Antibiotic Treatment In Children Research Articles

Topical Ciprofloxin Versus Topical Framycetin-Gramicidin-Dexamethasone in Australian Aboriginal Children With Recently Treated Chronic Suppurative Otitis Media

Chronic suppurative otitis media (CSOM) affects many children in disadvantaged populations. The most appropriate topical antibiotic treatment in children with persistent disease is unclear. Children with CSOM despite standard topical treatment were randomized to 6-8 weeks of topical ciprofloxacin (CIP) versus topical framycetin-gramicidin-dexamethasone (FGD). Otoscopic, audiologic, and microbiologic outcomes were measured using standardized assessments and blinding. Ninety-seven children were randomized. Ear discharge failed to resolve at the end of therapy in 70% children regardless of allocation [risk difference = -2%; (95% CI: -20 to 16)]. Healing of the tympanic membrane occurred in one of 50 children in the CIP group and none of 47 children in the FGD group. Severity of discharge failed to improve in more than 50% children in each group, and mean hearing threshold (38 dB and 35 dB) and proportion of children with greater than 25 dB hearing loss (98% and 88%) were not significantly different between the CIP and FGD groups. Side effects were rare. This study showed a similarly low rate of improvement or cure in children with persistent CSOM for both CIP and FGD topical therapies. Complications and side effects were insufficient to cease therapy or inform prescribing of either therapy.

Duration of IV Antibiotic Treatment for Children with Pyelonephritis

Whether the mode and duration of antibiotic treatment prevent development of renal scars in children with pyelonephritis remains controversial. In this

Randomised trial of oral versus sequential intravenous/oral cephalosporins in children with pyelonephritis

The hypothesis was tested that oral antibiotic treatment in children with acute pyelonephritis and scintigraphy-documented lesions is equally as efficacious as sequential intravenous/oral therapy with respect to the incidence of renal scarring. A randomised multi-centre trial was conducted in 365 children aged 6 months to 16 years with bacterial growth in cultures from urine collected by catheter. The children were assigned to receive either oral ceftibuten (9 mg/kg once daily) for 14 days or intravenous ceftriaxone (50 mg/kg once daily) for 3 days followed by oral ceftibuten for 11 days. Only patients with lesions detected on acute-phase dimercaptosuccinic acid (DMSA) scintigraphy underwent follow-up scintigraphy. Efficacy was evaluated by the rate of renal scarring after 6 months on follow-up scintigraphy. Of 219 children with lesions on acute-phase scintigraphy, 152 completed the study; 80 (72 females, median age 2.2 years) were given ceftibuten and 72 (62 females, median age 1.6 years) were given ceftriaxone/ceftibuten. Patients in the intravenous/oral group had significantly higher C-reactive protein (CRP) concentrations at baseline and larger lesion(s) on acute-phase scintigraphy. Follow-up scintigraphy showed renal scarring in 21/80 children treated with ceftibuten and 33/72 with ceftriaxone/ceftibuten (p = 0.01). However, after adjustment for the confounding variables (CRP and size of acute-phase lesion), no significant difference was observed for renal scarring between the two groups (p = 0.2). Renal scarring correlated with the extent of the acute-phase lesion (r = 0.60, p < 0.0001) and the grade of vesico-ureteric reflux (r = 0.31, p = 0.03), and was more frequent in refluxing renal units (p = 0.04). The majority of patients, i.e. 44 in the oral group and 47 in the intravenous/oral group, were managed as out-patients. Side effects were not observed. From this study, we can conclude that once-daily oral ceftibuten for 14 days yielded comparable results to sequential ceftriaxone/ceftibuten treatment in children aged 6 months to 16 years with DMSA-documented acute pyelonephritis and it allowed out-patient management in the majority of these children.

Otitis Media: Immediate Antibiotics or Watchful Waiting?

Immediate antibiotic treatment for children with acute otitis media (AOM) has been shown to improve symptoms, although failure, relapse and recurrence are common following antibiotic treatment. Until recently, almost all children in the USA received antibiotics for the immediate management of AOM. However, widespread use of antibiotics for AOM has led to the emergence of multidrug-resistant bacteria. Studies indicate that antibiotic prescribing for AOM can be reduced in children with nonsevere AOM by as much as 50% without serious harmful consequences, because symptoms can be effectively controlled in such children with analgesic medication alone. Substantial data now exist, and guidelines support, the use of watchful waiting or a wait-and-see prescription for selected children with AOM. This paper will summarize the reasons why watchful waiting may be an appropriate alternative treatment for selected children with AOM. We will also describe a simple screening method that can facilitate clinical decision making.

135 Intravenous antibiotic treatment in children with cystic fibrosis: home versus hospital setting

135 Intravenous antibiotic treatment in children with cystic fibrosis: home versus hospital setting

Antibiotic Treatment of Children with Erythema Migrans

Antibiotic Treatment of Children with Erythema Migrans

Antibiotic Treatment for Children with AOM: Who Benefits?

Antibiotic treatment for children with acute otitis media (AOM) remains controversial because only about one in eight treated children benefit (i.e.,

Surgical Excision versus Antibiotic Treatment for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis in Children: A Multicenter, Randomized, Controlled Trial

The optimal treatment of nontuberculosis mycobacterial cervical lymphadenitis in children has not been established. Until recently, surgical excision was the standard treatment, but the number of reports of successful antibiotic treatment is increasing, which questions whether surgery is the preferred treatment. In this randomized, multicenter trial, we compared surgical excision with antibiotic treatment. One hundred children with microbiologically proven nontuberculous mycobacterial cervicofacial lymphadenitis were randomly assigned to undergo surgical excision of the involved lymph nodes or to receive antibiotic therapy with clarithromycin and rifabutin for at least 12 weeks. The primary end point was cure, defined as regression of the lymph node enlargement by at least 75%, with cure of the fistula and total skin closure without local recurrence or de novo lesions after 6 months, as assessed by clinical and ultrasound evaluation. Secondary end points included complications of surgery and adverse effects of antibiotic therapy. Intention-to-treat analysis revealed that surgical excision was more effective than antibiotic therapy (cure rates, 96% and 66%, respectively; 95% confidence interval for the difference, 16%-44%). Treatment failures were explained neither by noncompliance nor by baseline or acquired in vitro resistance to clarithromycin or rifabutin. Surgical complications were seen in 14 (28%) of 50 patients; staphylococcal wound infection occurred in 6 patients, and a permanent grade 2 facial marginal branch dysfunction occurred in 1 patient. The vast majority of patients who were allocated to antibiotic therapy reported adverse effects (39 [78%] of 50 patients), including 4 patients who had to discontinue treatment. Surgical excision is more effective than antibiotic treatment for children with nontuberculous mycobacterial cervicofacial lymphadenitis.

Antibiotic Treatment of Children With Sore Throat

Antibiotic Treatment of Children With Sore Throat

Antibiotic treatment of children with sore throat: Linder JA, Bates, DW, Lee GM, et al. JAMA 2005;294:2315–22

This study was designed to measure rates of antibiotic prescribing and group A β-hemolytic streptococci (GABHS) testing, and to evaluate the association between testing and antibiotic treatment for children presenting with the chief complaint of sore throat. The researchers used data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1995 to 2003 to measure changes in the rate and type of antibiotics prescribed to children with a chief complaint of sore throat, and their relationship to GABHS testing.

Antibiotic Treatment of Children With Sore Throat

Of children with sore throat, 15% to 36% have pharyngitis caused by group A beta-hemolytic streptococci (GABHS). Performance of a GABHS test prior to antibiotic prescribing is recommended for children with sore throat. Penicillin, amoxicillin, erythromycin, and first-generation cephalosporins are the recommended antibiotics for treatment of sore throat due to GABHS. To measure rates of antibiotic prescribing and GABHS testing and to evaluate the association between testing and antibiotic treatment for children with sore throat. Analysis of visits by children aged 3 to 17 years with sore throat to office-based physicians, hospital outpatient departments, and emergency departments in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1995 to 2003 (N = 4158) and of a subset of visits with GABHS testing data (n = 2797). National rates of antibiotic prescribing, prescribing of antibiotics recommended and not recommended for GABHS, and GABHS testing. Physicians prescribed antibiotics in 53% (95% confidence interval [CI], 49%-56%) of an estimated 7.3 million annual visits for sore throat and nonrecommended antibiotics to 27% (95% CI, 24%-31%) of children who received an antibiotic. Antibiotic prescribing decreased from 66% of visits in 1995 to 54% of visits in 2003 (P = .01 for trend). This decrease was attributable to a decrease in the prescribing of recommended antibiotics (49% to 38%; P = .002). Physicians performed a GABHS test in 53% (95% CI, 48%-57%) of visits and in 51% (95% CI, 45%-57%) of visits at which an antibiotic was prescribed. GABHS testing was not associated with a lower antibiotic prescribing rate overall (48% tested vs 51% not tested; P = .40), but testing was associated with a lower antibiotic prescribing rate for children with diagnosis codes for pharyngitis, tonsillitis, and streptococcal sore throat (57% tested vs 73% not tested; P<.001). Physicians prescribed antibiotics to 53% of children with sore throat, in excess of the maximum expected prevalence of GABHS. Although there was a decrease in the proportion of children receiving antibiotics between 1995 and 2003, this was due to decreased prescribing of agents recommended for GABHS. Although GABHS testing was associated with a lower rate of antibiotic prescribing for children with diagnosis codes of pharyngitis, tonsillitis, and streptococcal sore throat, GABHS testing was underused.

Cefuroxime axetil versus placebo for children with acute respiratory infection and imaging evidence of sinusitis: A randomized, controlled trial

To evaluate the efficacy of antibiotic treatment in children who presented in medical care with respiratory infection and had imaging evidence of sinusitis. Eighty-two children (4-10 y) with acute respiratory symptoms and ultrasonography findings suggestive of acute rhinosinusitis were enrolled in a randomized, double-blind trial. The sinus findings were confirmed with plain radiographs. The children received either cefuroxime axetil in 125-mg capsules twice a day for 10 d or placebo. Main outcome measures were complete cure in 2 wk and absence of prolonged symptoms or complications. A total of 72 children (88%) completed follow-up. The sinusitis findings in the ultrasound could be confirmed with plain radiographs in 65 of the 72 patients (90%). The proportion of children completely cured by day 14 was similar in both groups (difference 6%, 95% confidence interval -16% to 29%). Similarly, there was no significant difference in the proportions of children who escaped prolonged disease and complications between the groups (difference 7%, -9% to 24%). A 10-d course of cefuroxime axetil offered no clinical benefit to children with an acute respiratory illness and imaging evidence of acute sinusitis.

Procalcitonin, C-reactive protein and leukocyte count in children with lower respiratory tract infection.

Lower respiratory tract infection is the most common infection leading to unnecessary antibiotic treatment in children. Etiologic diagnosis is not immediately achieved, and the pathogen remains unidentified in a large number of cases. Neither clinical nor laboratory factors allow for a rapid distinction between bacterial and viral etiology. The aim of our study was to evaluate the reliability of procalcitonin (PCT), C-reactive protein (CRP) and leukocyte count in distinguishing pneumococcal, atypical and viral lower respiratory tract infection. PCT, CRP and leukocyte count were measured in children with microbiologically documented diagnoses of lower respiratory tract infection. The results were compared of children with pneumococcal, atypical and viral etiologies. PCT and CRP showed significant correlation with a bacterial etiology of lower respiratory tract infection. No significance was found for leukocyte count. Using a cutoff point of 2 ng/ml for PCT and 65 mg/l for CRP, the sensitivities and specificities for distinguishing bacterial from viral lower respiratory tract infections were 68.6 and 79.4% for PCT and 79.1 and 67.1% for CRP. The sensitivities and specificities for distinguishing pneumococcal from other etiologies were 90.3 and 74.1% for PCT and 90.3 and 60% for CRP, respectively. High PCT and CRP values show a significant correlation with the bacterial etiology of lower respiratory tract infection. PCT and CRP show good sensitivity for distinguishing pneumococcal from other etiologies. PCT shows higher specificity than CRP. PCT and CRP can help make decisions about antibiotic therapy in children with lower respiratory tract infections.

Airway Resistance Measurements in Children with Cystic Fibrosis

Summary Background and Purpose Respiratory function test results are important indices of improvement in the treatment of respiratory infection in cystic fibrosis. The aim of this study was to assess the value of airways resistance measured by the interrupter technique (Rint) over a course of intravenous antibiotic treatment in children with cystic fibrosis. Methods Airways resistance was measured by the MicroRint at the beginning and end of treatment. Children aged five years and older also had respiratory function measured, using standard spirometry. Results Seventy-eight children were entered into the study. Children under two years of age were not able to achieve a satisfactory facemask seal. Six children under seven years of age could not provide satisfactory spirometric measurements but showed an improvement in Rint measurement. All respiratory function parameters improved significantly. Before and after treatment airways resistance values measured by the MicroRint showed a significant correlation with respiratory function test values measured by standard spirometry, eg for Rint and FEV 1 % predicted normal r=0.37 before treatment (p = 0.002), and r=0.39 after treatment (p = 0.002). Similar results were obtained for comparisons between Rint and FEF 25–75 % predicted normal values. The degree of change in the airways resistance values measured by the MicroRint when measurements at the beginning and end of treatment were compared did not show a significant correlation with the degree of change in spirometric values measured at the same times. Conclusions Children over two years of age tolerate Rint measurement well. In cystic fibrosis, over a course of intravenous antibiotic therapy, it may be a valuable additional measure of the response to treatment.

Exhaled nitric oxide increases following admission for intravenous antibiotics in children with cystic fibrosis

Background: Lack of standardisation for the measurement of exhaled nitric oxide (NO) (FE NO) has resulted in conflicting data in cystic fibrosis (CF). The aim of this study was to assess whether FE NO is a useful non-invasive marker of lung disease in CF by assessing the effect of intravenous (IV) antibiotics on FE NO. Methods: FE NO was measured on line, according to recently published ERS/ATS guidelines, using a chemiluminescence analyser together with pulmonary function in 14 CF children prior to and following a course of IV antibiotics. Results: There was a significant improvement in mean (S.E.M.) % FEV 1 from 60.0 (6.3) to 68.0 (5.4) ( P<0.05) and mean (S.E.M.) % FVC from 66.3 (5.5) to 75.1 (4.9) ( P<0.01). FE NO increased significantly from median (range) 5.8 (2.0–14.3) to 9.2 ppb (0.8–25.1) ( P<0.05). There was no correlation between FE NO and lung function. Subgroup analysis on those with chronic Pseudomonas aeruginosa infection ( n=6) demonstrated no significant change in FE NO. Conclusions: Using a flow of 50 ml/s, FE NO increases following admission for IV antibiotic treatment in children with CF but does not correlate with lung function. It is not a useful marker of lung diseases in CF, which has implications for clinical practice.

Effect of long term consumption of probiotic milk on infections in children attending day care centres: double blind, randomised trial

Objective: To examine whether long term consumption of a probiotic milk could reduce gastrointestinal and respiratory infections in children in day care centres.Design: Randomised, double blind, placebo controlled study over...

Risk of the Hemolytic–Uremic Syndrome after Antibiotic Treatment ofEscherichia coliO157:H7 Infections

C ORR ES POND ENCE 1. Tefferi A. Myelofibrosis with myeloid metaplasia. N Engl J Med 2000; Risk of the Hemolytic–Uremic Syndrome after Antibiotic Treatment of Escherichia coli O157:H7 Infections To the Editor: Wong et al. (June 29 issue) 1 report an as- sociation between antibiotic treatment in children with acute diarrhea caused by Escherichia coli O157:H7 and the devel- opment of the hemolytic–uremic syndrome. In Chile, shi- gella species cause 30 percent of cases of bloody diarrhea in children and enterohemorrhagic strains of E. coli cause 37 percent of such cases 2 — a situation that may also be com- mon in developing countries. For children with acute bloody diarrhea in these countries, the most widely accepted rec- ommendation is to obtain a stool culture and initiate empir- ical antibiotic treatment for shigella, because appropriate treatment shortens the duration of the diarrhea, decreases the incidence of complications, and reduces the risk of trans- mission by shortening the duration of bacterial shedding. 3 Given these points, the results presented by Wong et al. raise several questions. Knowing that E. coli O157:H7 and shigella species cannot be differentiated early in the clinical course on the basis of clinical findings or simple laboratory tests, does the potentially increased risk of the hemolytic– uremic syndrome associated with empirical antibiotic treat- ment of E. coli O157:H7 infections outweigh the risk of not treating shigella infections during the 72 hours need- ed to obtain culture results? In Chile, 70 percent of cases of the hemolytic–uremic syndrome are associated with se- rotypes of E. coli other than O157:H7. 4 Can the increased risk of the hemolytic–uremic syndrome in children who receive antibiotics for E. coli O157:H7 infections be extrap- olated to other strains of the organism? We worry that the message of this study will be extended prematurely to the treatment of bloody diarrhea worldwide. In places where the prevalence of shigella and E. coli infec- tions is similar and strains of E. coli other than O157:H7 are common, withholding antibiotic therapy until the cause of the diarrhea is known may have more risks than benefits. A M IGUEL O’R YAN , M.D. V ALERIA P RADO , M.D. University of Chile Santiago, Chile B Figure 1. Lesions of the Skin (Panel A) and Mouth (Panel B) in a Patient with Post-Polycythemic Myeloid Metaplasia. serious exacerbation of post-polycythemic myeloid metapla- sia in a patient who was receiving epoetin may be uncom- mon, but it is striking and should be recognized as a poten- tial sequela of such treatment. A BDUL R AHMAN J AZIEH , M.D., M.P.H. University of Cincinnati Cincinnati, OH 45267 1. Wong C, Jelacic S, Habeeb RL, Watkins SL, Tarr PI. The risk of the hemolytic–uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med 2000;342:1930-6. 2. Lopez EL, Prado-Jimenez V, O’Ryan-Gallardo M, Contrini MM. Shi- gella and Shiga toxin-producing Escherichia coli causing bloody diarrhea in Latin America. Infect Dis Clin North Am 2000;14:41-65, viii. 3. Haltalin KC, Nelson JD, Ring R III, Sladoje M, Hinton LV. Double- blind treatment study of shigellosis comparing ampicillin, sulfadiazine, and placebo. J Pediatr 1967;70:970-81. 4. Prado JV, Martinez DJ, Arellano CC, Levine MM. Variacion temporal de genotipos y serogrupos de E Coli enterohemorragicos aislados en ninos chilenos con infecciones intestinales o sindrome hemolitico-uremico. Rev Med Chil 1997;125:291-7. M OHAMMAD J. K YASA , M.D. University of Arkansas for Medical Sciences Little Rock, AR 72205 To the Editor: We question some of the epidemiologic concepts and analyses used by Wong et al. They justified the Vol ume 343 The New England Journal of Medicine Downloaded from nejm.org at Berkeley (UCB) on February 19, 2017. For personal use only. No other uses without permission. Copyright © 2000 Massachusetts Medical Society. All rights reserved. Numb e r 17

Get the vaccine not the 'flu: Gearing up for influenza vaccine campaign 2000

Every year, at some point between November and April, influenza strikes Canada. The duration and timing of the influenza season vary from year to year, although the peak in illness rarely occurs before December. Mass influenza vaccination campaigns generally begin between October and mid-November to ensure that immunity in vaccinated persons is established before the height of the season but not so early that antibody levels decline before the end of the season. As this year’s influenza season approaches, provincial and territorial public health departments, and the Canadian Coalition for Influenza Immunization (CCII) are preparing for the launch of their influenza immunization awareness campaigns. The CCII (originally called Flu-Alert by the Lung Association of Canada) is a coalition of national organizations (Table 1), including the Canadian Paediatric Society, with a primary aim of promoting immunization as the best way to prevent influenza. Physicians should watch for the CCII’s brightly coloured posters, entitled “Who Needs It? You Do”, in mailings from the Canadian Paediatric Society and the Canadian Medical Association, and they should display the posters where the public can see them. Physicians and their patients can also download information about influenza and influenza vaccine from the CCII web site . TABLE 1: Members of the Canadian Coalition for Influenza Immunization During September, publicity events will be held to launch the CCII’s influenza vaccine campaign, which will be staged in conjunction with provincial, territorial and CCII member organization events. CCII posters and other promotional materials (radio and print advertisements) are designed to prompt readers or listeners to ask doctors, nurses, pharmacists, and public health units and clinics whether they should get ‘the ’flu shot’. Influenza is recognized as an important cause of morbidity and mortality among the elderly and adults with conditions that place them at high risk of contracting the infection. Estimating the impact of influenza infection on young children has not been easy because infections from respiratory syncytial virus and other respiratory viruses tend to occur at a similar time as influenza. Recent studies from California and Tennessee that attempted to separate hospitalizations due to influenza from those due to respiratory syncytial virus suggest that healthy infants and toddlers are at increased risk of hospitalizations for acute respiratory disease attributable to influenza (1,2). In Tennessee, a substantial number of outpatient visits and courses of antibiotic treatment in children of all ages were attributed to influenza (2).

The Risk of the Hemolytic–Uremic Syndrome after Antibiotic Treatment ofEscherichia coliO157:H7 Infections

Children with gastrointestinal infections caused by Escherichia coli O157:H7 are at risk for the hemolytic-uremic syndrome. Whether antibiotics alter this risk is unknown.We conducted a prospective cohort study of 71 children younger than 10 years of age who had diarrhea caused by E. coli O157:H7 to assess whether antibiotic treatment in these children affects the risk of the hemolytic-uremic syndrome and to assess the influence of confounding factors on this outcome. Estimates of relative risks were adjusted for possible confounding effects with the use of logistic-regression analysis.Among the 71 children, 9 (13 percent) received antibiotics and the hemolytic-uremic syndrome developed in 10 (14 percent). Five of these 10 children had received antibiotics. Factors significantly associated with the hemolytic-uremic syndrome were a higher initial white-cell count (relative risk, 1.3; 95 percent confidence interval, 1.1 to 1.5), evaluation with stool culture soon after the onset of illness (relative risk, 0.3; 95 percent confidence interval, 0.2 to 0.8), and treatment with antibiotics (relative risk, 14.3; 95 percent confidence interval, 2.9 to 70.7). The clinical and laboratory characteristics of the 9 children who received antibiotics and the 62 who did not receive antibiotics were similar. In a multivariate analysis that was adjusted for the initial white-cell count and the day of illness on which stool was obtained for culture, antibiotic administration remained a risk factor for the development of the hemolytic uremic syndrome (relative risk, 17.3; 95 percent confidence interval, 2.2 to 137).Antibiotic treatment of children with E. coli O157:H7 infection increases the risk of the hemolytic-uremic syndrome.

Pharmacokinetics and pharmacodynamics of new and old antimicrobial agents for acute otitis media.

Selection of appropriate antibiotic treatment for children with acute otitis media (AOM) is challenging. Although the diagnosis is relatively easy for experienced clinicians, the distinction between AOM and otitis media with effusion is often more subtle. In general therapy is empiric and the pathogen causing disease in a given patient remains unknown. However, this situation is made even more difficult by the dynamic nature of the pathogenesis of AOM. Both the proportion of patients infected with one of the three primary pathogens, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, and the antimicrobial susceptibility patterns of these pathogens are changing. Currently there are 16 antibiotics labeled for use in AOM. Only 2 are reliably effective against penicillin-resistant pneumococcus: high dose amoxicillin (80 to 100 mg/kg/day) and im ceftriaxone. Among the others all are beta-lactamase-stable and have proven clinical effectiveness in AOM patients infected with H. influenzae or M. catarrhalis. Even with the high spontaneous resolution rate reported for AOM, antimicrobial therapy remains the standard of care in the United States. Recognition of the fundamental determinants of effective therapy should permit rational antibiotic selection for each patient.