Detection of Candida antigen in bronchoalveolar lavage fluid.

While bronchoalveolar lavage is frequently performed to evaluate immunocompromised hosts for infection, the significance of rare yeasts found on the cytologic examination of lavage fluid is unclear. This study used the latex agglutination method to test lavage fluids for Candida antigen to assess its usefulness in distinguishing Candida pneumonia from Candida colonization of the respiratory tract or oral contamination of the lavage specimen. Ninety-seven specimens from 87 patients were categorized on the basis of historical, microbiologic, cytologic and serologic data. Bronchoalveolar lavage fluids were positive for Candida antigen in 0 of 20 specimens from normal controls, 0 of 14 specimens from patient controls, 5 (36%) of 14 specimens from patients with Pneumocystis carinii pneumonia, 0 of 5 specimens from patients with gastrointestinal candidiasis, 0 of 9 specimens contaminated by oral-derived yeasts, 2 (10%) of 19 specimens from patients with probable Candida colonization and 15 (94%) of 16 specimens from patients with clinical and laboratory evidence of Candida pneumonia. We conclude that this test assists in the differentiation of Candida pneumonia from other situations in which yeasts are recovered by bronchoalveolar lavage.

Appropriateness of antiviral prescribing for influenza in primary care: a retrospective analysis.

BACKGROUND AND OBJECTIVE: Antiviral medications cost-effectively reduce influenza-related morbidity and potentially mortality. We sought to assess the appropriateness of antiviral prescribing for influenza. METHOD: We performed a retrospective analysis of visits by adults to primary care clinics during influenza seasons from 1 October 2000 to 31 May 2004 with a claims diagnosis of influenza (n=535) or with an electronic antiviral prescription (n=25). We defined appropriate antiviral prescribing as the patient having (a) symptoms for 2 or fewer days, (b) fever and (c) any two of headache, sore throat, cough, or myalgias. RESULTS AND DISCUSSION: Physicians diagnosed patients with influenza in 102 of 535 (19%) visits with a claims diagnosis of influenza. Physicians prescribed antivirals at 15 of 102 (15%) of these visits. The addition of 25 additional electronic antiviral prescriptions gave a sample of 127 visits and 40 (31%) antiviral prescriptions. Twenty-eight (70%) antiviral prescriptions were appropriate. Among patients who did not receive antivirals, 21 of 87 (24%) met criteria for appropriate antiviral prescribing. Antiviral prescribing was associated with a shorter median symptom duration (2 days vs. 3 days; P<0.01) and higher median temperature (37.8 degrees C vs. 36.9 degrees C; P<0.01). Physicians prescribed antivirals more frequently to patients who had myalgias (37% vs. 18%; P=0.04) and an influenza test (67% vs. 28%; P<0.01). Physicians prescribed antivirals more frequently to Blacks (44%) and patients with other race/ethnicity (67%) than to Whites (20%) or Hispanics (20%; P<0.0001). CONCLUSIONS: To improve antiviral prescribing for influenza in primary care, interventions need to target the accurate identification of influenza visits, undertreatment, as well as inappropriate treatment.

Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999.

CONTEXT: Most sore throats are due to viral upper respiratory tract infections. Group A beta-hemolytic streptococci (GABHS), the only common cause of sore throat warranting antibiotics, is cultured in 5% to 17% of adults with sore throat. The frequency of antibiotic use for pharyngitis has greatly exceeded the prevalence of GABHS, but less is known about specific classes of antibiotics used. Only penicillin and erythromycin are recommended as first-line antibiotics against GABHS. OBJECTIVES: To measure trends in antibiotic use for adults with sore throat and to determine predictors of antibiotic use and nonrecommended antibiotic use. DESIGN, SETTING, AND SUBJECTS: Retrospective analysis of 2244 visits to primary care physicians in office-based practices in the National Ambulatory Medical Care Survey, 1989-1999, by adults with a chief complaint of sore throat. MAIN OUTCOME MEASURES: Treatment with antibiotics and treatment with nonrecommended antibiotics, extrapolated to US annual national rates. RESULTS: There were an estimated 6.7 million annual visits in the United States by adults with sore throat between 1989 and 1999. Antibiotics were used in 73% (95% confidence interval [CI], 70%-76%) of visits. Patients treated with antibiotics were given nonrecommended antibiotics in 68% (95% CI, 64%-72%) of visits. From 1989 to 1999, there was a significant decrease in use of penicillin and erythromycin and an increase in use of nonrecommended antibiotics, especially extended-spectrum macrolides and extended-spectrum fluoroquinolones (P<.001 for all trends). In multivariable modeling, increasing patient age (odds ratio [OR], 0.86 per decade; 95% CI, 0.79-0.94) and general practice specialty (OR, 1.54 compared with family practice specialty; 95% CI, 1.10-2.14) were independent predictors of antibiotic use. Among patients receiving antibiotics, nonrecommended antibiotic use became more frequent over time (OR, 1.17 per year; 95% CI, 1.11-1.24). CONCLUSIONS: More than half of adults are treated with antibiotics for sore throat by community primary care physicians. Use of nonrecommended, more expensive, broader-spectrum antibiotics is frequent.