Efficacy of metered-dose inhalers for children with acute asthma exacerbations.

OBJECTIVE: To compare the effectiveness of the administration of inhaled beta-agonists delivered via a metered-dose inhaler (MDI) with spacers--as part of an evidence-based asthma pathway developed to manage acute asthma exacerbations in children at the emergency room level and in inpatient management--against administration via nebulization. DESIGN: Case with historical control. SETTING: KK Women's and Children's Hospital (Singapore). PARTICIPANTS: A total of 19,951 children (infants to older children) aged 18 years and younger who attended the emergency room for asthma exacerbations. MAIN OUTCOME MEASURES: Average length of stay, proportion admitted to high dependency or intensive care, proportion readmitted for unresolved symptoms within 72 hr, cost per patient and overall. RESULTS: There was no increase in the mean proportion of emergency room attendances admitted to inpatient care with use of an MDI (mean difference 0.97%, 95% CI: -1.6-3.5%, P = 0.447), nor of children admitted to intensive care (0.21 vs. 0.20 pre- and post-pathway, P = 0.827) or to high dependency units (2.21 vs. 1.37 pre- and post-pathway, P = 0.200) but a significant reduction in the within 72 hr re-attendance rate (mean difference 1.4%, 95% CI: 0.78-2.0%, P < 0.001) with use of an MDI. The average length and cost per patient for an inpatient stay for acute asthma exacerbations was reduced with use of an MDI. CONCLUSIONS: The use of an MDI with spacer as part of an evidence-based asthma pathway was effective in the management of acute asthma exacerbations in the emergency room setting and for inpatient management.

Lower respiratory tract infection in hospitalized children.

OBJECTIVE: The aim of the present study was to investigate the aetiology and antibiotic-resistance patterns of community-acquired lower respiratory tract infection (LRTI) in 1999 and compare it with data from 1995 and 1988. METHODOLOGY: A prospective observational study of LRTI in hospitalized children at KK Women's & Children's Hospital, Singapore, was undertaken. RESULTS: A positive isolate was found in 58% of patients (671/1158), comprising viruses (n = 477, 41.2%), non-type B Haemophilus influenzae (n = 101, 8.7%), Streptococcus pneumoniae (n = 66, 5.7%), Mycoplasma pneumoniae (n = 92, 8%), Moraxella catarrhalis (n = 19, 1.6%) and other bacteria (n = 19, 1.6%). Mixed virus-bacteria (n = 104, 9%) infections were comprised mostly of virus-H. influenzae combinations. In 1999, S. pneumoniae resistance rates were penicillin 44.6% (17%, 1995), amoxycillin 3% (18%, 1995; MIC 0.5-2 microg/mL reclassified as susceptible in 1999), erythromycin 55% (30%, 1995), trimethoprim-sulfamethoxazole (TMP/SMX) 60% (23%, 1995). H. influenzaeresistance rates were amoxycillin 26.7% (38%, 1995), erythromycin 99% (37%, 1995), TMP/SMX 98% (37%, 1995). There were 15 cases of empyema of which seven were proven S. pneumoniae and there was one pneumococcal death (0.08%). CONCLUSIONS: Pneumococcal pneumonia needs to be treated aggressively due to its high morbidity. Amoxycillin still remains useful for treating pneumococcus despite an increasing resistance to penicillin, erythromycin and TMP/SMX. Judicious use of antibiotics is needed to curb the increasing rate of antibiotic-resistance.