAP.2
How the guidelines define CAP. Pneumonia can be broadly defined as a lower respiratory tract infection, but definitions vary depending on the organization, institution, or health care setting. For instance, the World Health Organization (WHO) defines pneumonia solely on the basis of clinical findings obtained by visual inspection and timing of the respiratory rate.6 Another definition published by Bone and colleagues states that pneumonia is the “inflammation of the pulmonary parenchyma brought about by the presence of virulent pathogens; usually differentiated from isolated infections of the major airways.”7 The new pediatric guidelines define CAP as “the presence of signs and symptoms of pneumonia in a previously healthy child caused by an infection that has been acquired outside the hospital.”1
CAP pathogens vary with the child’s age
Typically, diagnostic testing of children will reveal several microbes, viral and bacterial, making it difficult to determine which might be the pathogen.1 Viral pathogens are more common causes of CAP in children younger than 2 years, accounting for 80% of cases1; bacterial pathogens are more common in older children.1
The virus detected most often among children younger than 2 years is respiratory syncytial virus (RSV).1,8-12 Less common viruses include adenovirus, influenza types A and B, parainfluenza 1, 2, and 3, and rhinovirus. Streptococcus pneumoniae is the most common bacterial pathogen identified in older children.1,13 The overall incidence of pneumonia decreases with age, but it has been reported that the proportion of cases from atypical bacterial pathogens—Chlamydia pneumoniae and Mycoplasma pneumoniae—may increase among older children.1,13
Signs and symptoms also vary
Signs and symptoms of CAP differ depending on the severity of the infection and the age of the child. In general, respiratory distress (tachypnea, nasal flaring, decreased breath sounds, cough, and rales) with fever are the prominent symptoms associated with pneumonia.1,13,14
Infants and children with mild to moderate infection most commonly exhibit a temperature <38°C and a respiratory rate <50 breaths per minute (bpm).
Children with severe CAP commonly present with a temperature >38°C, flaring of nostrils, grunting with breathing, tachypnea, tachycardia, and cyanosis. Tachypnea is defined as >60 bpm in infants younger than 2 months, >50 bpm in infants 2 to 12 months, and >40 bpm in children ages 1 to 5 years.8 Although respiratory rate is a valuable clinical sign, the work of breathing (as evidenced by nasal flaring, breathlessness, cough, or wheeze) required by the infant or child may be more indicative of pneumonia.15
Utilize diagnostic testing judiciously
Not all patients with suspected CAP require the same amount of diagnostic testing. In fact, IDSA/PIDS recommendations vary for hospitalized patients and for outpatients.1 In all cases, conduct testing quickly to expedite diagnosis and minimize the need for additional testing, to help validate treatment choices, and to reduce time spent in the hospital.1
Blood and sputum cultures not always indicated. The IDSA/PIDS guidelines strongly recommend obtaining blood cultures for hospitalized patients with moderate-to-severe pneumonia, particularly those with complications.1
The guidelines strongly recommend against blood cultures for fully immunized children with CAP who are treated as outpatients. However, blood cultures are strongly recommended for any child who fails to improve after initiation of antibiotic therapy.1 These recommendations are consistent with clinical data, expert opinion, and other treatment guidelines.1,8,13-18
A weak recommendation from the new guidelines states that if a hospitalized child with CAP can produce sputum, gram staining of the specimen may be warranted.1,8,13,15
Use pulse oximetry. The guidelines strongly recommend using pulse oximetry with all children who have pneumonia or suspected hypoxemia.1,18
When chest radiography can help. Routine chest radiography may not be warranted for suspected CAP treated in the outpatient setting. Order chest films for patients with suspected or confirmed hypoxemia or respiratory distress (who tend to have worse outcomes), and for patients who do not respond to initial antibiotic treatment.1,18 Follow-up radiographs are recommended for patients with advancing symptoms 2 to 3 days after starting antibiotics, complicated pneumonia with worsening respiratory distress, or clinical symptoms without improvement.1
Other diagnostic tests mentioned in the guidelines include complete blood cell counts, which are recommended in severe cases of pneumonia.1
Acute-phase reactants such as erythrocyte sedimentation rate (ESR), serum procalcitonin, and C-reactive protein concentrations cannot distinguish between viral and bacterial causes of CAP, and are not routinely recommended for patients treated in the outpatient setting.1,13
For patients requiring endotracheal intubation, gram staining and cultures of aspirates of the trachea and virus testing are recommended.1
Immunocompetent patients hospitalized with severe CAP may be candidates for percutaneous lung aspiration, open lung biopsy, bronchoalveolar lavage (BAL), or bronchoscopic or blind protected brush specimen collection if prior diagnostic tests are negative.1
CAP treatment and prevention
The guidelines provide recommendations for treating bacterial and viral CAP in either inpatient or outpatient settings, and discuss appropriate preventive techniques.
Antiviral therapy. As mentioned earlier, children less than 2 years of age are commonly infected with viral pathogens. Those with mild cases of viral CAP do not require anti-microbial therapy. For children with moderate-to-severe CAP consistent with influenza infection, administer influenza antiviral therapy as soon as possible, especially during a widespread local circulation of influenza viruses. Some influenza A strains will be susceptible to antiviral therapy, even though genetic variability is high each year. The guidelines’ recommended agents for treating influenza in pediatric patients are listed in TABLE 1.1
TABLE 1
Influenza antiviral therapy in pediatric patients*1
| Drug (brand name) | Formulation | Dosing |
|---|---|---|
| Oseltamivir (Tamiflu) | 75 mg capsule; 60 mg/5 mL suspension | 4-8 mo: 6 mg/kg/d in 2 doses 9-23 mo: 7 mg/kg/d in 2 doses ≥24 mo: ~4 mg/kg/d in 2 doses, for 5 days ≤15 kg: 60 mg/d in 2 divided doses >15-23 kg: 90 mg/d in 2 divided doses >23-40 kg: 120 mg/d in 2 divided doses >40 kg: 150 mg/d in 2 divided doses |
| Zanamivir (Relenza) | 5 mg per inhalation, using a Diskhaler | ≥7 y: 2 inhalations (10 mg total per dose), twice daily for 5 days |
| Amantadine (Symmetrel)† | 100 mg tablet; 50 mg/5 mL suspension | 1-9 y: 5-8 mg/kg/d as single daily dose or in 2 doses; not to exceed 150 mg/d 9-12 y: 200 mg/d in 2 doses (not studied as a single dose) |
| Rimantadine (Flumadine)† | 100 mg tablet; 50 mg/5 mL suspension | Not FDA approved for treatment in children, but published data exist on safety and efficacy in children Suspension: 1-9 y: 6.6 mg/kg/d (max 150 mg/kg/d) in 2 doses ≥10 y: 200 mg/d, as single daily dose or in 2 doses |
| *In children for whom prophylaxis is indicated, antiviral drugs should be continued for the duration of known influenza activity in the community (because of the potential for repeated exposures) or until immunity can be achieved as a result of immunization. †Amantadine and rimantadine should be used for treatment and prophylaxis only in the winter, when most isolated influenza A virus strains are susceptible to adamantine; the adamantines should not be used for primary therapy because of the rapid emergence of resistance. However, for patients requiring adamantine therapy, a treatment course of about 7 days is suggested, or one that runs until a day or 2 after the signs and symptoms have disappeared. | ||
Antibacterial therapy. For patients with a suspected bacterial pathogen, start empiric antibiotic therapy as soon as possible. Preferred and alternative agents for specific age groups, immunization status, and specific pathogen(s) appear in TABLE 2.1,19
TABLE 2
Empiric outpatient antibiotic therapy for pediatric CAP1,19
Duration of treatment is 10 days unless otherwise noted
| Patient age | Presumed bacterial pneumonia | Presumed atypical pneumonia |
|---|---|---|
| 3 mo to <5 y, regardless of immunization status | Preferred: amoxicillin 90 mg/kg/d PO in 2 divided doses Alternative: amoxicillin clavulanate 90 mg/kg/d PO in 2 divided doses | For all children regardless of age and immunization status: Preferred: azithromycin 10 mg/kg PO on Day 1, followed by 5 mg/kg PO once daily on Days 2-5 Alternative: clarithromycin 15 mg/kg/d PO in 2 divided doses OR In children >7 y: erythromycin 40 mg/kg/d PO in 4 divided doses; or doxycycline 2-4 mg/kg/d PO in 2 divided doses |
| ≥5 y and fully immunized against Streptococcus pneumoniae and Haemophilus influenzae | Preferred:* amoxicillin 90 mg/kg/d PO in 2 divided doses to a maximum 4 g/d, with or without a macrolide antibiotic Alternatives: Second- or third-generation cephalosporins such as oral cefpodoxime, cefuroxime, or cefprozil OR levofloxacin (5-16 y) 8-10 mg/kg PO once daily (max 750 mg/d)†OR linezolid (<12 y) 30 mg/kg/d PO (max 1200 mg/d) in 3 divided doses; or (≥12 y) 20 mg/kg/d (max 1200 mg/d) in 2 divided doses | |
| ≥5 y and NOT fully immunized against S pneumoniae and H influenzae | Preferred:* amoxicillin 90 mg/kg/d PO in 2 divided doses to a max of 4 g/d; or amoxicillin clavulanate 90 mg/kg/d PO in 2 divided doses Alternatives: Second- or third-generation cephalosporins such as oral cefpodoxime, cefuroxime, or cefprozil OR levofloxacin (5-16 y) 8-10 mg/kg PO once daily (max 750 mg/d)† | |
| CAP, community-acquired pneumonia. *Preferred treatments of choice change in areas of high S pneumoniae resistance. Refer to the complete guidelines for specific recommendations. †The guidelines do not fully address the controversy concerning the use of quinolones in children. The use of quinolones in infants and children is considered a risk vs benefit decision. | ||
Patients with mild or moderate CAP may be treated first in the outpatient setting with amoxicillin. This antibiotic has been the agent of choice for many years and continues to be the empiric therapy recommended in the guidelines.1 Appropriate dosing depends on the age of the patient.
TABLE 2 also includes treatment alternatives to amoxicillin for patients with drug allergies, treatment failures, or suspected atypical pathogens. Amoxicillin and the alternative treatments provide coverage for S pneumoniae, the most common invasive bacterial pathogen in older children.1,20 When atypical pathogens are suspected, macrolide antibiotics become the antibiotic drug class of choice, with azithromycin being the preferred first-line agent.1,21-23
Bacterial CAP necessitating hospitalization. The guidelines strongly recommend hospitalization for infants and children with respiratory distress or hypoxemia (oxygen saturation <90%); for suspicion of infection caused by community-acquired methicillin-resistant Staphylococcus aureus (MRSA) or any pathogen with high virulence; or for infants 3 to 6 months old.1
Treat with parenteral antibiotics to provide reliable blood and tissue concentrations (TABLE 3).1,19 Ampicillin or penicillin G may be given to fully immunized children; however, take into account the local resistance pattern of S pneumoniae to drugs within the penicillin class. For hospitalized children who are not yet fully immunized, who have life-threatening infections, or who are in a facility with a documented high rate of penicillin resistance, administer a third-generation parenteral cephalosporin such as ceftriaxone or cefotaxime empirically.1,24 In monotherapy treatment of pneumococcal pneumonia, non–beta-lactam agents such as vancomycin have not been shown to be more effective than the third-generation cephalosporins.1
TABLE 3
Empiric antibiotic therapy for hospitalized patients with CAP1,19
Duration of treatment is 10 days unless otherwise noted
| Patient age | Presumed bacterial pneumonia | Presumed atypical pneumonia |
|---|---|---|
| 3 mo to <5 y and fully immunized against Streptococcus pneumoniae and Haemophilus influenzae | Preferred:* ampicillin 150-200 mg/kg/d IV divided every 6 h; or penicillin G 200,000-250,000 units/kg/d IV divided every 4-6 h Alternatives: ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h | For all children regardless of age and immunization status: Preferred: azithromycin, 10 mg/kg IV (max of 500 mg) on Days 1 and 2, then transition to oral therapy 10 mg/kg/d for remaining 7-10 days of therapy Alternatives: erythromycin lactobionate 20 mg/kg/d IV divided every 6 h; or levofloxacin 16-20 mg/kg/d IV divided every 12 h to a max of 750 mg/d† |
| <5 y and NOT fully immunized against S pneumoniae and H influenzae | Preferred:* ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h Alternative: levofloxacin (6 mo–<5 y) 16-20 mg/kg/d IV divided every 12 h† | |
| ≥5 y and fully immunized against S pneumoniae and H influenzae | Preferred:* ampicillin 150-200 mg/kg/d IV divided every 6 h; or penicillin G 200,000-250,000 units/kg/d IV divided every 4-6 h Alternatives: ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h | |
| ≥5 y and NOT fully immunized against S pneumoniae and H influenzae | Preferred:* ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h Alternatives: ampicillin 150-200 mg/kg/d IV divided every 6 h; or levofloxacin 8-10 mg/kg IV once daily (max of 750 mg/d)† | |
| CAP, community-acquired pneumonia. *The addition of clindamycin 40 mg/kg/d IV divided every 6-8 hours or vancomycin 40-60 mg/kg/day IV divided every 6-8 hours is recommended for suspected or confirmed community-acquired methicillin-resistant Staphylococcus aureus. †The guidelines do not fully address the controversy concerning the use of quinolones in children. Use of quinolones in infants and children is considered a risk vs benefit decision. | ||
If S aureus is the suspected microorganism or is confirmed with clinical, laboratory, or imaging characteristics, give vancomycin or clindamycin with a beta-lactam agent.1,25-26 If you suspect an atypical pathogen such as M pneumoniae or C pneumoniae, start empiric therapy with an oral or parenteral macrolide in combination with a beta-lactam.1
Once a pathogen has been identified, adjust antimicrobial therapy as needed to target the specific microbe, to limit empiric antibiotic exposure, and to help limit the potential for antibiotic resistance.
Duration of treatment. The recommended duration of treatment for CAP is 10 days, supported by clinical data and the practice guidelines.1,27-29 Shorter treatment courses may be effective, especially in mild cases or outpatient treatment.1 Specific pathogens, such as MRSA, may need to be treated longer.30
If a patient is receiving intravenous antibiotics, switch to an oral agent as soon as clinically feasible to decrease risks from parenteral administration, and plan for the earliest possible discharge from the hospital to limit exposure to nosocomial pathogens. Hospital discharge may be considered when a child is clinically stable (improved appetite and activity level, afebrile for 24 hours), mental status is back to baseline or stable, and the pulse oximetry level is >90% on room air for at least 24 hours.1
Children receiving adequate therapy regimens should demonstrate both clinical and laboratory signs of improvement within 48 to 72 hours.1 If improvement does not occur, further your investigation with additional cultures, laboratory tests, and imaging evaluation.
For preventive measures, the guidelines recommend properly immunizing children with vaccines for bacterial pathogens such as S pneumoniae, Haemophilus influenzae, and Bordetella pertussis.1 Influenza vaccine should also be offered to prevent CAP in infants and children 6 months of age and older. Offer influenza and pertussis vaccines to adults and those caring for infants and children, to help prevent the spread of disease. Also consider immune prophylaxis with RSV-specific monoclonal antibody for premature infants or those with bronchopulmonary dysplasia, congenital heart disease, or immunodeficiency, to decrease the risk of severe pneumonia and hospitalization. For detailed recommendations on the use of prophylaxis against RSV, refer to the 2003 American Academy of Pediatrics statement.31
CORRESPONDENCE
Stephanie Schauner, PharmD, BCPS, University of Missouri-Kansas City, Health Science Building, Room 2241, 2464 Charlotte Street, Kansas City, MO 64108-2792; schauners@umkc.edu
1. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:e25-e76.Available at: http://cid.oxfordjournals.org/content/53/7/e25.long. Accessed December 17, 2012.
2. Centers for Disease Control and Prevention Pneumonia Can Be Prevented–Vaccines Can Help. Available at: http://www.cdc.gov/features/pneumonia. Accessed January 17, 2012.
3. Bulla A, Hitze KL. Acute respiratory infections: a review. Bull World Health Organ. 1978;56:481-498.
4. Baqui AH, Black RE, Arifeen SE, et al. Causes of childhood deaths in Bangladesh: results of a nationwide verbal autopsy study. Bull World Health Organ. 1998;76:161-171.
5. Murphy SL, Xu JQ, Kochanek KD. Deaths: Preliminary data for 2010. National vital statistics reports; vol 60 no 4. Hyattsville, Md: National Center for Health Statistics. 2012. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf. Accessed May 12, 2012.
6. Clinical management of acute respiratory infections in children: a WHO memorandum. Bull World Health Organ. 1981;59:707-716.
7. Feldman C, Anderson R. Community-acquired pneumonia. In; Bone RC, Dantzker DR, George RB, et al, eds. Pulmonary and Critical Care Medicine. Vol 2. St. Louis, Mo: Mosby-Year Book, Inc; 1997:719–733.
8. Davies HD. Community-acquired pneumonia in children. Paediatr Child Health. 2003;8:616-619.
9. Alexander ER, Foy HM, Kenny GE, et al. Pneumonia due to Mycoplasma pneumoniae. Its incidence in the membership of a co-operative medical group. N Engl J Med. 1966;275:131-136.
10. Foy HM, Cooney MK, Maletzky AJ, et al. Incidence and etiology of pneumonia, croup and bronchiolitis in preschool children belonging to a prepaid medical group over a four-year period. Am J Epidemiol. 1973;97:80-92.
11. Murphy TF, Henderson FW, Clyde WA, Jr, et al. Pneumonia: An eleven-year study in a pediatric practice. Am J Epidemiol. 1981;113:12-21.
12. Denny FW, Clyde WA. Acute lower respiratory tract infections in non-hospitalized children. J Pediatr. 1986;108:635-646.
13. Ostapchuk M, Roberts DM, Haddy R. Community-acquired pneumonia in infants and children. Am Fam Phys. 2004;70:899-908.
14. Margolis P, Gadomski A. The rational clinical examination. Does this infant have pneumonia? JAMA. 1998;279:308-313.
15. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax. 2011;66 (suppl 2):ii1-ii23.
16. Gaston B. Pneumonia. Pediatr Rev. 2002;23:132-140.
17. McIntosh K. Community-acquired pneumonia in children. N Engl J Med. 2002;346:429-437.
18. Skolnik N, Tien P. Managing community-acquired pneumonia in infants and children. Fam Pract News. November 10, 2011. Available at: http://www.familypracticenews.com/views/clinical-guidelines-for-family-physicians-by-dr-skolnik/blog/managing-community-acquired-pneumonia-in-infants-and-children/3a77ebb81a.html. Accessed January 17, 2012.
19. O’Mara N. Empiric treatment for pediatric community-acquired pneumonia. Pharmacist’s Letter. November 2011. Available at: http://www.pharmacistletter.com. Accessed February 25, 2012.
20. Klein JO. Bacterial pneumonias. In: Cherry J, Kaplan S, Demmler-Harrison G, eds. Feigin & Cherry’s Textbook of Pediatric Infectious Diseases. 6th ed. Vol 1. Philadelphia, Pa: Saunders/Elsevier; 2009:302–314.
21. Morita JY, Kahn E, Thompson T, et al. Impact of azithromycin on oropharyngeal carriage of group A Streptococcus and nasopharyngeal carriage of macrolide-resistant Streptococcus pneumoniae. Pediatr Infect Dis J. 2000;19:41-46.
22. Block S, Hedrick J, Hammerschlag MR, et al. Mycoplasma pneumoniae and Chlamydia pneumoniae in pediatric community-acquired pneumonia: comparative efficacy and safety of clarithromycin vs. erythromycin ethylsuccinate. Pediatr Infect Dis J. 1995;14:471-477.
23. Harris JA, Kolokathis A, Campbell M, et al. Safety and efficacy of azithromycin in the treatment of community-acquired pneumonia in children. Pediatr Infect Dis J. 1998;17:865-871.
24. Pallares R, Capdevila O, Linares J, et al. The effect of cephalosporin resistance on mortality in adult patients with nonmeningeal systemic pneumococcal infections. Am J Med. 2002;113:120-126.
25. Roson B, Carratala J, Tubau F, et al. Usefulness of betalactam therapy for community-acquired pneumonia in the era of drug-resistant Streptococcus pneumoniae: a randomized study of amoxicillin-clavulanate and ceftriaxone. Microb Drug Resist. 2001;7:85-96.
26. Miller LG, Kaplan SL. Staphylococcus aureus: a community pathogen. Infect Dis Clin North Am. 2009;23:35-52.
27. Haider BA, Saeed MA, Bhutta ZA. Short-course versus long-course antibiotic therapy for non-severe community-acquired pneumonia in children aged 2 months to 59 months. Cochrane Database Syst Rev. 2008;(2):CD005976.-
28. Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38:1651-1672.
29. Bradley JS, Ching DK, Hart CL. Invasive bacterial disease in childhood: efficacy of oral antibiotic therapy following short course parenteral therapy in non-central nervous system infections. Pediatr Infect Dis J. 1987;6:821-825.
30. Blaschke AJ, Heyrend C, Byington CL, et al. Molecular analysis improves pathogen identification and epidemiologic study of pediatric parapneumonic empyema. Pediatr Infect Dis J. 2011;30:289-294.
31. American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborn. Revised indications for the use of palivizumab and RSV immune globulin intravenous for the prevention of respiratory syncytial virus infection. Pediatrics. 2003;112:1442-1446.
• Chest x-rays and lab testing may be optional for children with community-acquired pneumonia (CAP) who are not seriously ill. A
• Start amoxicillin empirically for any child with mild-to-moderate CAP. B
• If an atypical bacterial pneumonia is suspected, azithromycin is the first-line treatment. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
What are the recommended antibiotic choices for children with mild-to-moderate bacterial community-acquired pneumonia (CAP) in the outpatient setting? How much diagnostic testing is required? When might hospitalization and combination antibiotic therapy be warranted?
Evidence-based answers to these and other questions relevant to the management of CAP in infants and children older than 3 months are provided in a set of guidelines jointly published by the Infectious Diseases Society of America (IDSA) and the Pediatric Infectious Diseases Society (PIDS) in 2011.1 We summarize them here.
What the guidelines do, and don’t, address
The IDSA/PIDS guidelines, which focus on the care of otherwise healthy children with CAP in both outpatient and inpatient settings, seek to decrease morbidity and mortality rates associated with this respiratory infection. The guidelines do not apply to children younger than 3 months, immunocompromised patients, children receiving home mechanical ventilation, or children with chronic conditions or underlying lung disease, such as cystic fibrosis.
The need for evidence-based guidance. Globally each year, 1.5 million children 5 years of age and younger suffer a pneumonia-related death, particularly in developing countries.2-5 This is more than the number of deaths associated with any other disease in the world, including acquired immune deficiency syndrome (AIDS), tuberculosis (TB), or malaria.2 In 2010, pneumonia was ranked in the United States as the sixth leading cause of death for children one to 4 years of age and the 10th leading cause of death in adolescents.5 It is estimated that out of every 1000 infants and children in North America and Europe, 35 to 40 will be affected by CAP.2
How the guidelines define CAP. Pneumonia can be broadly defined as a lower respiratory tract infection, but definitions vary depending on the organization, institution, or health care setting. For instance, the World Health Organization (WHO) defines pneumonia solely on the basis of clinical findings obtained by visual inspection and timing of the respiratory rate.6 Another definition published by Bone and colleagues states that pneumonia is the “inflammation of the pulmonary parenchyma brought about by the presence of virulent pathogens; usually differentiated from isolated infections of the major airways.”7 The new pediatric guidelines define CAP as “the presence of signs and symptoms of pneumonia in a previously healthy child caused by an infection that has been acquired outside the hospital.”1
CAP pathogens vary with the child’s age
Typically, diagnostic testing of children will reveal several microbes, viral and bacterial, making it difficult to determine which might be the pathogen.1 Viral pathogens are more common causes of CAP in children younger than 2 years, accounting for 80% of cases1; bacterial pathogens are more common in older children.1
The virus detected most often among children younger than 2 years is respiratory syncytial virus (RSV).1,8-12 Less common viruses include adenovirus, influenza types A and B, parainfluenza 1, 2, and 3, and rhinovirus. Streptococcus pneumoniae is the most common bacterial pathogen identified in older children.1,13 The overall incidence of pneumonia decreases with age, but it has been reported that the proportion of cases from atypical bacterial pathogens—Chlamydia pneumoniae and Mycoplasma pneumoniae—may increase among older children.1,13
Signs and symptoms also vary
Signs and symptoms of CAP differ depending on the severity of the infection and the age of the child. In general, respiratory distress (tachypnea, nasal flaring, decreased breath sounds, cough, and rales) with fever are the prominent symptoms associated with pneumonia.1,13,14
Infants and children with mild to moderate infection most commonly exhibit a temperature <38°C and a respiratory rate <50 breaths per minute (bpm).
Children with severe CAP commonly present with a temperature >38°C, flaring of nostrils, grunting with breathing, tachypnea, tachycardia, and cyanosis. Tachypnea is defined as >60 bpm in infants younger than 2 months, >50 bpm in infants 2 to 12 months, and >40 bpm in children ages 1 to 5 years.8 Although respiratory rate is a valuable clinical sign, the work of breathing (as evidenced by nasal flaring, breathlessness, cough, or wheeze) required by the infant or child may be more indicative of pneumonia.15
Utilize diagnostic testing judiciously
Not all patients with suspected CAP require the same amount of diagnostic testing. In fact, IDSA/PIDS recommendations vary for hospitalized patients and for outpatients.1 In all cases, conduct testing quickly to expedite diagnosis and minimize the need for additional testing, to help validate treatment choices, and to reduce time spent in the hospital.1
Blood and sputum cultures not always indicated. The IDSA/PIDS guidelines strongly recommend obtaining blood cultures for hospitalized patients with moderate-to-severe pneumonia, particularly those with complications.1
The guidelines strongly recommend against blood cultures for fully immunized children with CAP who are treated as outpatients. However, blood cultures are strongly recommended for any child who fails to improve after initiation of antibiotic therapy.1 These recommendations are consistent with clinical data, expert opinion, and other treatment guidelines.1,8,13-18
A weak recommendation from the new guidelines states that if a hospitalized child with CAP can produce sputum, gram staining of the specimen may be warranted.1,8,13,15
Use pulse oximetry. The guidelines strongly recommend using pulse oximetry with all children who have pneumonia or suspected hypoxemia.1,18
When chest radiography can help. Routine chest radiography may not be warranted for suspected CAP treated in the outpatient setting. Order chest films for patients with suspected or confirmed hypoxemia or respiratory distress (who tend to have worse outcomes), and for patients who do not respond to initial antibiotic treatment.1,18 Follow-up radiographs are recommended for patients with advancing symptoms 2 to 3 days after starting antibiotics, complicated pneumonia with worsening respiratory distress, or clinical symptoms without improvement.1
Other diagnostic tests mentioned in the guidelines include complete blood cell counts, which are recommended in severe cases of pneumonia.1
Acute-phase reactants such as erythrocyte sedimentation rate (ESR), serum procalcitonin, and C-reactive protein concentrations cannot distinguish between viral and bacterial causes of CAP, and are not routinely recommended for patients treated in the outpatient setting.1,13
For patients requiring endotracheal intubation, gram staining and cultures of aspirates of the trachea and virus testing are recommended.1
Immunocompetent patients hospitalized with severe CAP may be candidates for percutaneous lung aspiration, open lung biopsy, bronchoalveolar lavage (BAL), or bronchoscopic or blind protected brush specimen collection if prior diagnostic tests are negative.1
CAP treatment and prevention
The guidelines provide recommendations for treating bacterial and viral CAP in either inpatient or outpatient settings, and discuss appropriate preventive techniques.
Antiviral therapy. As mentioned earlier, children less than 2 years of age are commonly infected with viral pathogens. Those with mild cases of viral CAP do not require anti-microbial therapy. For children with moderate-to-severe CAP consistent with influenza infection, administer influenza antiviral therapy as soon as possible, especially during a widespread local circulation of influenza viruses. Some influenza A strains will be susceptible to antiviral therapy, even though genetic variability is high each year. The guidelines’ recommended agents for treating influenza in pediatric patients are listed in TABLE 1.1
TABLE 1
Influenza antiviral therapy in pediatric patients*1
| Drug (brand name) | Formulation | Dosing |
|---|---|---|
| Oseltamivir (Tamiflu) | 75 mg capsule; 60 mg/5 mL suspension | 4-8 mo: 6 mg/kg/d in 2 doses 9-23 mo: 7 mg/kg/d in 2 doses ≥24 mo: ~4 mg/kg/d in 2 doses, for 5 days ≤15 kg: 60 mg/d in 2 divided doses >15-23 kg: 90 mg/d in 2 divided doses >23-40 kg: 120 mg/d in 2 divided doses >40 kg: 150 mg/d in 2 divided doses |
| Zanamivir (Relenza) | 5 mg per inhalation, using a Diskhaler | ≥7 y: 2 inhalations (10 mg total per dose), twice daily for 5 days |
| Amantadine (Symmetrel)† | 100 mg tablet; 50 mg/5 mL suspension | 1-9 y: 5-8 mg/kg/d as single daily dose or in 2 doses; not to exceed 150 mg/d 9-12 y: 200 mg/d in 2 doses (not studied as a single dose) |
| Rimantadine (Flumadine)† | 100 mg tablet; 50 mg/5 mL suspension | Not FDA approved for treatment in children, but published data exist on safety and efficacy in children Suspension: 1-9 y: 6.6 mg/kg/d (max 150 mg/kg/d) in 2 doses ≥10 y: 200 mg/d, as single daily dose or in 2 doses |
| *In children for whom prophylaxis is indicated, antiviral drugs should be continued for the duration of known influenza activity in the community (because of the potential for repeated exposures) or until immunity can be achieved as a result of immunization. †Amantadine and rimantadine should be used for treatment and prophylaxis only in the winter, when most isolated influenza A virus strains are susceptible to adamantine; the adamantines should not be used for primary therapy because of the rapid emergence of resistance. However, for patients requiring adamantine therapy, a treatment course of about 7 days is suggested, or one that runs until a day or 2 after the signs and symptoms have disappeared. | ||
Antibacterial therapy. For patients with a suspected bacterial pathogen, start empiric antibiotic therapy as soon as possible. Preferred and alternative agents for specific age groups, immunization status, and specific pathogen(s) appear in TABLE 2.1,19
TABLE 2
Empiric outpatient antibiotic therapy for pediatric CAP1,19
Duration of treatment is 10 days unless otherwise noted
| Patient age | Presumed bacterial pneumonia | Presumed atypical pneumonia |
|---|---|---|
| 3 mo to <5 y, regardless of immunization status | Preferred: amoxicillin 90 mg/kg/d PO in 2 divided doses Alternative: amoxicillin clavulanate 90 mg/kg/d PO in 2 divided doses | For all children regardless of age and immunization status: Preferred: azithromycin 10 mg/kg PO on Day 1, followed by 5 mg/kg PO once daily on Days 2-5 Alternative: clarithromycin 15 mg/kg/d PO in 2 divided doses OR In children >7 y: erythromycin 40 mg/kg/d PO in 4 divided doses; or doxycycline 2-4 mg/kg/d PO in 2 divided doses |
| ≥5 y and fully immunized against Streptococcus pneumoniae and Haemophilus influenzae | Preferred:* amoxicillin 90 mg/kg/d PO in 2 divided doses to a maximum 4 g/d, with or without a macrolide antibiotic Alternatives: Second- or third-generation cephalosporins such as oral cefpodoxime, cefuroxime, or cefprozil OR levofloxacin (5-16 y) 8-10 mg/kg PO once daily (max 750 mg/d)†OR linezolid (<12 y) 30 mg/kg/d PO (max 1200 mg/d) in 3 divided doses; or (≥12 y) 20 mg/kg/d (max 1200 mg/d) in 2 divided doses | |
| ≥5 y and NOT fully immunized against S pneumoniae and H influenzae | Preferred:* amoxicillin 90 mg/kg/d PO in 2 divided doses to a max of 4 g/d; or amoxicillin clavulanate 90 mg/kg/d PO in 2 divided doses Alternatives: Second- or third-generation cephalosporins such as oral cefpodoxime, cefuroxime, or cefprozil OR levofloxacin (5-16 y) 8-10 mg/kg PO once daily (max 750 mg/d)† | |
| CAP, community-acquired pneumonia. *Preferred treatments of choice change in areas of high S pneumoniae resistance. Refer to the complete guidelines for specific recommendations. †The guidelines do not fully address the controversy concerning the use of quinolones in children. The use of quinolones in infants and children is considered a risk vs benefit decision. | ||
Patients with mild or moderate CAP may be treated first in the outpatient setting with amoxicillin. This antibiotic has been the agent of choice for many years and continues to be the empiric therapy recommended in the guidelines.1 Appropriate dosing depends on the age of the patient.
TABLE 2 also includes treatment alternatives to amoxicillin for patients with drug allergies, treatment failures, or suspected atypical pathogens. Amoxicillin and the alternative treatments provide coverage for S pneumoniae, the most common invasive bacterial pathogen in older children.1,20 When atypical pathogens are suspected, macrolide antibiotics become the antibiotic drug class of choice, with azithromycin being the preferred first-line agent.1,21-23
Bacterial CAP necessitating hospitalization. The guidelines strongly recommend hospitalization for infants and children with respiratory distress or hypoxemia (oxygen saturation <90%); for suspicion of infection caused by community-acquired methicillin-resistant Staphylococcus aureus (MRSA) or any pathogen with high virulence; or for infants 3 to 6 months old.1
Treat with parenteral antibiotics to provide reliable blood and tissue concentrations (TABLE 3).1,19 Ampicillin or penicillin G may be given to fully immunized children; however, take into account the local resistance pattern of S pneumoniae to drugs within the penicillin class. For hospitalized children who are not yet fully immunized, who have life-threatening infections, or who are in a facility with a documented high rate of penicillin resistance, administer a third-generation parenteral cephalosporin such as ceftriaxone or cefotaxime empirically.1,24 In monotherapy treatment of pneumococcal pneumonia, non–beta-lactam agents such as vancomycin have not been shown to be more effective than the third-generation cephalosporins.1
TABLE 3
Empiric antibiotic therapy for hospitalized patients with CAP1,19
Duration of treatment is 10 days unless otherwise noted
| Patient age | Presumed bacterial pneumonia | Presumed atypical pneumonia |
|---|---|---|
| 3 mo to <5 y and fully immunized against Streptococcus pneumoniae and Haemophilus influenzae | Preferred:* ampicillin 150-200 mg/kg/d IV divided every 6 h; or penicillin G 200,000-250,000 units/kg/d IV divided every 4-6 h Alternatives: ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h | For all children regardless of age and immunization status: Preferred: azithromycin, 10 mg/kg IV (max of 500 mg) on Days 1 and 2, then transition to oral therapy 10 mg/kg/d for remaining 7-10 days of therapy Alternatives: erythromycin lactobionate 20 mg/kg/d IV divided every 6 h; or levofloxacin 16-20 mg/kg/d IV divided every 12 h to a max of 750 mg/d† |
| <5 y and NOT fully immunized against S pneumoniae and H influenzae | Preferred:* ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h Alternative: levofloxacin (6 mo–<5 y) 16-20 mg/kg/d IV divided every 12 h† | |
| ≥5 y and fully immunized against S pneumoniae and H influenzae | Preferred:* ampicillin 150-200 mg/kg/d IV divided every 6 h; or penicillin G 200,000-250,000 units/kg/d IV divided every 4-6 h Alternatives: ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h | |
| ≥5 y and NOT fully immunized against S pneumoniae and H influenzae | Preferred:* ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h Alternatives: ampicillin 150-200 mg/kg/d IV divided every 6 h; or levofloxacin 8-10 mg/kg IV once daily (max of 750 mg/d)† | |
| CAP, community-acquired pneumonia. *The addition of clindamycin 40 mg/kg/d IV divided every 6-8 hours or vancomycin 40-60 mg/kg/day IV divided every 6-8 hours is recommended for suspected or confirmed community-acquired methicillin-resistant Staphylococcus aureus. †The guidelines do not fully address the controversy concerning the use of quinolones in children. Use of quinolones in infants and children is considered a risk vs benefit decision. | ||
If S aureus is the suspected microorganism or is confirmed with clinical, laboratory, or imaging characteristics, give vancomycin or clindamycin with a beta-lactam agent.1,25-26 If you suspect an atypical pathogen such as M pneumoniae or C pneumoniae, start empiric therapy with an oral or parenteral macrolide in combination with a beta-lactam.1
Once a pathogen has been identified, adjust antimicrobial therapy as needed to target the specific microbe, to limit empiric antibiotic exposure, and to help limit the potential for antibiotic resistance.
Duration of treatment. The recommended duration of treatment for CAP is 10 days, supported by clinical data and the practice guidelines.1,27-29 Shorter treatment courses may be effective, especially in mild cases or outpatient treatment.1 Specific pathogens, such as MRSA, may need to be treated longer.30
If a patient is receiving intravenous antibiotics, switch to an oral agent as soon as clinically feasible to decrease risks from parenteral administration, and plan for the earliest possible discharge from the hospital to limit exposure to nosocomial pathogens. Hospital discharge may be considered when a child is clinically stable (improved appetite and activity level, afebrile for 24 hours), mental status is back to baseline or stable, and the pulse oximetry level is >90% on room air for at least 24 hours.1
Children receiving adequate therapy regimens should demonstrate both clinical and laboratory signs of improvement within 48 to 72 hours.1 If improvement does not occur, further your investigation with additional cultures, laboratory tests, and imaging evaluation.
For preventive measures, the guidelines recommend properly immunizing children with vaccines for bacterial pathogens such as S pneumoniae, Haemophilus influenzae, and Bordetella pertussis.1 Influenza vaccine should also be offered to prevent CAP in infants and children 6 months of age and older. Offer influenza and pertussis vaccines to adults and those caring for infants and children, to help prevent the spread of disease. Also consider immune prophylaxis with RSV-specific monoclonal antibody for premature infants or those with bronchopulmonary dysplasia, congenital heart disease, or immunodeficiency, to decrease the risk of severe pneumonia and hospitalization. For detailed recommendations on the use of prophylaxis against RSV, refer to the 2003 American Academy of Pediatrics statement.31
CORRESPONDENCE
Stephanie Schauner, PharmD, BCPS, University of Missouri-Kansas City, Health Science Building, Room 2241, 2464 Charlotte Street, Kansas City, MO 64108-2792; schauners@umkc.edu
• Chest x-rays and lab testing may be optional for children with community-acquired pneumonia (CAP) who are not seriously ill. A
• Start amoxicillin empirically for any child with mild-to-moderate CAP. B
• If an atypical bacterial pneumonia is suspected, azithromycin is the first-line treatment. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
What are the recommended antibiotic choices for children with mild-to-moderate bacterial community-acquired pneumonia (CAP) in the outpatient setting? How much diagnostic testing is required? When might hospitalization and combination antibiotic therapy be warranted?
Evidence-based answers to these and other questions relevant to the management of CAP in infants and children older than 3 months are provided in a set of guidelines jointly published by the Infectious Diseases Society of America (IDSA) and the Pediatric Infectious Diseases Society (PIDS) in 2011.1 We summarize them here.
What the guidelines do, and don’t, address
The IDSA/PIDS guidelines, which focus on the care of otherwise healthy children with CAP in both outpatient and inpatient settings, seek to decrease morbidity and mortality rates associated with this respiratory infection. The guidelines do not apply to children younger than 3 months, immunocompromised patients, children receiving home mechanical ventilation, or children with chronic conditions or underlying lung disease, such as cystic fibrosis.
The need for evidence-based guidance. Globally each year, 1.5 million children 5 years of age and younger suffer a pneumonia-related death, particularly in developing countries.2-5 This is more than the number of deaths associated with any other disease in the world, including acquired immune deficiency syndrome (AIDS), tuberculosis (TB), or malaria.2 In 2010, pneumonia was ranked in the United States as the sixth leading cause of death for children one to 4 years of age and the 10th leading cause of death in adolescents.5 It is estimated that out of every 1000 infants and children in North America and Europe, 35 to 40 will be affected by CAP.2
How the guidelines define CAP. Pneumonia can be broadly defined as a lower respiratory tract infection, but definitions vary depending on the organization, institution, or health care setting. For instance, the World Health Organization (WHO) defines pneumonia solely on the basis of clinical findings obtained by visual inspection and timing of the respiratory rate.6 Another definition published by Bone and colleagues states that pneumonia is the “inflammation of the pulmonary parenchyma brought about by the presence of virulent pathogens; usually differentiated from isolated infections of the major airways.”7 The new pediatric guidelines define CAP as “the presence of signs and symptoms of pneumonia in a previously healthy child caused by an infection that has been acquired outside the hospital.”1
CAP pathogens vary with the child’s age
Typically, diagnostic testing of children will reveal several microbes, viral and bacterial, making it difficult to determine which might be the pathogen.1 Viral pathogens are more common causes of CAP in children younger than 2 years, accounting for 80% of cases1; bacterial pathogens are more common in older children.1
The virus detected most often among children younger than 2 years is respiratory syncytial virus (RSV).1,8-12 Less common viruses include adenovirus, influenza types A and B, parainfluenza 1, 2, and 3, and rhinovirus. Streptococcus pneumoniae is the most common bacterial pathogen identified in older children.1,13 The overall incidence of pneumonia decreases with age, but it has been reported that the proportion of cases from atypical bacterial pathogens—Chlamydia pneumoniae and Mycoplasma pneumoniae—may increase among older children.1,13
Signs and symptoms also vary
Signs and symptoms of CAP differ depending on the severity of the infection and the age of the child. In general, respiratory distress (tachypnea, nasal flaring, decreased breath sounds, cough, and rales) with fever are the prominent symptoms associated with pneumonia.1,13,14
Infants and children with mild to moderate infection most commonly exhibit a temperature <38°C and a respiratory rate <50 breaths per minute (bpm).
Children with severe CAP commonly present with a temperature >38°C, flaring of nostrils, grunting with breathing, tachypnea, tachycardia, and cyanosis. Tachypnea is defined as >60 bpm in infants younger than 2 months, >50 bpm in infants 2 to 12 months, and >40 bpm in children ages 1 to 5 years.8 Although respiratory rate is a valuable clinical sign, the work of breathing (as evidenced by nasal flaring, breathlessness, cough, or wheeze) required by the infant or child may be more indicative of pneumonia.15
Utilize diagnostic testing judiciously
Not all patients with suspected CAP require the same amount of diagnostic testing. In fact, IDSA/PIDS recommendations vary for hospitalized patients and for outpatients.1 In all cases, conduct testing quickly to expedite diagnosis and minimize the need for additional testing, to help validate treatment choices, and to reduce time spent in the hospital.1
Blood and sputum cultures not always indicated. The IDSA/PIDS guidelines strongly recommend obtaining blood cultures for hospitalized patients with moderate-to-severe pneumonia, particularly those with complications.1
The guidelines strongly recommend against blood cultures for fully immunized children with CAP who are treated as outpatients. However, blood cultures are strongly recommended for any child who fails to improve after initiation of antibiotic therapy.1 These recommendations are consistent with clinical data, expert opinion, and other treatment guidelines.1,8,13-18
A weak recommendation from the new guidelines states that if a hospitalized child with CAP can produce sputum, gram staining of the specimen may be warranted.1,8,13,15
Use pulse oximetry. The guidelines strongly recommend using pulse oximetry with all children who have pneumonia or suspected hypoxemia.1,18
When chest radiography can help. Routine chest radiography may not be warranted for suspected CAP treated in the outpatient setting. Order chest films for patients with suspected or confirmed hypoxemia or respiratory distress (who tend to have worse outcomes), and for patients who do not respond to initial antibiotic treatment.1,18 Follow-up radiographs are recommended for patients with advancing symptoms 2 to 3 days after starting antibiotics, complicated pneumonia with worsening respiratory distress, or clinical symptoms without improvement.1
Other diagnostic tests mentioned in the guidelines include complete blood cell counts, which are recommended in severe cases of pneumonia.1
Acute-phase reactants such as erythrocyte sedimentation rate (ESR), serum procalcitonin, and C-reactive protein concentrations cannot distinguish between viral and bacterial causes of CAP, and are not routinely recommended for patients treated in the outpatient setting.1,13
For patients requiring endotracheal intubation, gram staining and cultures of aspirates of the trachea and virus testing are recommended.1
Immunocompetent patients hospitalized with severe CAP may be candidates for percutaneous lung aspiration, open lung biopsy, bronchoalveolar lavage (BAL), or bronchoscopic or blind protected brush specimen collection if prior diagnostic tests are negative.1
CAP treatment and prevention
The guidelines provide recommendations for treating bacterial and viral CAP in either inpatient or outpatient settings, and discuss appropriate preventive techniques.
Antiviral therapy. As mentioned earlier, children less than 2 years of age are commonly infected with viral pathogens. Those with mild cases of viral CAP do not require anti-microbial therapy. For children with moderate-to-severe CAP consistent with influenza infection, administer influenza antiviral therapy as soon as possible, especially during a widespread local circulation of influenza viruses. Some influenza A strains will be susceptible to antiviral therapy, even though genetic variability is high each year. The guidelines’ recommended agents for treating influenza in pediatric patients are listed in TABLE 1.1
TABLE 1
Influenza antiviral therapy in pediatric patients*1
| Drug (brand name) | Formulation | Dosing |
|---|---|---|
| Oseltamivir (Tamiflu) | 75 mg capsule; 60 mg/5 mL suspension | 4-8 mo: 6 mg/kg/d in 2 doses 9-23 mo: 7 mg/kg/d in 2 doses ≥24 mo: ~4 mg/kg/d in 2 doses, for 5 days ≤15 kg: 60 mg/d in 2 divided doses >15-23 kg: 90 mg/d in 2 divided doses >23-40 kg: 120 mg/d in 2 divided doses >40 kg: 150 mg/d in 2 divided doses |
| Zanamivir (Relenza) | 5 mg per inhalation, using a Diskhaler | ≥7 y: 2 inhalations (10 mg total per dose), twice daily for 5 days |
| Amantadine (Symmetrel)† | 100 mg tablet; 50 mg/5 mL suspension | 1-9 y: 5-8 mg/kg/d as single daily dose or in 2 doses; not to exceed 150 mg/d 9-12 y: 200 mg/d in 2 doses (not studied as a single dose) |
| Rimantadine (Flumadine)† | 100 mg tablet; 50 mg/5 mL suspension | Not FDA approved for treatment in children, but published data exist on safety and efficacy in children Suspension: 1-9 y: 6.6 mg/kg/d (max 150 mg/kg/d) in 2 doses ≥10 y: 200 mg/d, as single daily dose or in 2 doses |
| *In children for whom prophylaxis is indicated, antiviral drugs should be continued for the duration of known influenza activity in the community (because of the potential for repeated exposures) or until immunity can be achieved as a result of immunization. †Amantadine and rimantadine should be used for treatment and prophylaxis only in the winter, when most isolated influenza A virus strains are susceptible to adamantine; the adamantines should not be used for primary therapy because of the rapid emergence of resistance. However, for patients requiring adamantine therapy, a treatment course of about 7 days is suggested, or one that runs until a day or 2 after the signs and symptoms have disappeared. | ||
Antibacterial therapy. For patients with a suspected bacterial pathogen, start empiric antibiotic therapy as soon as possible. Preferred and alternative agents for specific age groups, immunization status, and specific pathogen(s) appear in TABLE 2.1,19
TABLE 2
Empiric outpatient antibiotic therapy for pediatric CAP1,19
Duration of treatment is 10 days unless otherwise noted
| Patient age | Presumed bacterial pneumonia | Presumed atypical pneumonia |
|---|---|---|
| 3 mo to <5 y, regardless of immunization status | Preferred: amoxicillin 90 mg/kg/d PO in 2 divided doses Alternative: amoxicillin clavulanate 90 mg/kg/d PO in 2 divided doses | For all children regardless of age and immunization status: Preferred: azithromycin 10 mg/kg PO on Day 1, followed by 5 mg/kg PO once daily on Days 2-5 Alternative: clarithromycin 15 mg/kg/d PO in 2 divided doses OR In children >7 y: erythromycin 40 mg/kg/d PO in 4 divided doses; or doxycycline 2-4 mg/kg/d PO in 2 divided doses |
| ≥5 y and fully immunized against Streptococcus pneumoniae and Haemophilus influenzae | Preferred:* amoxicillin 90 mg/kg/d PO in 2 divided doses to a maximum 4 g/d, with or without a macrolide antibiotic Alternatives: Second- or third-generation cephalosporins such as oral cefpodoxime, cefuroxime, or cefprozil OR levofloxacin (5-16 y) 8-10 mg/kg PO once daily (max 750 mg/d)†OR linezolid (<12 y) 30 mg/kg/d PO (max 1200 mg/d) in 3 divided doses; or (≥12 y) 20 mg/kg/d (max 1200 mg/d) in 2 divided doses | |
| ≥5 y and NOT fully immunized against S pneumoniae and H influenzae | Preferred:* amoxicillin 90 mg/kg/d PO in 2 divided doses to a max of 4 g/d; or amoxicillin clavulanate 90 mg/kg/d PO in 2 divided doses Alternatives: Second- or third-generation cephalosporins such as oral cefpodoxime, cefuroxime, or cefprozil OR levofloxacin (5-16 y) 8-10 mg/kg PO once daily (max 750 mg/d)† | |
| CAP, community-acquired pneumonia. *Preferred treatments of choice change in areas of high S pneumoniae resistance. Refer to the complete guidelines for specific recommendations. †The guidelines do not fully address the controversy concerning the use of quinolones in children. The use of quinolones in infants and children is considered a risk vs benefit decision. | ||
Patients with mild or moderate CAP may be treated first in the outpatient setting with amoxicillin. This antibiotic has been the agent of choice for many years and continues to be the empiric therapy recommended in the guidelines.1 Appropriate dosing depends on the age of the patient.
TABLE 2 also includes treatment alternatives to amoxicillin for patients with drug allergies, treatment failures, or suspected atypical pathogens. Amoxicillin and the alternative treatments provide coverage for S pneumoniae, the most common invasive bacterial pathogen in older children.1,20 When atypical pathogens are suspected, macrolide antibiotics become the antibiotic drug class of choice, with azithromycin being the preferred first-line agent.1,21-23
Bacterial CAP necessitating hospitalization. The guidelines strongly recommend hospitalization for infants and children with respiratory distress or hypoxemia (oxygen saturation <90%); for suspicion of infection caused by community-acquired methicillin-resistant Staphylococcus aureus (MRSA) or any pathogen with high virulence; or for infants 3 to 6 months old.1
Treat with parenteral antibiotics to provide reliable blood and tissue concentrations (TABLE 3).1,19 Ampicillin or penicillin G may be given to fully immunized children; however, take into account the local resistance pattern of S pneumoniae to drugs within the penicillin class. For hospitalized children who are not yet fully immunized, who have life-threatening infections, or who are in a facility with a documented high rate of penicillin resistance, administer a third-generation parenteral cephalosporin such as ceftriaxone or cefotaxime empirically.1,24 In monotherapy treatment of pneumococcal pneumonia, non–beta-lactam agents such as vancomycin have not been shown to be more effective than the third-generation cephalosporins.1
TABLE 3
Empiric antibiotic therapy for hospitalized patients with CAP1,19
Duration of treatment is 10 days unless otherwise noted
| Patient age | Presumed bacterial pneumonia | Presumed atypical pneumonia |
|---|---|---|
| 3 mo to <5 y and fully immunized against Streptococcus pneumoniae and Haemophilus influenzae | Preferred:* ampicillin 150-200 mg/kg/d IV divided every 6 h; or penicillin G 200,000-250,000 units/kg/d IV divided every 4-6 h Alternatives: ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h | For all children regardless of age and immunization status: Preferred: azithromycin, 10 mg/kg IV (max of 500 mg) on Days 1 and 2, then transition to oral therapy 10 mg/kg/d for remaining 7-10 days of therapy Alternatives: erythromycin lactobionate 20 mg/kg/d IV divided every 6 h; or levofloxacin 16-20 mg/kg/d IV divided every 12 h to a max of 750 mg/d† |
| <5 y and NOT fully immunized against S pneumoniae and H influenzae | Preferred:* ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h Alternative: levofloxacin (6 mo–<5 y) 16-20 mg/kg/d IV divided every 12 h† | |
| ≥5 y and fully immunized against S pneumoniae and H influenzae | Preferred:* ampicillin 150-200 mg/kg/d IV divided every 6 h; or penicillin G 200,000-250,000 units/kg/d IV divided every 4-6 h Alternatives: ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h | |
| ≥5 y and NOT fully immunized against S pneumoniae and H influenzae | Preferred:* ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h Alternatives: ampicillin 150-200 mg/kg/d IV divided every 6 h; or levofloxacin 8-10 mg/kg IV once daily (max of 750 mg/d)† | |
| CAP, community-acquired pneumonia. *The addition of clindamycin 40 mg/kg/d IV divided every 6-8 hours or vancomycin 40-60 mg/kg/day IV divided every 6-8 hours is recommended for suspected or confirmed community-acquired methicillin-resistant Staphylococcus aureus. †The guidelines do not fully address the controversy concerning the use of quinolones in children. Use of quinolones in infants and children is considered a risk vs benefit decision. | ||
If S aureus is the suspected microorganism or is confirmed with clinical, laboratory, or imaging characteristics, give vancomycin or clindamycin with a beta-lactam agent.1,25-26 If you suspect an atypical pathogen such as M pneumoniae or C pneumoniae, start empiric therapy with an oral or parenteral macrolide in combination with a beta-lactam.1
Once a pathogen has been identified, adjust antimicrobial therapy as needed to target the specific microbe, to limit empiric antibiotic exposure, and to help limit the potential for antibiotic resistance.
Duration of treatment. The recommended duration of treatment for CAP is 10 days, supported by clinical data and the practice guidelines.1,27-29 Shorter treatment courses may be effective, especially in mild cases or outpatient treatment.1 Specific pathogens, such as MRSA, may need to be treated longer.30
If a patient is receiving intravenous antibiotics, switch to an oral agent as soon as clinically feasible to decrease risks from parenteral administration, and plan for the earliest possible discharge from the hospital to limit exposure to nosocomial pathogens. Hospital discharge may be considered when a child is clinically stable (improved appetite and activity level, afebrile for 24 hours), mental status is back to baseline or stable, and the pulse oximetry level is >90% on room air for at least 24 hours.1
Children receiving adequate therapy regimens should demonstrate both clinical and laboratory signs of improvement within 48 to 72 hours.1 If improvement does not occur, further your investigation with additional cultures, laboratory tests, and imaging evaluation.
For preventive measures, the guidelines recommend properly immunizing children with vaccines for bacterial pathogens such as S pneumoniae, Haemophilus influenzae, and Bordetella pertussis.1 Influenza vaccine should also be offered to prevent CAP in infants and children 6 months of age and older. Offer influenza and pertussis vaccines to adults and those caring for infants and children, to help prevent the spread of disease. Also consider immune prophylaxis with RSV-specific monoclonal antibody for premature infants or those with bronchopulmonary dysplasia, congenital heart disease, or immunodeficiency, to decrease the risk of severe pneumonia and hospitalization. For detailed recommendations on the use of prophylaxis against RSV, refer to the 2003 American Academy of Pediatrics statement.31
CORRESPONDENCE
Stephanie Schauner, PharmD, BCPS, University of Missouri-Kansas City, Health Science Building, Room 2241, 2464 Charlotte Street, Kansas City, MO 64108-2792; schauners@umkc.edu
1. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:e25-e76.Available at: http://cid.oxfordjournals.org/content/53/7/e25.long. Accessed December 17, 2012.
2. Centers for Disease Control and Prevention Pneumonia Can Be Prevented–Vaccines Can Help. Available at: http://www.cdc.gov/features/pneumonia. Accessed January 17, 2012.
3. Bulla A, Hitze KL. Acute respiratory infections: a review. Bull World Health Organ. 1978;56:481-498.
4. Baqui AH, Black RE, Arifeen SE, et al. Causes of childhood deaths in Bangladesh: results of a nationwide verbal autopsy study. Bull World Health Organ. 1998;76:161-171.
5. Murphy SL, Xu JQ, Kochanek KD. Deaths: Preliminary data for 2010. National vital statistics reports; vol 60 no 4. Hyattsville, Md: National Center for Health Statistics. 2012. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf. Accessed May 12, 2012.
6. Clinical management of acute respiratory infections in children: a WHO memorandum. Bull World Health Organ. 1981;59:707-716.
7. Feldman C, Anderson R. Community-acquired pneumonia. In; Bone RC, Dantzker DR, George RB, et al, eds. Pulmonary and Critical Care Medicine. Vol 2. St. Louis, Mo: Mosby-Year Book, Inc; 1997:719–733.
8. Davies HD. Community-acquired pneumonia in children. Paediatr Child Health. 2003;8:616-619.
9. Alexander ER, Foy HM, Kenny GE, et al. Pneumonia due to Mycoplasma pneumoniae. Its incidence in the membership of a co-operative medical group. N Engl J Med. 1966;275:131-136.
10. Foy HM, Cooney MK, Maletzky AJ, et al. Incidence and etiology of pneumonia, croup and bronchiolitis in preschool children belonging to a prepaid medical group over a four-year period. Am J Epidemiol. 1973;97:80-92.
11. Murphy TF, Henderson FW, Clyde WA, Jr, et al. Pneumonia: An eleven-year study in a pediatric practice. Am J Epidemiol. 1981;113:12-21.
12. Denny FW, Clyde WA. Acute lower respiratory tract infections in non-hospitalized children. J Pediatr. 1986;108:635-646.
13. Ostapchuk M, Roberts DM, Haddy R. Community-acquired pneumonia in infants and children. Am Fam Phys. 2004;70:899-908.
14. Margolis P, Gadomski A. The rational clinical examination. Does this infant have pneumonia? JAMA. 1998;279:308-313.
15. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax. 2011;66 (suppl 2):ii1-ii23.
16. Gaston B. Pneumonia. Pediatr Rev. 2002;23:132-140.
17. McIntosh K. Community-acquired pneumonia in children. N Engl J Med. 2002;346:429-437.
18. Skolnik N, Tien P. Managing community-acquired pneumonia in infants and children. Fam Pract News. November 10, 2011. Available at: http://www.familypracticenews.com/views/clinical-guidelines-for-family-physicians-by-dr-skolnik/blog/managing-community-acquired-pneumonia-in-infants-and-children/3a77ebb81a.html. Accessed January 17, 2012.
19. O’Mara N. Empiric treatment for pediatric community-acquired pneumonia. Pharmacist’s Letter. November 2011. Available at: http://www.pharmacistletter.com. Accessed February 25, 2012.
20. Klein JO. Bacterial pneumonias. In: Cherry J, Kaplan S, Demmler-Harrison G, eds. Feigin & Cherry’s Textbook of Pediatric Infectious Diseases. 6th ed. Vol 1. Philadelphia, Pa: Saunders/Elsevier; 2009:302–314.
21. Morita JY, Kahn E, Thompson T, et al. Impact of azithromycin on oropharyngeal carriage of group A Streptococcus and nasopharyngeal carriage of macrolide-resistant Streptococcus pneumoniae. Pediatr Infect Dis J. 2000;19:41-46.
22. Block S, Hedrick J, Hammerschlag MR, et al. Mycoplasma pneumoniae and Chlamydia pneumoniae in pediatric community-acquired pneumonia: comparative efficacy and safety of clarithromycin vs. erythromycin ethylsuccinate. Pediatr Infect Dis J. 1995;14:471-477.
23. Harris JA, Kolokathis A, Campbell M, et al. Safety and efficacy of azithromycin in the treatment of community-acquired pneumonia in children. Pediatr Infect Dis J. 1998;17:865-871.
24. Pallares R, Capdevila O, Linares J, et al. The effect of cephalosporin resistance on mortality in adult patients with nonmeningeal systemic pneumococcal infections. Am J Med. 2002;113:120-126.
25. Roson B, Carratala J, Tubau F, et al. Usefulness of betalactam therapy for community-acquired pneumonia in the era of drug-resistant Streptococcus pneumoniae: a randomized study of amoxicillin-clavulanate and ceftriaxone. Microb Drug Resist. 2001;7:85-96.
26. Miller LG, Kaplan SL. Staphylococcus aureus: a community pathogen. Infect Dis Clin North Am. 2009;23:35-52.
27. Haider BA, Saeed MA, Bhutta ZA. Short-course versus long-course antibiotic therapy for non-severe community-acquired pneumonia in children aged 2 months to 59 months. Cochrane Database Syst Rev. 2008;(2):CD005976.-
28. Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38:1651-1672.
29. Bradley JS, Ching DK, Hart CL. Invasive bacterial disease in childhood: efficacy of oral antibiotic therapy following short course parenteral therapy in non-central nervous system infections. Pediatr Infect Dis J. 1987;6:821-825.
30. Blaschke AJ, Heyrend C, Byington CL, et al. Molecular analysis improves pathogen identification and epidemiologic study of pediatric parapneumonic empyema. Pediatr Infect Dis J. 2011;30:289-294.
31. American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborn. Revised indications for the use of palivizumab and RSV immune globulin intravenous for the prevention of respiratory syncytial virus infection. Pediatrics. 2003;112:1442-1446.
1. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:e25-e76.Available at: http://cid.oxfordjournals.org/content/53/7/e25.long. Accessed December 17, 2012.
2. Centers for Disease Control and Prevention Pneumonia Can Be Prevented–Vaccines Can Help. Available at: http://www.cdc.gov/features/pneumonia. Accessed January 17, 2012.
3. Bulla A, Hitze KL. Acute respiratory infections: a review. Bull World Health Organ. 1978;56:481-498.
4. Baqui AH, Black RE, Arifeen SE, et al. Causes of childhood deaths in Bangladesh: results of a nationwide verbal autopsy study. Bull World Health Organ. 1998;76:161-171.
5. Murphy SL, Xu JQ, Kochanek KD. Deaths: Preliminary data for 2010. National vital statistics reports; vol 60 no 4. Hyattsville, Md: National Center for Health Statistics. 2012. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf. Accessed May 12, 2012.
6. Clinical management of acute respiratory infections in children: a WHO memorandum. Bull World Health Organ. 1981;59:707-716.
7. Feldman C, Anderson R. Community-acquired pneumonia. In; Bone RC, Dantzker DR, George RB, et al, eds. Pulmonary and Critical Care Medicine. Vol 2. St. Louis, Mo: Mosby-Year Book, Inc; 1997:719–733.
8. Davies HD. Community-acquired pneumonia in children. Paediatr Child Health. 2003;8:616-619.
9. Alexander ER, Foy HM, Kenny GE, et al. Pneumonia due to Mycoplasma pneumoniae. Its incidence in the membership of a co-operative medical group. N Engl J Med. 1966;275:131-136.
10. Foy HM, Cooney MK, Maletzky AJ, et al. Incidence and etiology of pneumonia, croup and bronchiolitis in preschool children belonging to a prepaid medical group over a four-year period. Am J Epidemiol. 1973;97:80-92.
11. Murphy TF, Henderson FW, Clyde WA, Jr, et al. Pneumonia: An eleven-year study in a pediatric practice. Am J Epidemiol. 1981;113:12-21.
12. Denny FW, Clyde WA. Acute lower respiratory tract infections in non-hospitalized children. J Pediatr. 1986;108:635-646.
13. Ostapchuk M, Roberts DM, Haddy R. Community-acquired pneumonia in infants and children. Am Fam Phys. 2004;70:899-908.
14. Margolis P, Gadomski A. The rational clinical examination. Does this infant have pneumonia? JAMA. 1998;279:308-313.
15. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax. 2011;66 (suppl 2):ii1-ii23.
16. Gaston B. Pneumonia. Pediatr Rev. 2002;23:132-140.
17. McIntosh K. Community-acquired pneumonia in children. N Engl J Med. 2002;346:429-437.
18. Skolnik N, Tien P. Managing community-acquired pneumonia in infants and children. Fam Pract News. November 10, 2011. Available at: http://www.familypracticenews.com/views/clinical-guidelines-for-family-physicians-by-dr-skolnik/blog/managing-community-acquired-pneumonia-in-infants-and-children/3a77ebb81a.html. Accessed January 17, 2012.
19. O’Mara N. Empiric treatment for pediatric community-acquired pneumonia. Pharmacist’s Letter. November 2011. Available at: http://www.pharmacistletter.com. Accessed February 25, 2012.
20. Klein JO. Bacterial pneumonias. In: Cherry J, Kaplan S, Demmler-Harrison G, eds. Feigin & Cherry’s Textbook of Pediatric Infectious Diseases. 6th ed. Vol 1. Philadelphia, Pa: Saunders/Elsevier; 2009:302–314.
21. Morita JY, Kahn E, Thompson T, et al. Impact of azithromycin on oropharyngeal carriage of group A Streptococcus and nasopharyngeal carriage of macrolide-resistant Streptococcus pneumoniae. Pediatr Infect Dis J. 2000;19:41-46.
22. Block S, Hedrick J, Hammerschlag MR, et al. Mycoplasma pneumoniae and Chlamydia pneumoniae in pediatric community-acquired pneumonia: comparative efficacy and safety of clarithromycin vs. erythromycin ethylsuccinate. Pediatr Infect Dis J. 1995;14:471-477.
23. Harris JA, Kolokathis A, Campbell M, et al. Safety and efficacy of azithromycin in the treatment of community-acquired pneumonia in children. Pediatr Infect Dis J. 1998;17:865-871.
24. Pallares R, Capdevila O, Linares J, et al. The effect of cephalosporin resistance on mortality in adult patients with nonmeningeal systemic pneumococcal infections. Am J Med. 2002;113:120-126.
25. Roson B, Carratala J, Tubau F, et al. Usefulness of betalactam therapy for community-acquired pneumonia in the era of drug-resistant Streptococcus pneumoniae: a randomized study of amoxicillin-clavulanate and ceftriaxone. Microb Drug Resist. 2001;7:85-96.
26. Miller LG, Kaplan SL. Staphylococcus aureus: a community pathogen. Infect Dis Clin North Am. 2009;23:35-52.
27. Haider BA, Saeed MA, Bhutta ZA. Short-course versus long-course antibiotic therapy for non-severe community-acquired pneumonia in children aged 2 months to 59 months. Cochrane Database Syst Rev. 2008;(2):CD005976.-
28. Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38:1651-1672.
29. Bradley JS, Ching DK, Hart CL. Invasive bacterial disease in childhood: efficacy of oral antibiotic therapy following short course parenteral therapy in non-central nervous system infections. Pediatr Infect Dis J. 1987;6:821-825.
30. Blaschke AJ, Heyrend C, Byington CL, et al. Molecular analysis improves pathogen identification and epidemiologic study of pediatric parapneumonic empyema. Pediatr Infect Dis J. 2011;30:289-294.
31. American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborn. Revised indications for the use of palivizumab and RSV immune globulin intravenous for the prevention of respiratory syncytial virus infection. Pediatrics. 2003;112:1442-1446.
Children frequently bullied due to food allergies
One in three children treated at a food allergy clinic reported being bullied specifically because of food allergies, suggesting higher rates of bullying than the approximately 17% previously reported in the U.S. general population.
Although bullying was significantly associated with a lower quality of life and higher distress levels in the children and in the parents of bullied children, parental knowledge of the bullying mediated these measures in both parents and children, according to a study published Dec. 24 in Pediatrics.
Parents were aware of only 52% of their children’s reports of bullying in this sample, but "when parents knew that their children [were] being bullied for any reason, the parents’ quality of life was significantly lower, and the child’s quality of life was significantly better," reported Dr. Eyal Shemesh at New York’s Mount Sinai Medical Center and his associates (Pediatrics 2012 Dec. 24 [doi:10.1542/peds.2012-1180]).
The data come from 251 predominantly white, affluent families who visited Mount Sinai’s Elliot and Roslyn Jaffe Food Allergy Institute between April 2011 and November 2011. All the children participating, aged 8-17 years, had at least one diagnosed food allergy and completed modified versions of the Revised Olweus Bully/Victim Questionnaire. Their parents filled out separate surveys about their children’s experiences of being bullied.
Quality of life and distress were assessed using the Multidimensional Anxiety Scale for Children10 items and the Pediatric Quality of Life Inventory 4.0 in children and the Impact of Events Scale and 17-item Food Allergy Quality of Life Parental Burden in the parents.
The researchers attempted to control for the burden of the food allergy’s severity as a possible confounder in the relationship among bullying, quality of life, and distress by including in the analysis the number of allergies each child had and whether the parents had ever had to use epinephrine.
Nearly half of the children (45%) reported being bullied for any reason (compared with 36% of parents who reported knowing their child had been bullied), and 32% reported being bullied specifically because of their food allergy (compared with 25% of parents reporting knowledge of food allergy–specific bullying).
Although being teased was the most common form of bullying (42% of children), 30% reported having food waved at them, 12% had been forced to touch food, and 10% had had food thrown at them.
Most of the bullying (60%) occurred at school, and classmates were the most common perpetrators, reported by 80% of the bullied children. The children also reported being bullied about food allergies by other students at the school (34%), teachers or staff (11%), and siblings (13%).
Meanwhile, 87% of the children said they told someone about the bullying, usually their parents (71%), a teacher (35%), or a friend (32%). Since children’s quality of life was better and anxiety was lower when their parents knew about the bullying, the researchers suggested that helping children identify and report bullying appears to lessen its impact.
Children reporting frequent bullying had significantly worse quality of life scores compared with children bullied less, but there were no significant differences in anxiety levels between children bullied more or less often.
Limitations of the study included self-reporting and the possibility that children’s reports of bullying due to food allergy and bullying for any reason were conflated. The primarily white, affluent children are also not representative of the general population, and the study lacked a control group of children without food allergies.
Funding for the study came from the Jaffe Family Foundation, the National Institute of Allergy and Infectious Diseases, the Food Allergy Initiative, and and the National Institute of Diabetes and Digestive and Kidney Diseases. One of Dr. Shemesh’s associates in the study, Dr. Scott H. Sicherer, consults for the Food Allergy Initiative and is an adviser for the Food Allergy and Anaphylaxis Network.
Bullies are familiar as the characters we have always loved to hate in television, films, and books, but bullies have recently become something more, said Dr. Mark Schuster and Dr. Laura Bogart. "The bully is no longer simply a representation of a moral lesson or a source of humor."
The bully is now also recognized as a source of long-term health issues, including depression, anxiety, posttraumatic stress, and suicidal ideation. But bullies can be motivated by others’ health conditions, too. Dr. Shemesh’s article about high rates of bullying related to children’s food allergies "underscores the importance of addressing food allergies in a way that protects but does not stigmatize children who have them."
Clinicians should watch for signs a child is being bullied – including emotional symptoms and chronic physical symptoms, as well as physical bruises and scratches – paying particular attention to children with "stigmatizing characteristics that could lead to bullying," such as obesity, disabilities, or gender nonconformity. Providers must also involve parents in recognizing bullying and its harmful long-term effects and making sure they are neither ignoring nor engaging in bullying themselves. "We need a cultural evolution in awareness and repudiation of bullying."
Dr. Schuster is at Boston Children’s Hospital and Dr. Bogart is at Harvard Medical School, Boston. Their comments were taken from an editorial accompanying Dr. Shemesh’s study (Pediatrics 2012 Dec. 24 [doi:10.1542/peds.2012-3253]).
Bullies are familiar as the characters we have always loved to hate in television, films, and books, but bullies have recently become something more, said Dr. Mark Schuster and Dr. Laura Bogart. "The bully is no longer simply a representation of a moral lesson or a source of humor."
The bully is now also recognized as a source of long-term health issues, including depression, anxiety, posttraumatic stress, and suicidal ideation. But bullies can be motivated by others’ health conditions, too. Dr. Shemesh’s article about high rates of bullying related to children’s food allergies "underscores the importance of addressing food allergies in a way that protects but does not stigmatize children who have them."
Clinicians should watch for signs a child is being bullied – including emotional symptoms and chronic physical symptoms, as well as physical bruises and scratches – paying particular attention to children with "stigmatizing characteristics that could lead to bullying," such as obesity, disabilities, or gender nonconformity. Providers must also involve parents in recognizing bullying and its harmful long-term effects and making sure they are neither ignoring nor engaging in bullying themselves. "We need a cultural evolution in awareness and repudiation of bullying."
Dr. Schuster is at Boston Children’s Hospital and Dr. Bogart is at Harvard Medical School, Boston. Their comments were taken from an editorial accompanying Dr. Shemesh’s study (Pediatrics 2012 Dec. 24 [doi:10.1542/peds.2012-3253]).
Bullies are familiar as the characters we have always loved to hate in television, films, and books, but bullies have recently become something more, said Dr. Mark Schuster and Dr. Laura Bogart. "The bully is no longer simply a representation of a moral lesson or a source of humor."
The bully is now also recognized as a source of long-term health issues, including depression, anxiety, posttraumatic stress, and suicidal ideation. But bullies can be motivated by others’ health conditions, too. Dr. Shemesh’s article about high rates of bullying related to children’s food allergies "underscores the importance of addressing food allergies in a way that protects but does not stigmatize children who have them."
Clinicians should watch for signs a child is being bullied – including emotional symptoms and chronic physical symptoms, as well as physical bruises and scratches – paying particular attention to children with "stigmatizing characteristics that could lead to bullying," such as obesity, disabilities, or gender nonconformity. Providers must also involve parents in recognizing bullying and its harmful long-term effects and making sure they are neither ignoring nor engaging in bullying themselves. "We need a cultural evolution in awareness and repudiation of bullying."
Dr. Schuster is at Boston Children’s Hospital and Dr. Bogart is at Harvard Medical School, Boston. Their comments were taken from an editorial accompanying Dr. Shemesh’s study (Pediatrics 2012 Dec. 24 [doi:10.1542/peds.2012-3253]).
One in three children treated at a food allergy clinic reported being bullied specifically because of food allergies, suggesting higher rates of bullying than the approximately 17% previously reported in the U.S. general population.
Although bullying was significantly associated with a lower quality of life and higher distress levels in the children and in the parents of bullied children, parental knowledge of the bullying mediated these measures in both parents and children, according to a study published Dec. 24 in Pediatrics.
Parents were aware of only 52% of their children’s reports of bullying in this sample, but "when parents knew that their children [were] being bullied for any reason, the parents’ quality of life was significantly lower, and the child’s quality of life was significantly better," reported Dr. Eyal Shemesh at New York’s Mount Sinai Medical Center and his associates (Pediatrics 2012 Dec. 24 [doi:10.1542/peds.2012-1180]).
The data come from 251 predominantly white, affluent families who visited Mount Sinai’s Elliot and Roslyn Jaffe Food Allergy Institute between April 2011 and November 2011. All the children participating, aged 8-17 years, had at least one diagnosed food allergy and completed modified versions of the Revised Olweus Bully/Victim Questionnaire. Their parents filled out separate surveys about their children’s experiences of being bullied.
Quality of life and distress were assessed using the Multidimensional Anxiety Scale for Children10 items and the Pediatric Quality of Life Inventory 4.0 in children and the Impact of Events Scale and 17-item Food Allergy Quality of Life Parental Burden in the parents.
The researchers attempted to control for the burden of the food allergy’s severity as a possible confounder in the relationship among bullying, quality of life, and distress by including in the analysis the number of allergies each child had and whether the parents had ever had to use epinephrine.
Nearly half of the children (45%) reported being bullied for any reason (compared with 36% of parents who reported knowing their child had been bullied), and 32% reported being bullied specifically because of their food allergy (compared with 25% of parents reporting knowledge of food allergy–specific bullying).
Although being teased was the most common form of bullying (42% of children), 30% reported having food waved at them, 12% had been forced to touch food, and 10% had had food thrown at them.
Most of the bullying (60%) occurred at school, and classmates were the most common perpetrators, reported by 80% of the bullied children. The children also reported being bullied about food allergies by other students at the school (34%), teachers or staff (11%), and siblings (13%).
Meanwhile, 87% of the children said they told someone about the bullying, usually their parents (71%), a teacher (35%), or a friend (32%). Since children’s quality of life was better and anxiety was lower when their parents knew about the bullying, the researchers suggested that helping children identify and report bullying appears to lessen its impact.
Children reporting frequent bullying had significantly worse quality of life scores compared with children bullied less, but there were no significant differences in anxiety levels between children bullied more or less often.
Limitations of the study included self-reporting and the possibility that children’s reports of bullying due to food allergy and bullying for any reason were conflated. The primarily white, affluent children are also not representative of the general population, and the study lacked a control group of children without food allergies.
Funding for the study came from the Jaffe Family Foundation, the National Institute of Allergy and Infectious Diseases, the Food Allergy Initiative, and and the National Institute of Diabetes and Digestive and Kidney Diseases. One of Dr. Shemesh’s associates in the study, Dr. Scott H. Sicherer, consults for the Food Allergy Initiative and is an adviser for the Food Allergy and Anaphylaxis Network.
One in three children treated at a food allergy clinic reported being bullied specifically because of food allergies, suggesting higher rates of bullying than the approximately 17% previously reported in the U.S. general population.
Although bullying was significantly associated with a lower quality of life and higher distress levels in the children and in the parents of bullied children, parental knowledge of the bullying mediated these measures in both parents and children, according to a study published Dec. 24 in Pediatrics.
Parents were aware of only 52% of their children’s reports of bullying in this sample, but "when parents knew that their children [were] being bullied for any reason, the parents’ quality of life was significantly lower, and the child’s quality of life was significantly better," reported Dr. Eyal Shemesh at New York’s Mount Sinai Medical Center and his associates (Pediatrics 2012 Dec. 24 [doi:10.1542/peds.2012-1180]).
The data come from 251 predominantly white, affluent families who visited Mount Sinai’s Elliot and Roslyn Jaffe Food Allergy Institute between April 2011 and November 2011. All the children participating, aged 8-17 years, had at least one diagnosed food allergy and completed modified versions of the Revised Olweus Bully/Victim Questionnaire. Their parents filled out separate surveys about their children’s experiences of being bullied.
Quality of life and distress were assessed using the Multidimensional Anxiety Scale for Children10 items and the Pediatric Quality of Life Inventory 4.0 in children and the Impact of Events Scale and 17-item Food Allergy Quality of Life Parental Burden in the parents.
The researchers attempted to control for the burden of the food allergy’s severity as a possible confounder in the relationship among bullying, quality of life, and distress by including in the analysis the number of allergies each child had and whether the parents had ever had to use epinephrine.
Nearly half of the children (45%) reported being bullied for any reason (compared with 36% of parents who reported knowing their child had been bullied), and 32% reported being bullied specifically because of their food allergy (compared with 25% of parents reporting knowledge of food allergy–specific bullying).
Although being teased was the most common form of bullying (42% of children), 30% reported having food waved at them, 12% had been forced to touch food, and 10% had had food thrown at them.
Most of the bullying (60%) occurred at school, and classmates were the most common perpetrators, reported by 80% of the bullied children. The children also reported being bullied about food allergies by other students at the school (34%), teachers or staff (11%), and siblings (13%).
Meanwhile, 87% of the children said they told someone about the bullying, usually their parents (71%), a teacher (35%), or a friend (32%). Since children’s quality of life was better and anxiety was lower when their parents knew about the bullying, the researchers suggested that helping children identify and report bullying appears to lessen its impact.
Children reporting frequent bullying had significantly worse quality of life scores compared with children bullied less, but there were no significant differences in anxiety levels between children bullied more or less often.
Limitations of the study included self-reporting and the possibility that children’s reports of bullying due to food allergy and bullying for any reason were conflated. The primarily white, affluent children are also not representative of the general population, and the study lacked a control group of children without food allergies.
Funding for the study came from the Jaffe Family Foundation, the National Institute of Allergy and Infectious Diseases, the Food Allergy Initiative, and and the National Institute of Diabetes and Digestive and Kidney Diseases. One of Dr. Shemesh’s associates in the study, Dr. Scott H. Sicherer, consults for the Food Allergy Initiative and is an adviser for the Food Allergy and Anaphylaxis Network.
FROM PEDIATRICS
Major Finding: A third (32%) of children reported being bullied because of a food allergy; 25% of parents reported knowing their child was bullied for the same reason.
Data Source: Child and parent surveys from 251 families visiting Jaffe Food Allergy Institute at Mount Sinai Medical Center, New York.
Disclosures: Funding was provided by the Jaffe Family Foundation and several of the National Institutes of Health. One of Dr. Shemesh’s associates in the study, Dr. Scott H. Sicherer, consults for the Food Allergy Initiative and the Food Allergy and Anaphylaxis Network.
Acetazolamide and CPAP combined improve OSA at high altitude
Using a combination treatment of acetazolamide and auto-CPAP therapy in patients with obstructive sleep apnea traveling to high altitudes was more effective than CPAP use alone, according to a study published in JAMA.
Patients with obstructive sleep apnea (OSA) who took acetazolamide and used CPAP at two different altitudes higher than baseline had lower apnea/hypopnea index scores and higher nighttime oxygen saturation percentages than patients who took a placebo and used CPAP.
Dr. Tsogyal Latshang and associates at the University Hospital Zurich reported the results of their randomized, placebo-controlled, double-blind crossover study with 51 OSA patients in JAMA Dec. 12 (2012 [doi:10.1001/jama.2012.94847]).
All the patients, who normally live below 800 meters altitude and use CPAP regularly, underwent sleep studies during the summer of 2009, first at the University Hospital Zurich (490 m) and then at two Swiss mountain resorts, one at 1,630 m and one at 2,590 m, during two 3-day trips.
The patients took either acetazolamide or a placebo while spending 2 days at 1,630 m and 1 day at 2,590 m. The acetazolamide was dispensed as one 250-mg dose each morning and two 250-mg doses each evening before meals; the placebo looked identical.
After 2 weeks spent below 800 m following the first 3-day trip, the patients then spent another 3 days at the high-altitude resorts to take the other intervention (acetazolamide or placebo). During the sleep studies, instead of using their own CPAP devices, the patients all used the same type of autoadjusting CPAP machine with their own masks.
The combination therapy of acetazolamide and CPAP increased the patients’ median nighttime oxygen saturation at 1,630 meters by 1%, from 93% with placebo to 94% with combination therapy. At 2,590 meters, the increase was 2%, from 89% with placebo to 91% with combination therapy. At the higher altitude, patients receiving combination therapy spent a median 13% of nighttime sleep with oxygen saturation below 90%, compared to a median of 57% (P less than .001) below 90% oxygen saturation with placebo.
Patients receiving combination therapy also had lower apnea/hypopnea index scores at both altitudes, compared with placebo. The median at baseline, in the hospital at 490 meters with CPAP only, was 6.6 events/hour. At 1,630 meters, patients with placebo had a median 10.7 events/h, compared with 5.8 when taking acetazolamide. At 2,590 m, patients’ median apnea/hypopnea index improved from 19.3 events/h with placebo to 6.8 with acetazolamide. (All P values under .001)
"The reduction in the apnea/hypopnea index was mainly related to a lower number of central apneas/hypopneas, particularly during nonrapid eye movement sleep, but obstructive apneas/hypopneas were slightly reduced as well (at 2,590 m)," the researchers reported.
Secondary outcomes measured included sleep time, exercise performance, vigilance symptoms, and adverse effects. Patients taking acetazolamide slept a median 24 minutes more (451 minutes, compared with 427) at 1,630 m and 34 minutes more (446 minutes, compared with 412) at 2,590 m (P less than .001). Sleep efficiency and nonrapid eye movement sleep were also higher with combination therapy than placebo, although self-reported daytime sleepiness was not significantly different.
Patients’ heart rate was slightly lower with combination therapy (59 beats per minute, compared with 60 at 1,630 m; and 61 bmp, compared with 64 at 2,590 m), and patients taking acetazolamide had lower blood pressure at altitude than with placebo (96 mm HG, compared with 101 mm HG at 1,630 m; and 99 mm HG, compared with 104 mm HG at 2,590 m; P < .05)
The most common adverse effects reported with acetazolamide were an unpleasant taste in the mouth and mild to moderate paresthesias, but no patients discontinued therapy. Primary study limitations include the limited ability to generalize beyond short high-altitude duration and beyond the predominantly middle-aged male cohort, who were moderately obese and had only stable comorbidities.
The study was funded by grants from the Swiss National Science Foundation, Lung Leagues of Zurich and Schaffhausen, Center for Clinical Research, University of Zurich, University Hospital Zurich, and Philips Respironics (unconditional grant) in Switzerland. The only disclosure reported was Dr. Bloch’s consultancy for IMT Medical and his receipt of unconditional institutional grants from Philips Respironics and ResMed.
Dr. Paul A. Selecky comments: Very interesting findings that will be useful to physicians with OSA patients who want to go to higher altitudes.
Dr. Paul A. Selecky |
Dr. Paul A. Selecky comments: Very interesting findings that will be useful to physicians with OSA patients who want to go to higher altitudes.
Dr. Paul A. Selecky |
Dr. Paul A. Selecky comments: Very interesting findings that will be useful to physicians with OSA patients who want to go to higher altitudes.
Dr. Paul A. Selecky |
Using a combination treatment of acetazolamide and auto-CPAP therapy in patients with obstructive sleep apnea traveling to high altitudes was more effective than CPAP use alone, according to a study published in JAMA.
Patients with obstructive sleep apnea (OSA) who took acetazolamide and used CPAP at two different altitudes higher than baseline had lower apnea/hypopnea index scores and higher nighttime oxygen saturation percentages than patients who took a placebo and used CPAP.
Dr. Tsogyal Latshang and associates at the University Hospital Zurich reported the results of their randomized, placebo-controlled, double-blind crossover study with 51 OSA patients in JAMA Dec. 12 (2012 [doi:10.1001/jama.2012.94847]).
All the patients, who normally live below 800 meters altitude and use CPAP regularly, underwent sleep studies during the summer of 2009, first at the University Hospital Zurich (490 m) and then at two Swiss mountain resorts, one at 1,630 m and one at 2,590 m, during two 3-day trips.
The patients took either acetazolamide or a placebo while spending 2 days at 1,630 m and 1 day at 2,590 m. The acetazolamide was dispensed as one 250-mg dose each morning and two 250-mg doses each evening before meals; the placebo looked identical.
After 2 weeks spent below 800 m following the first 3-day trip, the patients then spent another 3 days at the high-altitude resorts to take the other intervention (acetazolamide or placebo). During the sleep studies, instead of using their own CPAP devices, the patients all used the same type of autoadjusting CPAP machine with their own masks.
The combination therapy of acetazolamide and CPAP increased the patients’ median nighttime oxygen saturation at 1,630 meters by 1%, from 93% with placebo to 94% with combination therapy. At 2,590 meters, the increase was 2%, from 89% with placebo to 91% with combination therapy. At the higher altitude, patients receiving combination therapy spent a median 13% of nighttime sleep with oxygen saturation below 90%, compared to a median of 57% (P less than .001) below 90% oxygen saturation with placebo.
Patients receiving combination therapy also had lower apnea/hypopnea index scores at both altitudes, compared with placebo. The median at baseline, in the hospital at 490 meters with CPAP only, was 6.6 events/hour. At 1,630 meters, patients with placebo had a median 10.7 events/h, compared with 5.8 when taking acetazolamide. At 2,590 m, patients’ median apnea/hypopnea index improved from 19.3 events/h with placebo to 6.8 with acetazolamide. (All P values under .001)
"The reduction in the apnea/hypopnea index was mainly related to a lower number of central apneas/hypopneas, particularly during nonrapid eye movement sleep, but obstructive apneas/hypopneas were slightly reduced as well (at 2,590 m)," the researchers reported.
Secondary outcomes measured included sleep time, exercise performance, vigilance symptoms, and adverse effects. Patients taking acetazolamide slept a median 24 minutes more (451 minutes, compared with 427) at 1,630 m and 34 minutes more (446 minutes, compared with 412) at 2,590 m (P less than .001). Sleep efficiency and nonrapid eye movement sleep were also higher with combination therapy than placebo, although self-reported daytime sleepiness was not significantly different.
Patients’ heart rate was slightly lower with combination therapy (59 beats per minute, compared with 60 at 1,630 m; and 61 bmp, compared with 64 at 2,590 m), and patients taking acetazolamide had lower blood pressure at altitude than with placebo (96 mm HG, compared with 101 mm HG at 1,630 m; and 99 mm HG, compared with 104 mm HG at 2,590 m; P < .05)
The most common adverse effects reported with acetazolamide were an unpleasant taste in the mouth and mild to moderate paresthesias, but no patients discontinued therapy. Primary study limitations include the limited ability to generalize beyond short high-altitude duration and beyond the predominantly middle-aged male cohort, who were moderately obese and had only stable comorbidities.
The study was funded by grants from the Swiss National Science Foundation, Lung Leagues of Zurich and Schaffhausen, Center for Clinical Research, University of Zurich, University Hospital Zurich, and Philips Respironics (unconditional grant) in Switzerland. The only disclosure reported was Dr. Bloch’s consultancy for IMT Medical and his receipt of unconditional institutional grants from Philips Respironics and ResMed.
Using a combination treatment of acetazolamide and auto-CPAP therapy in patients with obstructive sleep apnea traveling to high altitudes was more effective than CPAP use alone, according to a study published in JAMA.
Patients with obstructive sleep apnea (OSA) who took acetazolamide and used CPAP at two different altitudes higher than baseline had lower apnea/hypopnea index scores and higher nighttime oxygen saturation percentages than patients who took a placebo and used CPAP.
Dr. Tsogyal Latshang and associates at the University Hospital Zurich reported the results of their randomized, placebo-controlled, double-blind crossover study with 51 OSA patients in JAMA Dec. 12 (2012 [doi:10.1001/jama.2012.94847]).
All the patients, who normally live below 800 meters altitude and use CPAP regularly, underwent sleep studies during the summer of 2009, first at the University Hospital Zurich (490 m) and then at two Swiss mountain resorts, one at 1,630 m and one at 2,590 m, during two 3-day trips.
The patients took either acetazolamide or a placebo while spending 2 days at 1,630 m and 1 day at 2,590 m. The acetazolamide was dispensed as one 250-mg dose each morning and two 250-mg doses each evening before meals; the placebo looked identical.
After 2 weeks spent below 800 m following the first 3-day trip, the patients then spent another 3 days at the high-altitude resorts to take the other intervention (acetazolamide or placebo). During the sleep studies, instead of using their own CPAP devices, the patients all used the same type of autoadjusting CPAP machine with their own masks.
The combination therapy of acetazolamide and CPAP increased the patients’ median nighttime oxygen saturation at 1,630 meters by 1%, from 93% with placebo to 94% with combination therapy. At 2,590 meters, the increase was 2%, from 89% with placebo to 91% with combination therapy. At the higher altitude, patients receiving combination therapy spent a median 13% of nighttime sleep with oxygen saturation below 90%, compared to a median of 57% (P less than .001) below 90% oxygen saturation with placebo.
Patients receiving combination therapy also had lower apnea/hypopnea index scores at both altitudes, compared with placebo. The median at baseline, in the hospital at 490 meters with CPAP only, was 6.6 events/hour. At 1,630 meters, patients with placebo had a median 10.7 events/h, compared with 5.8 when taking acetazolamide. At 2,590 m, patients’ median apnea/hypopnea index improved from 19.3 events/h with placebo to 6.8 with acetazolamide. (All P values under .001)
"The reduction in the apnea/hypopnea index was mainly related to a lower number of central apneas/hypopneas, particularly during nonrapid eye movement sleep, but obstructive apneas/hypopneas were slightly reduced as well (at 2,590 m)," the researchers reported.
Secondary outcomes measured included sleep time, exercise performance, vigilance symptoms, and adverse effects. Patients taking acetazolamide slept a median 24 minutes more (451 minutes, compared with 427) at 1,630 m and 34 minutes more (446 minutes, compared with 412) at 2,590 m (P less than .001). Sleep efficiency and nonrapid eye movement sleep were also higher with combination therapy than placebo, although self-reported daytime sleepiness was not significantly different.
Patients’ heart rate was slightly lower with combination therapy (59 beats per minute, compared with 60 at 1,630 m; and 61 bmp, compared with 64 at 2,590 m), and patients taking acetazolamide had lower blood pressure at altitude than with placebo (96 mm HG, compared with 101 mm HG at 1,630 m; and 99 mm HG, compared with 104 mm HG at 2,590 m; P < .05)
The most common adverse effects reported with acetazolamide were an unpleasant taste in the mouth and mild to moderate paresthesias, but no patients discontinued therapy. Primary study limitations include the limited ability to generalize beyond short high-altitude duration and beyond the predominantly middle-aged male cohort, who were moderately obese and had only stable comorbidities.
The study was funded by grants from the Swiss National Science Foundation, Lung Leagues of Zurich and Schaffhausen, Center for Clinical Research, University of Zurich, University Hospital Zurich, and Philips Respironics (unconditional grant) in Switzerland. The only disclosure reported was Dr. Bloch’s consultancy for IMT Medical and his receipt of unconditional institutional grants from Philips Respironics and ResMed.
FROM JAMA
Major Finding: The combined use of acetazolamide (750 mg/day) and auto-CPAP therapy for obstructive sleep apnea at high altitudes resulted in higher nighttime oxygen saturation (94% at 1,630 meters and 91% at 2,590 m), compared with placebo (93% and 89%, respectively).
Data Source: A randomized, placebo-controlled, double-blind, crossover trial with 51 obstructive sleep apnea patients.
Disclosures: The study was funded by grants from the Swiss National Science Foundation, Lung Leagues of Zurich and Schaffhausen, Center for Clinical Research, University of Zurich, University Hospital Zurich, and Philips Respironics (unconditional grant) in Switzerland. The only disclosure reported was Dr. Bloch’s consultancy for IMT Medical and his receipt of unconditional institutional grants from Philips Respironics and ResMed.
How long should a cough last?
NEW ORLEANS – Patients tend to underestimate how long a cough should last, leading to unnecessary and inappropriate use of antibiotics, according to a review of the evidence and a survey of patient beliefs.
Cough is the third most frequent reason for physician office visits, and yet doctors and patients don’t seem to have an understanding of the natural history of cough and the expected duration, said Dr. Mark Ebell of the department of epidemiology at the University of Georgia College of Public Health in Athens.
The National Ambulatory Medical Survey in 2007 showed that there were 27 million outpatient visits for cough that year. That constitutes 2%-3% of all family practice visits, said Dr. Ebell. Half of patients received an antibiotic for their cough, and half the time, it was a broad spectrum antibiotic.
"There are some real issues with how we manage cough," said Dr. Ebell. Cough can indicate a condition that needs medical attention and a prescription therapy, but often, it is treated without evidence for antibiotics because the patient or doctor is uncomfortable with its duration.
Before patients ask their doctor how long a cough should last, they are likely to ask Google, he said. In conducting his own Google search, he found estimates ranging from 7 days to 14 days.
To get a sense of what patients think, Dr. Ebell and his colleagues surveyed Georgia residents by adding questions to the Georgia Poll, which is conducted twice a year by the Survey Research Center at the University of Georgia. Potential participants – aged 18 years or older – are randomly selected and contacted by phone. Almost 500 participated; 63% were women. It was an older population because the survey is conducted through landlines.
Participants were asked about their beliefs concerning antibiotics and the effectiveness of these drugs when the main symptom was a cough. They were asked how long they think it would take for the cough to get better if they were not taking any medicine, in six different scenarios: dry cough, coughing up yellow mucus or green mucus, or any of those kinds of cough with a slight fever, or no fever.
Patients with self-reported chronic lung disease or asthma were excluded from the survey.
Some respondents thought they would be better in as few as 2 days. Some thought the cough would last several months, but almost everyone thought it would take less than 2 weeks. There was not much difference between the scenarios, except when the scenario involved green phlegm.
The participants who had previously used antibiotics thought the cough would last longer, as did women, whites, and those with less education.
To determine how long a cough actually does last, Dr. Ebell conducted a literature search. After combing through several 100,000 potential studies, excluding those in sinusitis or people with a clear bacterial diagnosis, and focusing on those in community-dwelling, otherwise healthy adults with undifferentiated acute cough or bronchitis, he and his colleagues were left with 18 studies. In the end, only 5 of those 18 provided useful data.
The mean duration was 17-18 days. "So now we know how long a cough lasts," said Dr. Ebell.
Although the cough usually improves significantly in 2 weeks, most patients think it should be over in a week. "And that’s a big driver, or may be a big driver, of antibiotic use," he said. It may also lead to patients seeking repeat visits after 4 days, or asking for a "better" antibiotic after 8 or 9 days, which results in more prescriptions for broad spectrum antibiotics.
And the next time around, they are likely to say that the only drug that works for them is a broad spectrum antibiotic.
Dr. Ebell and his colleagues said they are exploring the clinical issue further, researching what physicians believe about cough, how messages in the media influence behavior, and whether there might be a discrepancy between the reality of an acute illness – its natural history – and perception.
Most importantly, he said he hopes to determine whether his findings can be used "to educate patients, to educate physicians, and hopefully create more realistic expectations about the duration of a cough [and] the duration of an acute illness, and thereby, hopefully reduce the demand for antibiotics."
Dr. Ebell reported having no relevant financial conflicts.
NEW ORLEANS – Patients tend to underestimate how long a cough should last, leading to unnecessary and inappropriate use of antibiotics, according to a review of the evidence and a survey of patient beliefs.
Cough is the third most frequent reason for physician office visits, and yet doctors and patients don’t seem to have an understanding of the natural history of cough and the expected duration, said Dr. Mark Ebell of the department of epidemiology at the University of Georgia College of Public Health in Athens.
The National Ambulatory Medical Survey in 2007 showed that there were 27 million outpatient visits for cough that year. That constitutes 2%-3% of all family practice visits, said Dr. Ebell. Half of patients received an antibiotic for their cough, and half the time, it was a broad spectrum antibiotic.
"There are some real issues with how we manage cough," said Dr. Ebell. Cough can indicate a condition that needs medical attention and a prescription therapy, but often, it is treated without evidence for antibiotics because the patient or doctor is uncomfortable with its duration.
Before patients ask their doctor how long a cough should last, they are likely to ask Google, he said. In conducting his own Google search, he found estimates ranging from 7 days to 14 days.
To get a sense of what patients think, Dr. Ebell and his colleagues surveyed Georgia residents by adding questions to the Georgia Poll, which is conducted twice a year by the Survey Research Center at the University of Georgia. Potential participants – aged 18 years or older – are randomly selected and contacted by phone. Almost 500 participated; 63% were women. It was an older population because the survey is conducted through landlines.
Participants were asked about their beliefs concerning antibiotics and the effectiveness of these drugs when the main symptom was a cough. They were asked how long they think it would take for the cough to get better if they were not taking any medicine, in six different scenarios: dry cough, coughing up yellow mucus or green mucus, or any of those kinds of cough with a slight fever, or no fever.
Patients with self-reported chronic lung disease or asthma were excluded from the survey.
Some respondents thought they would be better in as few as 2 days. Some thought the cough would last several months, but almost everyone thought it would take less than 2 weeks. There was not much difference between the scenarios, except when the scenario involved green phlegm.
The participants who had previously used antibiotics thought the cough would last longer, as did women, whites, and those with less education.
To determine how long a cough actually does last, Dr. Ebell conducted a literature search. After combing through several 100,000 potential studies, excluding those in sinusitis or people with a clear bacterial diagnosis, and focusing on those in community-dwelling, otherwise healthy adults with undifferentiated acute cough or bronchitis, he and his colleagues were left with 18 studies. In the end, only 5 of those 18 provided useful data.
The mean duration was 17-18 days. "So now we know how long a cough lasts," said Dr. Ebell.
Although the cough usually improves significantly in 2 weeks, most patients think it should be over in a week. "And that’s a big driver, or may be a big driver, of antibiotic use," he said. It may also lead to patients seeking repeat visits after 4 days, or asking for a "better" antibiotic after 8 or 9 days, which results in more prescriptions for broad spectrum antibiotics.
And the next time around, they are likely to say that the only drug that works for them is a broad spectrum antibiotic.
Dr. Ebell and his colleagues said they are exploring the clinical issue further, researching what physicians believe about cough, how messages in the media influence behavior, and whether there might be a discrepancy between the reality of an acute illness – its natural history – and perception.
Most importantly, he said he hopes to determine whether his findings can be used "to educate patients, to educate physicians, and hopefully create more realistic expectations about the duration of a cough [and] the duration of an acute illness, and thereby, hopefully reduce the demand for antibiotics."
Dr. Ebell reported having no relevant financial conflicts.
NEW ORLEANS – Patients tend to underestimate how long a cough should last, leading to unnecessary and inappropriate use of antibiotics, according to a review of the evidence and a survey of patient beliefs.
Cough is the third most frequent reason for physician office visits, and yet doctors and patients don’t seem to have an understanding of the natural history of cough and the expected duration, said Dr. Mark Ebell of the department of epidemiology at the University of Georgia College of Public Health in Athens.
The National Ambulatory Medical Survey in 2007 showed that there were 27 million outpatient visits for cough that year. That constitutes 2%-3% of all family practice visits, said Dr. Ebell. Half of patients received an antibiotic for their cough, and half the time, it was a broad spectrum antibiotic.
"There are some real issues with how we manage cough," said Dr. Ebell. Cough can indicate a condition that needs medical attention and a prescription therapy, but often, it is treated without evidence for antibiotics because the patient or doctor is uncomfortable with its duration.
Before patients ask their doctor how long a cough should last, they are likely to ask Google, he said. In conducting his own Google search, he found estimates ranging from 7 days to 14 days.
To get a sense of what patients think, Dr. Ebell and his colleagues surveyed Georgia residents by adding questions to the Georgia Poll, which is conducted twice a year by the Survey Research Center at the University of Georgia. Potential participants – aged 18 years or older – are randomly selected and contacted by phone. Almost 500 participated; 63% were women. It was an older population because the survey is conducted through landlines.
Participants were asked about their beliefs concerning antibiotics and the effectiveness of these drugs when the main symptom was a cough. They were asked how long they think it would take for the cough to get better if they were not taking any medicine, in six different scenarios: dry cough, coughing up yellow mucus or green mucus, or any of those kinds of cough with a slight fever, or no fever.
Patients with self-reported chronic lung disease or asthma were excluded from the survey.
Some respondents thought they would be better in as few as 2 days. Some thought the cough would last several months, but almost everyone thought it would take less than 2 weeks. There was not much difference between the scenarios, except when the scenario involved green phlegm.
The participants who had previously used antibiotics thought the cough would last longer, as did women, whites, and those with less education.
To determine how long a cough actually does last, Dr. Ebell conducted a literature search. After combing through several 100,000 potential studies, excluding those in sinusitis or people with a clear bacterial diagnosis, and focusing on those in community-dwelling, otherwise healthy adults with undifferentiated acute cough or bronchitis, he and his colleagues were left with 18 studies. In the end, only 5 of those 18 provided useful data.
The mean duration was 17-18 days. "So now we know how long a cough lasts," said Dr. Ebell.
Although the cough usually improves significantly in 2 weeks, most patients think it should be over in a week. "And that’s a big driver, or may be a big driver, of antibiotic use," he said. It may also lead to patients seeking repeat visits after 4 days, or asking for a "better" antibiotic after 8 or 9 days, which results in more prescriptions for broad spectrum antibiotics.
And the next time around, they are likely to say that the only drug that works for them is a broad spectrum antibiotic.
Dr. Ebell and his colleagues said they are exploring the clinical issue further, researching what physicians believe about cough, how messages in the media influence behavior, and whether there might be a discrepancy between the reality of an acute illness – its natural history – and perception.
Most importantly, he said he hopes to determine whether his findings can be used "to educate patients, to educate physicians, and hopefully create more realistic expectations about the duration of a cough [and] the duration of an acute illness, and thereby, hopefully reduce the demand for antibiotics."
Dr. Ebell reported having no relevant financial conflicts.
AT THE ANNUAL MEETING OF THE NORTH AMERICAN PRIMARY CARE RESEARCH GROUP
Major Finding: Acute cough due to nonbacterial causes lasts 17-18 days, but patients believe that a cough should resolve in a week or two.
Data Source: A survey of 500 patients.
Disclosures: Dr. Ebell reported having no relevant financial conflicts.
FDA okays second quadrivalent influenza vaccine
The quadrivalent version of the Fluarix influenza vaccine has been approved by the Food and Drug Administration, the second quadrivalent seasonal influenza vaccine approved by the agency.
The FDA approved Fluarix Quadrivalent vaccine Dec. 14 for vaccination against seasonal influenza in people aged 3 years and older. Quadrivalent seasonal influenza vaccines contain two influenza A and two influenza B strains, instead of trivalent seasonal influenza vaccines’ two A strains and one B strain.
The newly approved quadrivalent vaccine contains two strains of type A influenza (A/H1N1 and A/H3N2) and two type B strains, a Yamagata lineage strain and a Victoria lineage strain.
This is second quadrivalent influenza vaccine to be approved by the agency. In February, the FDA approved a quadrivalent version of the FluMist influenza vaccine, the intranasal influenza vaccine manufactured by MedImmune, in people aged 2-49 years.
The Fluarix Quadrivalent vaccine will be available in time for the 2013-2014 influenza season, manufacturer GlaxoSmithKline said in a statement Dec. 17. GSK also plans to fulfill orders for the trivalent version of Fluarix, because health care providers typically order influenza vaccine about a year before the next influenza season.
Every year, public health officials have had the difficult task of choosing which B strain to include in the annual seasonal influenza vaccine, based on the different B strains circulating worldwide. The ability to include the two B lineage strains should increase the likelihood that the vaccine will protect people from the influenza B strains that circulate during the influenza season.
The Fluarix Quadrivalent vaccine has not been approved in any country other than the United States, according to GSK.
More information on the two quadrivalent influenza vaccines approved to date is available here.
The quadrivalent version of the Fluarix influenza vaccine has been approved by the Food and Drug Administration, the second quadrivalent seasonal influenza vaccine approved by the agency.
The FDA approved Fluarix Quadrivalent vaccine Dec. 14 for vaccination against seasonal influenza in people aged 3 years and older. Quadrivalent seasonal influenza vaccines contain two influenza A and two influenza B strains, instead of trivalent seasonal influenza vaccines’ two A strains and one B strain.
The newly approved quadrivalent vaccine contains two strains of type A influenza (A/H1N1 and A/H3N2) and two type B strains, a Yamagata lineage strain and a Victoria lineage strain.
This is second quadrivalent influenza vaccine to be approved by the agency. In February, the FDA approved a quadrivalent version of the FluMist influenza vaccine, the intranasal influenza vaccine manufactured by MedImmune, in people aged 2-49 years.
The Fluarix Quadrivalent vaccine will be available in time for the 2013-2014 influenza season, manufacturer GlaxoSmithKline said in a statement Dec. 17. GSK also plans to fulfill orders for the trivalent version of Fluarix, because health care providers typically order influenza vaccine about a year before the next influenza season.
Every year, public health officials have had the difficult task of choosing which B strain to include in the annual seasonal influenza vaccine, based on the different B strains circulating worldwide. The ability to include the two B lineage strains should increase the likelihood that the vaccine will protect people from the influenza B strains that circulate during the influenza season.
The Fluarix Quadrivalent vaccine has not been approved in any country other than the United States, according to GSK.
More information on the two quadrivalent influenza vaccines approved to date is available here.
The quadrivalent version of the Fluarix influenza vaccine has been approved by the Food and Drug Administration, the second quadrivalent seasonal influenza vaccine approved by the agency.
The FDA approved Fluarix Quadrivalent vaccine Dec. 14 for vaccination against seasonal influenza in people aged 3 years and older. Quadrivalent seasonal influenza vaccines contain two influenza A and two influenza B strains, instead of trivalent seasonal influenza vaccines’ two A strains and one B strain.
The newly approved quadrivalent vaccine contains two strains of type A influenza (A/H1N1 and A/H3N2) and two type B strains, a Yamagata lineage strain and a Victoria lineage strain.
This is second quadrivalent influenza vaccine to be approved by the agency. In February, the FDA approved a quadrivalent version of the FluMist influenza vaccine, the intranasal influenza vaccine manufactured by MedImmune, in people aged 2-49 years.
The Fluarix Quadrivalent vaccine will be available in time for the 2013-2014 influenza season, manufacturer GlaxoSmithKline said in a statement Dec. 17. GSK also plans to fulfill orders for the trivalent version of Fluarix, because health care providers typically order influenza vaccine about a year before the next influenza season.
Every year, public health officials have had the difficult task of choosing which B strain to include in the annual seasonal influenza vaccine, based on the different B strains circulating worldwide. The ability to include the two B lineage strains should increase the likelihood that the vaccine will protect people from the influenza B strains that circulate during the influenza season.
The Fluarix Quadrivalent vaccine has not been approved in any country other than the United States, according to GSK.
More information on the two quadrivalent influenza vaccines approved to date is available here.
