Is the management of acute otitis media in children by primary care physicians in Kingston consistent with evidenced-based medicine?

OBJECTIVE: to explore the knowledge and actual management practice of acute otitis media (AOM) by primary care physicians. METHODS: A 19-item questionnaire was administered to all Kingston-based general practitioners and pediatricians currently listed by two major pharmaceutical companies. Data obtained included knowledge, diagnostic and therapuetic practice, and reported involvment in continuing medical education. There were 91 responders, consisting of 53 percent of the general practitioners (GPs) and 90 percent of the paediatricians listed. RESULTS: All the physicians except three of the GPs were participating in some aspect of continuing medical education. Fifty-two different criteria were used for the diagnosis of AOM. Only 15 of these were consistent with current best management guidelines. There was no statistically significant difference in diagnostic ability between the two groups of physicians. The four major causative agents of AOM were correctly listed by 7 percent GPs and 23 percent pediatricians (p=0.05). Amoxicillin was prescribed as first line agent for treatment of AOM by 62 percent of pediatricians and 22 percent of GPs. Trimethoprimsulfmethoxazole was still being used as first line agent by 17 percent of GPs. All physicians considered the use of analgesics as appropriate and steroids inappropriate in the management of AOM. There was significant difference between groups concerning the use of antihistamines (84 percent GPs, 53 percent paediatricians) and decongestants (91 percent GPs, 52 percent paediatricians, p<0.001) in the management of AOM. Most physicians recommeneded routine follow-up of patients at the end of the course of antibiotic treatment. CONCLUSIONS: Factors other than evidence-based medicine influence the current management of otitis media by primary care physicians. Exploration of the factors that determine management practice is being proposed. The results under-score the need for a re-accreditation process for physicians in the Caribbean region. (AU)

Antimicrobial sensitivity of Haemophilus influenzae isolates from bacterial conjunctivitis

Haemophilus influenzae is one of the common bacterial pathogens which affect children. Resistance to frequently use antibiotics is becoming a significant problem in community isolates of common pathogens. A retrospective review was conducted of the serotypes and antimicrobial sensitivity of H influenzae isolates from bacterial conjunctivitis, over an 18-month period. Data on antimicrobial sensitivity (obtained by the National Committee for Clinical Laboratory Standards disk diffusion method) and B-lactamase production, and typing results, were analysed. Ninety-nine islolates were recovered, of which 87 were typed. Most isolates were recovered from children under one year of age. Ninety-three percent were unencapsulated and biotypes I and IV were most common. H influenzae type b was recovered only twice. B-lactamase was produced by 41 percent isolates while four isolates were ampicillin-resistant but did not produce B-lactamase. All isolates were sensitive to chloramphenicol and 45 percent were co-trimoxazole sensitive. H influenzae is commonly isolated from bacterial conjunctivitis in Barbados and, as elsewhere, the majority of isolates are from small children and are non-encapsulated. However, there is a high prevalence of B-lactamase production, which may serve as a reservoir for transfer to more invasive encapsulated strains of H influenzae within the oropharyngeal flora.(Au)

Methicillin resistance among Trinidadian isolates of community and hospital strains of Staphylococcus aureus and their patterns of resistance to non-beta-lactam antibiotics

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) strains in Trinidad and the extent of their resistance to other antimicrobial agents in hospital-acquired infections were evaluated over a 2-year period. A total of 450 S. aureus strains were isolated from different patients. The prevalence of methicillin resistance among S. aureus strains was 9.8 percent (44/450). The proportion of MRSA isolated from hospital sources and community sources was 12.5 percent (38/305) and 4.1 percent (6/145) respectively (P<0.05). The resistant rates of MRSA to the non-beta-lactam antibodies were as follows: 93.2 percent resistance to tetracycline, 68.2 percent to erythromycin, 61.4 percent to gentamicin, 45.5 percent to co-trimoxazole, and 20.5 percent to ciprofloxacin. No MRSA resistant to vancomycin was observed in this study. Study results showed significant increases in MRSA in hospital, 2 percent in 1995 to 12.5 percent in 1998 (P<0.05), and community, 0 percent in 1995 to 4.1 percent in 1998 (P<0.05). It has become apparent that infection must be focussed now on the community in order to monitor and limit the spread of this new and expanding reservoir of MRSA. (AU)

Methicillin resistance among Trinidadian isolates of community and hospital strains of Staphylococcus aureus and their patterns of resistance to non-beta-lactam antibiotics

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) strains in Trinidad and the extent of their resistance to other antimicrobial agents in hospital-acquired and community-acquired infections were evaluated over a 2-year period. A total of 450 S. aureus strains were isolated from different patients. The prevalence of methicillin resistance among S. aureus strains was 9.8% (44/450). The proportion of MRSA isolated from hospital sources and community sources was 12.5% (38/305) and 4.1% (6/145), respectively (P < 0.05). The resistant rates of MRSA to the non-beta-lactam antibiotics were as follows: 93.2% resistance to tetracycline, 68.2% to erythromycin, 61.4% to gentamicin, 45.5% to co-trimoxazole, and 20.5% to ciprofloxacin. No MRSA resistant to vancomycin was observed in this study. Study results showed significant increases in MRSA in hospital, 2% in 1995 to 12.5% in 1998 (P < 0.05), and community, 0% in 1995 to 4.1% in 1998 (P < 0.05). It has become apparent that infection control and surveillance initiatives must be focused now on the community in order to monitor and limit the spread of this new and expanding reservoir of MRSA.

Pneumocystis pneumonia in the acquired immune deficiency syndrome (AIDS) - abstract

We present a retrospective analysis of Pneumocystis carinii pneumonia (PCP) in patients with AIDS at our institution. Data were collected by chart and radiological review. Since February 1983 we have treated 24 patients with AIDS and PCP. All except three were homosexual males, with seventeen (17 percent) having PCP as the initial manifestation of AIDS. All patients had CXR changes on presentation. Three had atypical changes including lobar consolidation and multiple cavities. Arterial pO2 on room air ranged from 33 to 83 (av. 59). Diagnosis was made in 28 of 30 episodes (93 percent) using bronchoalveolar lavage. One patient was positive on induced sputum, and one had a positive open lung biopsy. Other respiratory pathogens were also isolated in 20 of 30 episodes (67 percent). Therapy was initiated with trimethoprim-sulpha (T-S) or pentamidine (P). Seven of 21 episodes (33 percent) were successfully treated with T-S alone vs one of nine (11 percnet) with P alone. Eight of 21 (38 percent) experienced adverse effects with T-S vs six of nine (67 percent) with P. Adjunctive steriod therapy was required in 11 of 30 episodes (37 percent) with four deaths subsequently. Overall, six of 30 episodes (20 percent) resulted in death, three in association with concomitant CMV infection. Six of 24 patients (25 percent) had two or more episodes of PCP occurring within 5-17M. (av. 9M) of successful therapy. Our experience parallels that reported from other centres in North America (AU)