Antibiotic noncompliance and waste in upper respiratory infections and acute diarrhea.

A prospective cohort study was conducted to analyze factors associated with antibiotic noncompliance and waste among patients suffering acute respiratory infection (ARI) and acute diarrhea (AD). The study took place in four primary health care clinics in Mexico City, two belonging to the Ministry of Health (MoH) and two to the Mexican Social Security Institute (IMSS). Two hundred twenty-two patients with ARI and 155 with AD were included. Data about study variables and the assessment of compliance were obtained through patient interviews and direct observation. Factors associated with noncompliance were assessed through a multiple logistic regression procedure. Noncompliance was 60% for ARI and 55.5% for AD in both health care systems. Prescription of an antibiotic was justified only in 13.5% of cases. Associated factors were: increased duration of illness (OR 2.95; 95% CI, 1.17-7.41); complexity of the treatment: 3 or more doses per day (OR 2.47; 95% CI, 1.56-3.92), and treatment for more than 7 days (OR 1.94; 95% CI, 1.16-3.26); younger age of patient (OR 1.89; 95% CI, 1.18-3.02); and an inadequate physician-patient relationship (OR 1.87; 95% CI, 1.16-3.02). Antibiotic waste was higher in IMSS (ARI 39.3%, AD 32.6%), than in the MoH (ARI 21.2%, AD 16.4%). Educational strategies to modify physician prescribing practices and strengthen physician-patient relationships might improve compliance and decrease drug waste.

An intercultural comparison of home case management of acute diarrhea in Mexico: implications for program planners.

BACKGROUND: The objective was to assess the extent to which similarities in cultural beliefs and practices related to home management of diarrhea would permit general recommendations to improve the content of health care messages. METHODS: We studied six communities in Mexico, covering rural and urban conditions, different ethnic groups, and different socioeconomic levels. Systematic data collection relied on open-ended, face-to-face interviews with mothers of children under 5 years of age who had had an episode of diarrhea. Similarities among communities were assessed by means of a quadratic assignment procedure applied to signs, symptoms, and treatment matrices. Significant similarity among most of the communities sustained use of a global composite matrix to represent all communities. RESULTS: We suggest specific recommendations to promote sound home management of diarrhea based on significant correlations among signs and symptoms with treatments. Signs and symptoms include those promoted by the National Program for the Control of Diarrheal Diseases (diarrhea, fever, vomiting) and others commonly mentioned by mothers (stomach ache, sadness, restlessness, refusal to eat). Similarly, recommendations to use home-based treatments based on beliefs related to their use may include the feeding of rice water, soups, and broth to a child who is sad, or rice-gruel and teas for a child with a fever. CONCLUSIONS: Our study supports that there are enough similarities among mothers' beliefs and practices for the care of acute diarrhea in childhood to support general recommendations at the program level.

From research to public health interventions. I. Impact of an educational strategy for physicians to improve treatment practices of common diseases.

Errors in treating common diseases occur very frequently in primary health care practice. While many of these mistakes are not life-threatening, the costs of abuse in drug prescription may be greatly increased. An educational strategy aimed to improve physicians' prescribing practices for acute diarrhea (AD) and acute respiratory infection (ARI) was developed as a research study, involving three medical care units. The strategy was largely based on promoting active participation of the trainees in the whole process, including: (a) group participation in a literature review of updated articles related to management of AD and ARI; (b) analysis of prescribing practices before the intervention; (c) participation in the development of a clinical algorithm for the therapeutic management of these illnesses; and (d) discussion of the usefulness of the algorithm during peer review committee meetings. Successful results of this intervention, as judged by the improvement of treatment practices and the persistence of changes for up to 2 years after the intervention, as well as its ease of application and low costs, motivated its extension to a health District and a State. In these sites, the intervention was in charge of medical leaders from the clinics and medical heads of the local health systems, respectively. The extension of the educational strategy was accompanied by a relative reduction in AD from 46.7% to 6.5% and in ARI from 32.6% to 8.5%. However, the benefit-cost ratio showed a dramatic increase when comparing results from the research study and from the State intervention, for both AD (from 3.3 to 4.4) and ARI (from 16.2 to 21.6), for an overall net increase of 33.3%. Based on these results, the educational strategy was adopted by the National Program for the Control of Diarrheal Diseases, and was used to train public health physicians throughout the country, from 1992 to 1994.

Improving physician prescribing patterns to treat rhinopharyngitis. Intervention strategies in two health systems of Mexico.

To improve prescribing practices for rhinopharyngitis, an interactive educational intervention and a managerial intervention were carried out in 18 primary care facilities in metropolitan Mexico City. Four family medicine clinics of the Mexican Social Security Institute (IMSS) and 14 health centres of the Ministry of Health (SSA) were included. A quasi-experimental design was employed. One hundred and nineteen physicians (IMSS 68, SSA 51) participated. Sixty-five physicians (IMSS 32, SSA 33) were in the study group, while 54 were in the control group (IMSS 36, SSA 18). The study had four stages: (I) baseline, to evaluate the physicians' prescribing behaviour for rhinopharyngitis; (II) intervention, using an interactive educational workshop and a managerial peer review committee; (III) post-intervention evaluation of short-term impact; and (IV) follow-up evaluation of long-term effect 18 months after the workshop. The control group did not receive any intervention but was evaluated at the same time as the study group. At baseline, most patients in both institutions received antibiotic prescriptions (IMSS 85.2%, SSA 68.8%). After the workshop, the percentage of patients receiving antibiotic prescriptions in the IMSS went from 85.2% to 48.1%, while in the SSA it went from 68.8% to 49.1%. Appropriateness of treatment was analyzed using the physician as the unit of analysis. At baseline, 30% of IMSS physicians in the study group treated their patients appropriately. After the intervention, this percentage increased to 57.7%, and at the 18-month follow-up it was 54.2%. The SSA study group increased the appropriate use of antibiotics from 35.7% to 46.2%, with this percentage falling to 40.9% after the 18-month follow-up period. In the control group there were no significant changes in prescribing patterns with respect to either the prescribing of antibiotics or the appropriateness of treatment. The intervention strategies were successful in both institutions. Forty per cent of physicians improved their prescribing practices after the workshop, with this change remaining in 27.5% of them throughout the follow-up period. On the other hand, 42.5% of the physicians did not change their prescribing practices after the intervention. The rest (17.5%) showed appropriate prescribing practices during all the stages of the study. We conclude that it is possible to improve the physicians' prescribing practices through interactive educational strategies and managerial interventions. This type of intervention can be an affordable way to provide continuing medical education to primary care physicians who do not have access to continuing educational activities, and to improve the quality of care they provide.

Reversible hearing loss after meningitis. Prospective assessment using auditory evoked responses.

Hearing loss (HL) was prospectively studied in 236 children with meningitis using brainstem auditory evoked responses. Hearing loss was detected in 38 (16.1%) in the acute phase of the disease and in 10 (5.2%) of 193 patients who were tested 6 months later. Hearing loss was more frequent and more severe in patients with bacterial meningitis (25.4% in the acute phase, and 8% 6 months later) than in patients with viral and tuberculous meningitis. In half of the affected cases the auditory lesion was bilateral. Follow-up was possible in 32 patients with early postmeningitic HL. Ten (31.2%) had permanent HL while the remaining 22 (68.7%) recovered normal hearing. Severe initial losses tended to be permanent, whereas minimal and intermediate losses were generally reversible and patients recovered completely in 1 to 6 months. The high incidence of HL in bacterial meningitis suggests that any one of the existing methods of auditory screening should be performed in all patients during the convalescent period.

Hearing loss after Hemophilus influenzae meningitis. Follow-up study with auditory brainstem potentials.

Hearing loss was studied prospectively using auditory brainstem potentials in 34 children with Hemophilus influenzae meningitis treated with chloramphenicol and in 36 children with purulent meningitis caused by microorganisms other than H influenzae treated with ampicillin. Our results indicate that high doses of ampicillin are not associated with permanent hearing loss. Moreover, no statistically significant difference was found in the incidence of hearing loss following H influenzae meningitis and that following meningitis caused by other microorganisms, either during the acute phase or in the convalescent period. Neurological damage, when present, was probably located in the inner ear or in the auditory nerve. Finally, early hearing loss in purulent meningitis does not always constitute an irreversible lesion.

Validation of the verbal autopsy method to ascertain acute respiratory infection as cause of death.

The validity of the Verbal Autopsy (VA) in death due to acute respiratory infection (ARI), was tested in 36 children who died by any acute infectious disease as stated by the necropsy diagnosis, at two public hospitals in Mexico City; the illness started at home. Clinical data obtained through VA were compared with diagnoses of necropsies, which were considered as "gold standard". The presence of dyspnoea for more than one day showed sensitivity of 0.69 and specificity of 0.74, while history of coughing showed a sensitivity of 0.61 and a specificity of 0.73. Combination of both clinical data improved specificity (0.83), but decreased sensitivity (0.54). Additional sources of diagnosis (a panel of assessors, the clinical record and the death certificate), also showed good sensitivity (0.69-0.77) and specificity (0.74-7.8). Focus on history of dyspnea and/or cough in children with an infectious syndrome should be emphasized, as a useful epidemiologic tool to determine children's mortality due to ARI in areas where diagnosis resources are constrained.

[Child health care program in Mexico. Evaluation of the quality of the integrated health care given in training centers]. / Programa de atención a la salud del niño en México. Evaluación de la calidad de la atención integrada que se otorga en los centros de capacitación.

OBJECTIVE: To assess the quality of the integral care of children under five years old (AIMCA) at three first level care units, that without additional resources, were selected by the Child Health Care Program (PASN) to function as statewide training centers. MATERIAL AND METHODS: Using matching list, structure, validated by a consensus of experts and a pilot test, six components of the AIMCA were assessed. The study included children under five years old outpatient clinic, during a period of a week: on the average 30 at each unit. RESULTS: Although there were differences between each health unit, in a high number of cases, the score given to each component of the AIMCA was optimum or satisfactory. The most relevant deficiencies were those related to the mother's training. The assessment allowed for correcting deficiencies in the AIMCA and others related with the organization of Training Centers. CONCLUSIONS: It is possible to have an AIMCA of good quality, at first level units without additional resources. We propose that the mother's training be given mainly by a nurse, especially in children with factors of poor prognosis. The methodology used can be employed to evaluate the AIMCA periodically at training centers.

Sensitive enzyme immunoassay for early diagnosis of tuberculous meningitis.

Cerebrospinal fluid from patients with tuberculous, pyogenic, and viral meningitis, as well as from appropriate control individuals, were assayed for immunoglobulin G and immunoglobulin M antibody activity to Mycobacterium bovis BCG by an enzyme-linked immunosorbent assay. BCG linked covalently to plastic disks served as the antigen in a classical indirect enzyme-linked immunosorbent assay. A significant difference was found between the tuberculous meningitis group and the nontuberculous meningitis and control groups. All samples from the tuberculous meningitis group gave a positive reaction, and none of the known negative samples gave false-positive reactions. Because of its sensitivity, specificity, and predictive value, this test may be useful in the early diagnosis of tuberculous meningitis.

[Cellulitis in pediatrics. Diagnostic and therapeutic considerations]. / Celulitis en pediatría. Consideraciones diagnósticas y terapéuticas.

The clinical histories of 180 cases of cellulitis or phlegmona diffusa were studied at the Hospital de Pediatría del Centro Medico Nacional. The disease prevailed in infants and preschool children. Staphylococcus aureus was the etiological agent most frequently found, but with the presence of enterobacteriaceae in 39% of patients under 2 years of age. One third of the children with cellulitis showed one or several complications. Lethality reached 5% (9 cases), but always related to septicemia from S. aureus. In 14.4%, osteoarthritis was present; frequently there was: fever for over 5 days in spite of adequate treatment, a history of late initiation of the antimicrobial drug (over 1 week) and phlogosis or functional limitation. The radiological picture that shows the bony lesion was evident only after two weeks. One half these cases remained with sequelae. Considerations are made on the adequate plans for antibiotic treatment and the early diagnosis of the osteoarticular complication.

Colonization by Clostridium difficile in hospitalized children: risk factors and typification of the isolated strains.

The frequency of colonization by Clostridium difficile in 273 hospitalized children under 15 years of age was studied. Feces were collected from patients attending the infectious disease service at the Pediatric Hospital IMSS, during a period of 11 months. No colonization was detected in 16 neonates; whereas 10 of 103 children (9.7%) under one year of age, 7 of 84 children (8.3%) from one to five years and 3 of 70 children (4.2%) from five to 15 years of age were colonized. The use of antibiotics and the nutritional state were studied as possible risk factors for colonization. The frequency of colonization was not influenced by the nutritional state, whereas the treatment with antibiotics decreased significantly the colonization in children under one year of age but not in those children over one year of age. In children under one year of age, the cytotoxin was more frequent in cases of diarrhea, and in those over one year no association was found. The 50 strains isolated from these children were classified according to: toxigenicity, sensitivity to antibiotics, phages and bacteriocins. Strains acquired before hospitalization were more toxigenic than those acquired intrahospital. Twelve resistotypes were detected; one of them (V) was more frequent in intrahospital strains. Ten phagobacteriocin types were found, and two of then (D and I) were present only in intrahospital strains. Using this classification scheme, it was found that eight patients were colonized with two different strains at the same time.