Antibiotic-seeking behavior in college students: what do they really expect?

Injudicious use of antibiotics contributes to increased bacterial resistance, and patient expectations encourage physicians to overuse antibiotics. The authors evaluated the level of ill college students' antibiotic-seeking behavior to determine if receiving an antibiotic prescription influenced patients' satisfaction with visits to a clinician. Of 129 students with upper respiratory complaints presenting to a university health center, 55% expected an antibiotic prescription. Antibiotic expectation was significantly more likely among students who thought they had a bacterial versus a viral infection (90% vs 40%; p < .01). A clear diagnosis, an explanation of the rationale for treatment, and an antibiotic prescription were significantly associated with patient satisfaction. Clinicians prescribed an antibiotic for 36% of the students; only 13% of these 46 had requested an antibiotic during the visit. At some previous time, one third of the students had taken an antibiotic prescribed for an earlier illness or for another person. Better patient education and improved clinician-patient communication can potentially help to reduce the injudicious use of antibiotics.

Medical exclusion of sick children from child care centers: a plea for reconciliation.

BACKGROUND: Policies for excluding ill children from child care can affect parental absenteeism from the workplace and the utilization of pediatric health care resources. METHODS: We surveyed a representative sample of 310 child care centers throughout Virginia to assess policies for excluding children with fever, common upper respiratory tract illnesses, or head lice. RESULTS: Of the 183 center directors (59%) who returned completed surveys, 119 (69%) considered a temperature of 100.0 degrees F to 100.4 degrees F to represent fever, but methods for measuring temperature varied widely. Most centers excluded children with low-grade fever, even in the absence of changes in their behavior. Other low-threshold policies could exclude afebrile children with white nasal or eye discharge and children with hair nits, even after treated with a pediculicidal shampoo. CONCLUSIONS: Exclusion policies among child care centers in Virginia vary widely and often are inconsistent with current standards of medical practice. More uniform implementation of exclusion policies established by national consensus panels of experts is needed to reduce unnecessary exclusion of children from child care centers.

Alliteration in medicine: a puzzling profusion of p's.

PROBLEM: Puzzling, progressive profusion of alliterative "p's" in published papers. PURPOSE: To depict this particular "p" predominance with pinpoint precision. PLAN: Periodic, painstaking perusal of periodicals by a professor of paediatrics. PROPOSAL: The "p" plethora is positively perplexing and potentially perturbing.

Parental knowledge about common respiratory infections and antibiotic therapy in children.

BACKGROUND: Widespread antibiotic use has fostered the emergence of antibiotic-resistant bacteria. Parental expectations have been cited as one reason for physicians to overprescribe antibiotics. The objective of this study was to determine parental knowledge about antibiotics and their use for common respiratory tract infections. METHODS: A survey was administered to 100 adults at a rural pediatric office. RESULTS: Many respondents had misconceptions about the etiology of common respiratory tract infections and the effects of antibiotic therapy. Only 54% knew that a virus is the usual cause of the common cold, and 33% thought that a virus causes strep throat. Almost half (46%) believed that antibiotics kill viruses, while 17% were not sure whether antibiotics kill viruses. Most respondents (60%) had never heard about antibiotic resistance. CONCLUSION: Parental knowledge about common respiratory tract infections and about antibiotic therapy is often lacking. Improved parent education may alter parents' expectations concerning antibiotic therapy for their ill children.

Pertussis in primary care practice. Recent advances in diagnosis, treatment, and prevention.

Pertussis continues to be an important vaccine-preventable disease. The recent multiple outbreaks of pertussis have heightened interest in its diagnosis, treatment, and prevention. Diagnosis remains challenging, although new diagnostic tests, including enzyme-linked immunosorbent assay of sera and polymerase chain reaction of nasopharyngeal aspirates, offer the possibility of more rapid diagnosis. Erythromycin remains the preferred antimicrobial to reduce secondary transmission of pertussis. The recent approval of acellular pertussis vaccine for the primary series of immunizations ushers in an exciting new era of pertussis prevention.

Structured guidelines for the use of influenza vaccine among children with chronic pulmonary disorders.

National committees recommend annual influenza vaccination for children > or = 6 months of age with chronic pulmonary diseases, but several studies have suggested that many high risk children do not receive the vaccine. The purpose of this pilot study was to determine whether the use of structured guidelines for which pulmonary disorders warrant influenza vaccination would increase agreement among physicians on whether specific children should be vaccinated. Hospital records of 73 children with an outpatient appointment during the previous month in the pulmonary, allergy or high risk neonatology clinics were reviewed independently by 4 pediatricians. Two reviewers used a set of specific guidelines in deciding whether influenza vaccination was indicated, whereas the other 2 used unspecified clinical judgment. Interrater agreement concerning the advisability of vaccination was higher between the reviewers using the guidelines (overall agreement, 0.89; kappa = 0.73) than between the reviewers using clinical judgment (overall agreement, 0.68; kappa = 0.31). Even among the 34 children for whom all 4 reviewers thought the vaccine advisable, only 13 (38%) had been vaccinated. Studies to define the risk of severe influenza among children with specific lung disorders are needed, but these guidelines can serve as a starting point for the identification of children who deserve individual consideration for annual influenza vaccination.

Kawasaki syndrome masquerading as bacterial lymphadenitis.

We present two case reports of older children who initially presented with cervical lymphadenitis and who were eventually diagnosed and treated for Kawasaki syndrome (KS). Both children presented with unilateral cervical lymphadenopathy and fever and later developed additional clinical features of KS, including cardiac aneurysms in one of the patients. Of the five KS clinical criteria which accompany fever for 5 days, cervical lymphadenopathy of > or = 1.5 cm is the least commonly found. Both patients were treated as having bacterial adenitis prior to the diagnosis of KS. We hope to illustrate that in the case of atypical cervical lymphadenitis, KS should be carefully considered in the differential diagnosis.

Explanation for false-positive urine cultures obtained by bag technique.

OBJECTIVE: To test whether a urine bag technique, previously shown in circumcised male infants 1 month to 1 year of age to yield no false-positive cultures, would give similar results in newborns (females and circumcised and uncircumcised males). DESIGN: Prospective study in which periurethral and urine specimens were obtained from healthy newborns. After the periurethral specimen was obtained, the perineum was washed and a urine bag applied. The urine bag was removed immediately after voiding and the urine was cultured. SETTING: Normal newborn nursery and pediatric hospital. SUBJECTS: Ninety-eight healthy full-term newborns (49 female and 49 male) admitted to the normal nursery during a 4-month period. MAIN RESULTS: Isolation of a pathogen from the bag urine reflected periurethral flora. In 20 (95%) of the 21 urine specimens from which a pathogen was isolated, the same pathogen was detected on the periurethra. Sixteen of the 21 urine cultures were falsely positive (> 10(4) colony-forming units of pathogen per milliliter). In 50 (98%) of the 52 urine samples that yielded no growth, the periurethral culture was also negative. In the remaining 25 urine samples in which nonpathogens were detected, the periurethra yielded nonpathogens or no growth. Thus, if a pathogen was isolated from a bag urine sample, the same pathogen was detected on the periurethra 95% of the time. Conversely, if the bag urine sample was negative for a pathogen, the periurethral culture was negative 100% of the time. The presence of a pathogen on the periurethra was more common in female than male neonates (16 of 49 vs four of 49; P = .004), and none of the 14 circumcised male neonates had a pathogen detected on their periurethra or in their urine. CONCLUSION: This study explains the finding of false-positive cultures with the bag technique. Pathogens detected in bag urine samples reflected pathogens on the periurethra. Until a bag collection technique that avoids contamination by periurethral flora can be developed, urethral catheterization and suprapubic aspiration remain the methods of choice for obtaining a urine specimen in female and uncircumcised male neonates.

Frequency and correlates of bacteriuria among children with neurogenic bladder.

Bacteriuria is a common clinical problem among children with neurogenic bladder due to meningomyelocele or traumatic spinal cord injury. To determine the frequency of bacteriuria among affected children at our institution, we obtained 257 urine specimens from 105 children being seen as outpatients for routine care over a 2-year study period. Specimens were obtained via catheterization. Almost half of these specimens (110/257 or 43%) yielded positive results when tested for urinary pathogens. To assess whether any characteristics of these children were related to the likelihood of bacteriuria, we analyzed further a subgroup of 46 children with normal renal ultrasonography from whom two to five specimens were obtained. There were no statistically significant associations between the likelihood of bacteriuria and the following characteristics: age, gender, socioeconomic status, level of spinal cord lesion, voiding technique, and use of prophylactic antibiotics. Children with neurogenic bladder are at high risk for bacteriuria. The pathogenesis of this bacteriuria, its part in deterioration of the urinary tract, and the possible means of its prevention in this special population all deserve further study.

Skin disorders encountered in a pediatric emergency department.

A total of 1381 visits to a pediatric emergency department (ED) during a six-week period were surveyed to determine the types and frequency of skin disorders encountered. A primary skin complaint accounted for 431 (31%) visits. There was a skin complaint of secondary importance in another 35 (3%) visits, and a skin disorder not mentioned by the patient or parent was detected on examination in a further 88 (6%) visits. In total, 554 (40%) visits included a skin complaint or a skin finding. As expected, cutaneous trauma (including abrasions, contusions, lacerations, and burns) accounted for a substantial number of visits, but a wide range of other dermatologic conditions was also represented, including skin infections, contact dermatitis, and numerous other disorders. Skin diseases are encountered frequently in the pediatric ED setting and should be included in the formal teaching curriculum for training programs in pediatrics and emergency medicine.

Acyclovir treatment of varicella in otherwise healthy adolescents. The Collaborative Acyclovir Varicella Study Group.

STUDY OBJECTIVE: To determine whether orally administered acyclovir is of therapeutic benefit for varicella in otherwise healthy adolescents, and to compare the severity of the disease in adolescents with that in younger children. DESIGN: Multicenter, randomized, placebo-controlled, double-blind trial. SETTING: Patients' homes and university hospital clinics. PATIENTS: Sixty-eight adolescents between 13 and 18 years of age with varicella entered the study. Of the 62 adolescents with laboratory-confirmed varicella who were included in the final analysis, 31 received acyclovir and 31 received placebo. INTERVENTIONS: Placebo or an 800 mg acyclovir tablet was given orally four times daily for 5 days, beginning within 24 hours of onset of rash. MEASUREMENTS AND MAIN RESULTS: Acyclovir recipients had significant reductions in times to cessation of new lesion formation (p less than 0.001), maximum number of lesions (p = 0.019), and defervescence (p = 0.045). Mean constitutional illness score was significantly reduced on day 4 (0.5 vs 1.5, p = 0.05), as was the mean number of residual hypopigmented lesions present on 28-day follow-up examination (22.7 vs 92.7, p = 0.018). Two complications, both bacterial superinfections, occurred in placebo recipients. Adverse experiences and varicella-zoster virus antibody titers measured 28 days after enrollment were similar in both treatment groups. Comparison of placebo recipients with children 2 to 12 years of age participating in a companion study indicated that varicella is more severe in adolescents: mean maximum total lesions (421 vs 347, p = 0.003), mean maximum constitutional illness score (3.1 vs 2.2, p = 0.032), and mean number of residual lesions (92.7 vs 33.2, p = 0.01) were all greater in the adolescent population. CONCLUSIONS: Oral acyclovir therapy is safe and effective for treatment of varicella in otherwise healthy adolescents; this may be an appropriate subgroup for treatment with antiviral drugs because the disease is more severe in them than in younger children.

Latex agglutination testing directly from throat swabs for rapid detection of beta-hemolytic streptococci from Lancefield serogroup C.

A latex agglutination method for the rapid detection of beta-hemolytic streptococci from Lancefield serogroup C in throat swabs from 403 university students with symptomatic pharyngitis was evaluated. Compared with culture, the rapid test was poorly sensitive (34.4%) but very specific (98.4%) in detecting group C beta-hemolytic streptococci. The sensitivity of the rapid test improved with an increasing quantity of growth on culture.

Vaccine storage practices in pediatric offices.

Fifty pediatric offices and clinics in the metropolitan Los Angeles area were visited to assess vaccine storage practices. Questionnaires were administered to the personnel responsible for vaccine storage and the vaccine refrigerators were inspected. Only 16% of vaccine storage coordinators could cite appropriate storage temperatures for vaccines and 18% were unaware that heat can harm certain vaccines. Refrigerator thermometers were checked at least weekly in only 20% of offices, and 22% of the refrigerators had inappropriately high temperatures. Vaccines were routinely stored outside of the refrigerator uninsulated during the practice day in 16% of the offices visited. It is concluded that vaccine storage errors occur in pediatric offices at an unacceptably high frequency. Pediatricians should familiarize themselves with the guidelines for optimal vaccine storage in order to minimize the potential for vaccine failure in primary care practice.

Periurethral colonization and urinary leukocytes as markers for bacteriuria in children with neurogenic bladder.

Bacteriuria and associated renal damage is common in children with a neurogenic bladder, but the pathogenesis of urinary tract infection (UTI) is undefined. We examined the association between periurethral bacterial colonization and the presence of urinary leukocytes in 76 catheter urine specimens from children with neurogenic bladders. Although all the children were asymptomatic, 38/76 (50%) of the urine cultures were positive. Periurethral colonization was significantly more common with positive than with negative urine cultures, suggesting a pathogenetic role for periurethral bacteria in infection of the neurogenic bladder. Urinary leukocytes were present in 24/38 (63%) with positive cultures, as against none (0/38) of those with negative urine cultures, and their presence represents a host response to bladder bacteriuria.

A controlled trial of acyclovir for chickenpox in normal children.

BACKGROUND: Chickenpox, the primary infection caused by the varicella-zoster virus, affects more than 3 million children a year in the United States. Although usually self-limited, chickenpox can cause prolonged discomfort and is associated with infrequent but serious complications. METHODS: To evaluate the effectiveness of acyclovir for the treatment of chickenpox, we conducted a multicenter, double-blind, placebo-controlled study involving 815 healthy children 2 to 12 years old who contracted chickenpox. Treatment with acyclovir was begun within the first 24 hours of rash and was administered by the oral route in a dose of 20 mg per kilogram of body weight four times daily for five days. RESULTS: The children treated with acyclovir had fewer varicella lesions than those given placebo (mean number, 294 vs 347; P less than 0.001), and a smaller proportion of them had more than 500 lesions (21 percent, as compared with 38 percent with placebo; P less than 0.001). In over 95 percent of the recipients of acyclovir no new lesions formed after day 3, whereas new lesions were forming in 20 percent of the placebo recipients on day 6 or later. The recipients of acyclovir also had accelerated progression to the crusted and healed stages, less itching, and fewer residual lesions after 28 days. In the children treated with acyclovir the duration of fever and constitutional symptoms was limited to three to four days, whereas in 20 percent of the children given placebo illness lasted more than four days. There was no significant difference between groups in the distribution of 11 disease complications (10 bacterial skin infections and 1 case of transient cerebellar ataxia). Acyclovir was well tolerated, and there was no significant difference between groups in the titers of antibodies against varicella-zoster virus. CONCLUSIONS: Acyclovir is a safe treatment that reduces the duration and severity of chickenpox in normal children when therapy is initiated during the first 24 hours of rash. Whether treatment with acyclovir can reduce the rare, serious complications of chickenpox remains uncertain.

Association of group C beta-hemolytic streptococci with endemic pharyngitis among college students.

Throat cultures were performed throughout 2 school years to determine whether non-group A beta-hemolytic streptococci (NGA BHS) could be isolated more frequently in 232 college students who had symptomatic pharyngitis than from 198 age-matched controls with noninfectious problems. Duplicate throat swabs were inoculated onto plates that contained sheep blood agar, one plate being incubated in a 5% CO2 atmosphere and the other in an anaerobic environment. The BHS were grouped using latex agglutination. Among the NGA BHS, only those from group C were isolated significantly more often among the patients compared with the controls (26% vs 11%). Quantitative colony counts of isolates of group C BHS were generally higher among patients than controls. Patients with group C BHS had fever, exudative tonsillitis, and anterior cervical adenopathy significantly more frequently than did patients who had throat cultures that were negative for group C BHS. Group C BHS were epidemiologically associated with endemic pharyngitis in this college student population.

Changing the needle when inoculating blood cultures. A no-benefit and high-risk procedure.

Although the Centers for Disease Control recommends that needles should never be recapped, many phlebotomists routinely recap and change needles before blood culture inoculation. This study compared the extrinsic contamination rate in blood cultures when the needle was and was not changed. One hundred eight medical students obtained 182 blood specimens from each other by means of standard methods. Each specimen was inoculated into two culture bottles. The first bottle was inoculated with the needle used for phlebotomy, and the second was inoculated after needle change. Four (2.2%) of 182 bottles were contaminated when the needle was not changed, compared with one (0.6%) when the needle was changed. This small difference was not statistically significant, and the likelihood of having failed to detect a 5% difference in contamination rate was small. The risk of needle-stick injury incurred by changing the needle before inoculation of blood culture bottles seems to be unjustified.

Worldwide control of disease through immunization. Progress and prospects.

In summary, tremendous advances have been made over the past 15 years toward the development of effective national immunization programs throughout the world. Immunization levels among children in the developing world have risen dramatically, and in some instances, now equal or exceed levels in industrialized nations. There is no room for complacency, however, because millions of children remain incompletely immunized and many die each year from measles, pertussis, and neonatal tetanus. Immunization activities need to be intensified, accelerated, and sustained within the context of the primary health care system. Expansion of immunization programs to include additional vaccines and other simple health interventions will yield further benefits in the years ahead.

Non-group A streptococci in the pharynx. Pathogens or innocent bystanders?

OBJECTIVE: To determine whether beta-hemolytic streptococci from groups other than A are an important cause of sporadic pharyngitis in children. DESIGN: Cross-sectional, case-referent survey. SETTING: General pediatric clinic at a military base in Ohio. PARTICIPANTS: One hundred fifty children with symptomatic pharyngitis and 150 controls matched for age and time of presentation over a 20-month study period. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: Anaerobic culture technique was used to improve isolation of beta-hemolytic streptococci. Group A beta-hemolytic streptococci were detected significantly more often among the ill children than among the controls (39% vs 16%, respectively). In contrast, non-group A beta-hemolytic streptococci were isolated in similar frequency from the ill and control children (17% vs 21%, respectively). Non-group A beta-hemolytic streptococci from groups B, C, F, and G were each isolated in similar frequency among the ill and control children. The isolation rate of non-group A organisms increased with age among both patients and controls. CONCLUSIONS: Non-group A beta-hemolytic streptococci seemed not to be an important cause of sporadic pharyngitis in this pediatric population.