Azithromycin for acute lower respiratory tract infections.

BACKGROUND: Acute lower respiratory tract infections (LRTI) range from acute bronchitis and acute exacerbations of chronic bronchitis to pneumonia. Approximately five million people die of acute respiratory tract infections annually. Among these, pneumonia represents the most frequent cause of mortality, hospitalization and medical consultation. Azithromycin is a new macrolide antibiotic, structurally modified from erythromycin and noted for its activity against some gram-negative organisms associated with respiratory tract infections, particularly Haemophilus influenzae (H. influenzae). OBJECTIVES: To compare the effectiveness of azithromycin to amoxycillin or amoxycillin/clavulanic acid (amoxyclav) in the treatment of LRTI, in terms of clinical failure, incidence of adverse events and microbial eradication. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007 Issue 2), MEDLINE (January 1966 to July 2007), and EMBASE (January 1974 to July 2007). SELECTION CRITERIA: Randomized and quasi-randomized controlled trials, comparing azithromycin to amoxycillin or amoxycillin/clavulanic acid in participants with clinical evidence of acute LRTI: acute bronchitis, pneumonia, and acute exacerbation of chronic bronchitis were studied. DATA COLLECTION AND ANALYSIS: The criteria for assessing study quality were generation of allocation sequence, concealment of treatment allocation, blinding, and completeness of the trial. All types of acute LRTI were initially pooled in the meta-analyses. The heterogeneity of results was investigated by the forest plot and Chi-square test. Index of I-square (I(2)) was also used to measure inconsistent results among trials. Subgroup and sensitivity analyses were conducted. MAIN RESULTS: Fifteen trials were analysed. The pooled analysis of all trials showed that there was no significant difference in the incidence of clinical failure on about day 10 to 14 between the two groups (relative risk (RR), random-effects 1.09; 95% confidence interval (CI) 0.64 to 1.85). Sensitivity analysis showed a reduction of clinical failure in azithromycin-treated participants (RR 0.55; 95% CI 0.25 to 1.21) in three adequately concealed studies, compared to RR 1.32; 95% CI 0.70 to 2.49 in 12 studies with inadequate concealment. Twelve trials reported the incidence of microbial eradication and there was no significant difference between the two groups (RR 0.95; 95% CI 0.87 to 1.03). The reduction of adverse events in the azithromycin group was RR 0.76 (95% CI 0.57 to 1.00). AUTHORS' CONCLUSIONS: There is unclear evidence that azithromycin is superior to amoxicillin or amoxyclav in treating acute LRTI. In patients with acute bronchitis of a suspected bacterial cause, azithromycin tends to be more effective in terms of lower incidence of treatment failure and adverse events than amoxicillin or amoxyclav. Future trials of high methodological quality are needed.

Corticosteroids for treating dengue shock syndrome.

BACKGROUND: Dengue shock syndrome is the most severe from of dengue haemorrhagic fever, one of the leading causes of death in children. Observational studies have suggested corticosteroids may benefit people with dengue shock syndrome. OBJECTIVES: To compare corticosteroids with placebo or no corticosteroids for treating dengue shock syndrome. SEARCH STRATEGY: We searched the Cochrane Infectious Disease Group Specialized Register (January 2006), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to January 2006), EMBASE, (1974 to January 2006), LILACS (1982 to January 2006), and reference lists. We also contacted researchers. SELECTION CRITERIA: Randomized and quasi-randomized controlled trials comparing corticosteroids with no corticosteroids or placebo in people diagnosed with dengue shock syndrome. DATA COLLECTION AND ANALYSIS: Two authors independently applied the inclusion criteria, extracted data, and assessed methodological quality. We calculated the relative risk (RR) for dichotomous data and weighted mean difference for continuous data, and presented them with 95% confidence intervals (CI). MAIN RESULTS: Four trials involving 284 participants met the inclusion criteria. Corticosteroids were no more effective than placebo or no treatment for reducing the number of deaths (RR 0.68, 95% CI 0.42 to 1.11; 284 participants, 4 trials), the need for blood transfusion (RR 1.08, 0.52 to 2.24; 89 participants, 2 trials), or the number of serious complications (convulsions and pulmonary haemorrhage) as reported in one trial (63 participants). AUTHORS' CONCLUSIONS: There is insufficient evidence to justify the use of corticosteroids in managing dengue shock syndrome. As corticosteroids can potentially do harm, clinicians should not use them unless they are participating in a randomized controlled trial comparing corticosteroids with placebo.

Antibiotics for treating scrub typhus.

BACKGROUND: Scrub typhus is a cause of fever in regions of Asia and the Pacific. Recently, resistance to antibiotics has been reported. OBJECTIVES: To assess treatment regimens for scrub typhus through time to fever resolution and incidence of relapse. SEARCH STRATEGY: Cochrane Controlled Trials Register, MEDLINE, EMBASE, and contacted individual researchers for unpublished data. SELECTION CRITERIA: Randomised and pseudorandomised studies; patients diagnosed with scrub typhus defined by authors; any comparison of antibiotic regimens for treating scrub typhus. DATA COLLECTION AND ANALYSIS: Trial quality was assessed, and data abstracted by both reviewers. MAIN RESULTS: Three trials met the inclusion criteria. One small trial compared tetracycline against chloramphenicol. The other two trials compared doxycycline with tetracycline, and showed little difference in the proportion febrile at 48 hours, with no relapses after either drug. REVIEWER'S CONCLUSIONS: Tetracycline and doxycycline seem to be effective in treating scrub typhus. Further research is required to identify appropriate treatment in areas where Orientia tsutsugamushi resistant to doxycycline has been reported.

Growth monitoring in children.

BACKGROUND: Growth monitoring is widely accepted and strongly supported by health professionals, and is a standard component of community paediatric services throughout the world. We sought to evaluate research evidence of its impact. This requires definition, consideration of the setting, and discussion of the intended effects of this activity. In this review, we define growth monitoring as the regular recording of a child's weight, coupled with some specified remedial actions if the weight is abnormal in some way. Although the causes of growth faltering and the responses to it may be region specific, the process is the same, and we consider here growth monitoring in both the deprived and richer populations of the world. OBJECTIVES: Growth monitoring consists of routine measurements to detect abnormal growth, combined with some action when this is detected. As primary care workers worldwide invest time in this activity, we sought evidence of its benefits and harms. The review objectives are to evaluate the effects of routine growth monitoring on: 1. The child, in relation to preventing death, illness or malnutrition; and referrals for medical care, medical specialist assessment or professional social support follow-up. 2. The mother, in relation to nutritional knowledge, anxiety or reassurance about the child's health, and satisfaction with services. SEARCH STRATEGY: Cochrane Controlled Trials Register; MEDLINE; EMBASE; CINAHL; World Health Organization and World Bank publications; specialists in this area; citations in existing reviews and identified studies. SELECTION CRITERIA: Randomised or quasi-randomised trials comparing routine growth monitoring (regular monitoring of growth, plotting on a chart, combined with referral or intervention when growth is abnormal) with no growth monitoring. DATA COLLECTION AND ANALYSIS: Trial quality was assessed, and data abstracted by both reviewers. MAIN RESULTS: Two studies included, both conducted in developing countries. In one, the nutritional status at 30 months in 500 children showed no difference between those allocated to growth monitoring and those not. The other study examined whether counselling improved mothers' knowledge of the growth chart, and reported better test scores at four months. REVIEWER'S CONCLUSIONS: Given the level of investment in growth monitoring worldwide, it is surprising there is so little research evaluating its potential benefits and harms.

Antibiotics for treating scrub typhus.

BACKGROUND: Scrub typhus is a bacterial disease in regions of Asia and the Pacific. Antibiotics (chloramphenicol, tetracycline, and doxycycline) have been used to treat the disease. Resistance to these antibiotics has been reported. OBJECTIVES: To evaluate antibiotic regimens for treating scrub typhus. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group specialized trials register (March 2002); the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002); MEDLINE (1966 to March 2002); EMBASE (1988 to January 2002); LILACS (2001, 40a Edition CD-ROM). We checked references and contacted authors for additional data. SELECTION CRITERIA: Randomized and quasi-randomized studies comparing antibiotic regimens in people diagnosed with scrub typhus. DATA COLLECTION AND ANALYSIS: One reviewer screened the search results; both reviewers assessed eligibility, quality and extracted data. We used Review Manager (Version 4.1), and expressed results as Relative Risk (binary) or weighted mean difference (continuous), with 95% confidence intervals. MAIN RESULTS: Four trials involving 451 adults met the inclusion criteria. One small study did not demonstrate a difference between tetracycline with chloramphenicol (participants afebrile after 48 hours, Relative Risk 1.00; 95% confidence interval 0.07 to 15.26). Two small trials did not show a difference between doxycycline and tetracycline (participants afebrile after 48 hours, Relative Risk 0.46; 95% confidence interval 0.12 to 1.75). One trial showed rifampicin to be more effective than doxycycline (for eliminating fever, Relative Risk 0.41; 95% confidence interval 0.22 to 0.77; no relapses in either group). REVIEWER'S CONCLUSIONS: Limited data has not demonstrated a difference between tetracycline and doxycycline. Limited data suggest rifampicin is effective in areas where scrub typhus appears to respond poorly to standard anti-rickettsial drugs.

Azithromycin for acute lower respiratory tract infections.

BACKGROUND: The spectrum of acute lower respiratory tract infection ranges from acute bronchitis and acute exacerbations of chronic bronchitis to pneumonia. Annually approximately five million people die of acute respiratory tract infections. Among these, pneumonia represents the most frequent cause of mortality, hospitalization and medical consultation. Azithromycin is a new macrolide antibiotic, structurally modified from erythromycin and is noted for its activity against some gram-negative organisms associated with respiratory tract infections, particularly Haemophilus influenzae (H. influenzae). OBJECTIVES: To compare the effectiveness of azithromycin to amoxycillin or amoxycillin/clavulanic acid (amoxyclav) in the treatment of LRTI, in terms of clinical failure, incidence of adverse events and microbial eradication. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2003), MEDLINE (January 1966 to January Week 3, 2004), and EMBASE (January 1988 to 2003). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials, which compared azithromycin to amoxycillin or amoxycillin/clavulanic acid in patients with clinical evidence of acute LRTI: acute bronchitis, pneumonia, and acute exacerbation of chronic bronchitis were studied. DATA COLLECTION AND ANALYSIS: The criteria for assessing study quality were generation of allocation sequence, concealment of treatment allocation, blinding, and completeness of the trial. All types of acute lower respiratory tract infections were initially pooled in the meta-analyses. Funnel plot was used to examine publication bias. The heterogeneity of results was investigated by the forest plot and Chi-square test. Index of I(2) was also used to measure inconsistency results among trials. Subgroup analysis was conducted for age, types of respiratory tract infection and types of antibiotic in control groups. Sensitivity analysis was conducted under the condition of trial size and concealment of treatment allocation. MAIN RESULTS: Fourteen trials with 2,521 enrolled patients used 2,416 patients in the analysis. A total of 1,350 patients received azithromycin and 1,066 received amoxicillin or amoxicillin-clavulanic acid. The pooled analysis of all trials showed that there was no significant difference in the incidence of clinical failure on about day 10 to 14 after therapy started between the two groups (relative risk (RR) (random effects) 0.96; 95% CI 0.58 to 1.57). Sensitivity analysis showed that a reduction of clinical failure in azithromycin-treated patients (RR 0.52; 95% CI 0.24 to 1.12) in three adequately concealed studies, compared to RR 1.14 (95% CI 0.62 to 2.08) in eleven studies with inadequate concealment. Eleven trials reported the incidence of microbial eradication and there was no significant difference between the two groups (RR 0.98; 95% CI 0.91 to 1.07). The reduction of adverse events in azithromycin group was RR 0.75 (95% CI 0.56 to 1.00). REVIEWERS' CONCLUSIONS: There is unclear evidence that azithromycin is superior to amoxicillin or amoxicillin-clavulanic acid in treating acute LRTI. Future trials with high methodological quality are needed.

Nutritional problems in children aged 1-24 months: comparison of hill-tribe and Thai children.

A cross-sectional survey was conducted in Maecham district, Chiang Mai. The objective was to determine the magnitude of nutritional problems in children aged 1-24 months, both of hill-tribe and Thai communities, where breast-feeding is highly prevalent. Three hundred and fifty nine children were recruited, 252 were hill-tribe (Karen and Lahu), and 107 were Thai children. Anthropometric measurements were taken and mothers were interviewed. In a group of hill-tribe children, the prevalence of malnutrition (Z score of weight for age < -2) was 25.0 compared with 12.1 per cent for Thai children (p <0.01). The prevalence was highest in children aged between 12-24 months. This corresponded to the time children were weaned. The prevalence of stunting (Z score of height for age < -2) in hill-tribe and Thai children was 25.4 and 12.1 per cent respectively (p <0.01). There was no significant difference of wasting (Z score of weight for height < -2) between hill-tribe and Thai children, 9.1 and 8.4 per cent respectively. The mean (SD) Z scores of weight for age, weight for height, and height for age for both groups declined significantly as the age increased (p <0.001). In conclusion, this study revealed the nutritional problems of young hill-tribe children were more severe than those of Thai children. The factors that could be related with this, were socioeconomic status, as also genetics, as well as cultural beliefs concerning child raising. Such ethnic minorities therefore should be considered as special cases in programs of health and nutrition promotion.

Is routine growth monitoring effective? A systematic review of trials.

BACKGROUND: Growth monitoring consists of routine measurements to detect abnormal growth, combined with some action when this is detected. It aims to improve nutrition, reduce the risk of death or inadequate nutrition, help educate carers, and lead to early referral for conditions manifest by growth disorders. As primary care workers world wide invest time in this activity, evidence for its benefits and harms was sort. STUDIES: randomised or quasi-randomised controlled trials of growth monitoring. INTERVENTIONS: regular growth monitoring, combined with some intervention targeted at abnormal growth, compared with controls. OUTCOMES: anthropometric measures; referrals to primary and specialist care, or community services; maternal knowledge, anxiety, and satisfaction; child morbidity and mortality. COMPARISONS: Routine growth monitoring compared with no routine growth monitoring; routine growth monitoring by plotting onto a standard chart compared with monitoring with no chart. SEARCH STRATEGY: Cochrane controlled trials register; World Health Organisation and World Bank publications; contact with specialist community paediatricians working in the field. RESULTS: Two trials met the inclusion criteria. One compared growth monitoring with no growth monitoring, in a cluster randomised trial nested in a nutritional intervention programme, and detected no difference in nutritional outcomes between the two groups. Another trial compared growth monitoring with and without a standard chart, measuring maternal knowledge of women about nutrition. It showed small numerical differences in test scores. DISCUSSION AND IMPLICATIONS: Current policies appear to be based on the opinion that investment in the activity has worthwhile health benefits, and does no harm. No reliable evidence was found to support or refute this.

Are orphans at increased risk of malnutrition in Malawi?

The objective of this study was to compare the nutritional status and health problems of village orphans, non-orphans and orphanage children, and to identify factors associated with undernutrition. A cross-sectional study was conducted in three orphanages and two villages near Blantyre, Malawi. Seventy-six orphanage children, 137 village orphans and 80 village non-orphans were recruited. Anthropometric measurement was done and guardians were interviewed. In the group of children aged < 5 years, the prevalence of undernutrition in orphanage children was 54.8% compared with 33.3% and 30% of village orphans and non-orphans, respectively. Sixty-four per cent of young orphanage children were stunted compared with 50% of village orphans and 46.4% of non-orphans. The mean (SD) Z-score of height/age was significantly lower in the orphanage group, -2.75 (1.29) compared with -2.20 (1.51) and -1.61 (1.57) in the village orphan and non-orphan groups (p < 0.05). Conversely, older orphanage children (> or = 5 years) were less stunted and wasted than orphans and non-orphans in villages. Illness of children in the last month was reported to be higher in the non-orphan group, especially diarrhoeal disease, which occurred in 30% compared with 10.8% of village orphans and 6.6% of orphanage children. More than three children in a family being cared for by guardians was significantly associated with undernutrition. Orphanage girls were more likely to be malnourished than orphanage boys. Children who had been admitted to an orphanage for more than a year were less malnourished. In village orphans, there was no association between undernutrition and duration of stay in extended families. Age and education of guardians were not associated with the nutritional status of children. We conclude that young orphanage children are more likely to be undernourished and more stunted than village children. Older orphanage children seem to have better nutrition than village orphans. There was no significant difference in nutritional status between village orphans and non-orphans.