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1.
Int J Qual Stud Health Well-being ; 16(1): 2003520, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34793292

RESUMO

PURPOSE: Bronchiectasis is a chronic respiratory disease that impacts significantly on quality of life for those who have it. There is a paucity of literature exploring the perspectives of children and young people. The aim of this study was to examine the day-to-day life experience of a group of young people with bronchiectasis. METHOD: A qualitative study using semi-structured interviews explored fifteen young people's perspectives of life with bronchiectasis. Key themes were identified using an inductive iterative approach through constant comparative analysis guided by Thorne's interpretive description. RESULTS: Life with bronchiectasis was conceptualized by participants as "Pretty Normal". This consisted of two co-existing life views which represented how young people balanced the ups and downs of adolescence while learning to accommodate the demands of living with bronchiectasis. Three key thematic elements "sore and tired", 'life interrupted and "looking after self", influenced and challenged these two views of life. CONCLUSIONS: Young people with bronchiectasis portray life as being the same as their peers. Despite this, they recognized that the symptoms, interruptions, and self-management responsibilities led them to find ways of coping and integrating their experience into a new and modified view of normal.


Assuntos
Bronquiectasia , Autogestão , Adaptação Psicológica , Adolescente , Criança , Humanos , Pesquisa Qualitativa , Qualidade de Vida
2.
Pediatr Pulmonol ; 56(9): 2949-2957, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34232567

RESUMO

AIM: The incidence of childhood empyema has been increasing in some developed countries despite the introduction of pneumococcal vaccination. This study aimed to document the incidence, bacterial pathogens, and morbidity/mortality of parapneumonic effusion/empyema in New Zealand. METHODS: A prospective study of 102 children <15 years of age requiring hospitalization with parapneumonic effusion/empyema between May 1, 2014 and May 31, 2016 notified via the New Zealand Paediatric Surveillance Unit. Parapneumonic effusion/empyema was defined as pneumonia and pleural effusion persisting ≥7 days, and/or any pneumonia, and pleural effusion necessitating drainage. Notifying pediatricians completed standardized questionnaires. RESULTS: Annual pediatric parapneumonic effusion/empyema incidence was 5.6/100,000 (95% confidence interval [CI]: 4.7-6.9). Most children (80%) required surgical intervention and 31% required intensive care. A causative organism was identified in 71/102 (70%) cases. Although Staphylococcus aureus (25%) and Streptococcus pneumoniae (25%) infection rates were equal, prolonged hospitalization and intensive care admission were more common in children with S. aureus PPE/E. Maori and Pasifika children were over-represented at 2.2 and 3.5 times, their representation in the New Zealand pediatric population. Pneumococcal vaccination was incomplete, with only 61% fully immunized and 30% unimmunized. Haemophilus influenzae type b vaccine uptake was near complete at 89/94 (95%), with influenza immunization only 3/78 (4%). CONCLUSIONS: New Zealand has a high incidence of pediatric complicated parapneumonic effusion/empyema with significant morbidity. S. aureus was a significant cause of severe empyema in New Zealand, particularly for Maori and Pasifika children. Improvements in vaccine coverage are needed along with strategies to reduce S. aureus disease morbidity.

5.
Eur J Pediatr ; 180(10): 3171-3179, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33909156

RESUMO

Non-cystic fibrosis bronchiectasis is increasingly described in the paediatric population. While diagnosis is by high-resolution chest computed tomography (CT), chest X-rays (CXRs) remain a first-line investigation. CXRs are currently insensitive in their detection of bronchiectasis. We aim to determine if quantitative digital analysis allows CT features of bronchiectasis to be detected in contemporaneously taken CXRs. Regions of radiologically (A) normal, (B) severe bronchiectasis, (C) mild airway dilation and (D) other parenchymal abnormalities were identified in CT and mapped to corresponding CXR. An artificial neural network (ANN) algorithm was used to characterise regions of classes A, B, C and D. The algorithm was then tested in 13 subjects and compared to CT scan features. Structural changes in CT were reflected in CXR, including mild airway dilation. The areas under the receiver operator curve for ANN feature detection were 0.74 (class A), 0.71 (class B), 0.76 (class C) and 0.86 (class D). CXR analysis identified CT measures of abnormality with a better correlation than standard radiological scoring at the 99% confidence level.Conclusion: Regional abnormalities can be detected by digital analysis of CXR, which may provide a low-cost and readily available tool to indicate the need for diagnostic CT and for ongoing disease monitoring. What is Known: • Bronchiectasis is a severe chronic respiratory disorder increasingly recognised in paediatric populations. • Diagnostic computed tomography imaging is often requested only after several chest X-ray investigations. What is New: • We show that a digital analysis of chest X-ray could provide more accurate identification of bronchiectasis features.


Assuntos
Bronquiectasia , Algoritmos , Bronquiectasia/diagnóstico por imagem , Criança , Humanos , Tórax , Tomografia Computadorizada por Raios X , Raios X
6.
Emerg Infect Dis ; 27(2): 641-643, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33263515

RESUMO

In March 2020, a national elimination strategy for coronavirus disease was introduced in New Zealand. Since then, hospitalizations for lower respiratory tract infection among infants <2 years of age and cases of respiratory syncytial or influenza virus infection have dramatically decreased. These findings indicate additional benefits of coronavirus disease control strategies.


Assuntos
COVID-19/epidemiologia , Hospitalização/estatística & dados numéricos , Influenza Humana/epidemiologia , Infecções por Vírus Respiratório Sincicial/epidemiologia , Infecções Respiratórias/epidemiologia , COVID-19/virologia , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Influenza Humana/virologia , Masculino , Nova Zelândia/epidemiologia , Orthomyxoviridae , Infecções por Vírus Respiratório Sincicial/virologia , Vírus Sincicial Respiratório Humano , Infecções Respiratórias/virologia , SARS-CoV-2 , Estações do Ano
7.
J Paediatr Child Health ; 57(4): 548-553, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33185946

RESUMO

AIM: To determine whether the transfer of young people with cystic fibrosis (CF) or bronchiectasis from paediatric to adult services is associated with changes in service engagement and/or health outcomes. METHODS: Young people aged ≥15 years of age with CF or bronchiectasis who transferred from the Auckland-based paediatric service (Starship Children's Hospital) to one of three Auckland-based District Health Boards between 2005 and 2012 were identified and included if they had 3 years care both pre-transfer and post-transfer care. Transfer preparation, service engagement (clinics scheduled, clinics attended) and health outcomes (lung function, hospitalisations) were collected per annum. RESULTS: Fifty-seven young people transferred in this period with 46 meeting inclusion criteria (CF n = 20, bronchiectasis n = 26). The CF group had better transfer documentation, were transferred at an older age (11 months older P < 0.0001 95%CI: 6.7 months, 14.7 months), were 20 times more likely to attend clinics (P < 0.0001, 95%CI: 7.8, 66.1) and had 3-4 more clinics scheduled pre-transfer (P < 0.0001, 95%CI: 3.4, 4.9) and post-transfer (P < 0.0001, 95%CI: 2.4, 3.8) despite having less severe respiratory disease as measured by FEV1 for each year (P < 0.01, 95%CI: 0.34, 1.22). CONCLUSION: The transfer of young people with CF to adult services did not affect health engagement or outcomes, in contrast to those with bronchiectasis. Use of a formalised transfer process, more clinic appointments offered and greater resources for CF may be responsible for this difference. Comprehensive transition with purposeful, planned movement and developmentally appropriate care is a key goal.


Assuntos
Bronquiectasia , Fibrose Cística , Adolescente , Adulto , Idoso , Bronquiectasia/terapia , Criança , Fibrose Cística/terapia , Hospitais Pediátricos , Humanos , Lactente , Motivação , Avaliação de Resultados em Cuidados de Saúde
8.
J Cyst Fibros ; 19(6): 868-871, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33183965

RESUMO

With the growing SARS-CoV-2 pandemic, we need to better understand its impact in specific patient groups like those with Cystic Fibrosis (CF). We report on 181 people with CF (32 post-transplant) from 19 countries diagnosed with SARS-CoV-2 prior to 13 June 2020. Infection with SARS-CoV-2 appears to exhibit a similar spectrum of outcomes to that seen in the general population, with 11 people admitted to intensive care (7 post-transplant), and 7 deaths (3 post-transplant). A more severe clinical course may be associated with older age, CF-related diabetes, lower lung function in the year prior to infection, and having received an organ transplant. Whilst outcomes in this large cohort are better than initially feared overall, possibly due to a protective effect of the relatively younger age of the CF population compared to other chronic conditions, SARS-CoV-2 is not a benign disease for all people in this patient group.


Assuntos
COVID-19 , Fibrose Cística , Hospitalização/estatística & dados numéricos , Transplante de Pulmão/estatística & dados numéricos , SARS-CoV-2/isolamento & purificação , Adulto , Fatores Etários , Idoso , COVID-19/epidemiologia , COVID-19/prevenção & controle , COVID-19/terapia , Teste para COVID-19/métodos , Comorbidade , Fibrose Cística/epidemiologia , Fibrose Cística/cirurgia , Feminino , Saúde Global , Humanos , Pulmão/diagnóstico por imagem , Masculino , Mortalidade , Avaliação de Resultados em Cuidados de Saúde , Sistema de Registros/estatística & dados numéricos , Testes de Função Respiratória/métodos , Fatores de Risco , Fatores Sexuais , Tomografia Computadorizada por Raios X/métodos
9.
Pediatr Pulmonol ; 55(4): 975-985, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32096916

RESUMO

OBJECTIVE: The sole prospective longitudinal study of children with either chronic suppurative lung disease (CSLD) or bronchiectasis published in the current era was limited to a single center. We sought to extend this study by evaluating the longer-term clinical and lung function outcomes and their associated risk factors in Indigenous children of adolescents from Australia, Alaska, and New Zealand who participated in our previous CSLD or bronchiectasis studies during 2004-2010. METHODS: Between 2015 and 2018, we evaluated 131 out of 180 (72.8%) children of adolescents from the original studies at a single follow-up visit. We administered standardized questionnaires, reviewed medical records, undertook clinical examinations, performed spirometry, and scored available chest computed tomography scans. RESULTS: Participants were seen at a mean age of 12.3 years (standard deviation: 2.6) and a median of 9.0 years (range: 5.0-13.0) after their original recruitment. With increasing age, rates of acute lower respiratory infections (ALRI) declined, while lung function was mostly within population norms (median forced expiry volume in one-second = 90% predicted, interquartile range [IQR]: 81-105; forced vital capacity [FVC] = 98% predicted, IQR: 85-114). However, 43 out of 111 (38.7%) reported chronic cough episodes. Their overall global rating judged by symptoms, including ALRI frequency, examination findings, and spirometry was well (20.3%), stable (43.9%), or improved (35.8%). Multivariable regression identified household tobacco exposure and age at first ALRI-episode as independent risk factors associated with lower FVC% predicted values. CONCLUSION: Under our clinical care, the respiratory outcomes in late childhood or early adolescence are encouraging for these patient populations at high-risk of premature mortality. Prospective studies to further inform management throughout the life course into adulthood are now needed.


Assuntos
Bronquiectasia/diagnóstico , Adolescente , Adulto , Alaska/epidemiologia , Alaska/etnologia , Austrália/epidemiologia , Austrália/etnologia , Criança , Doença Crônica , Tosse/etiologia , Feminino , Seguimentos , Humanos , Povos Indígenas , Estudos Longitudinais , Pneumopatias/diagnóstico , Masculino , Nova Zelândia/etnologia , Estudos Prospectivos , Infecções Respiratórias/complicações , Fatores de Risco , Espirometria , Supuração/complicações , Capacidade Vital
10.
Eur Respir J ; 55(4)2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31949117

RESUMO

Little is known about early predictors of later cystic fibrosis (CF) structural lung disease. This study examined early predictors of progressive structural lung abnormalities in children who completed the Australasian CF Bronchoalveolar Lavage (ACFBAL) clinical trial at age 5-years and participated in an observational follow-up study (CF-FAB).Eight Australian and New Zealand CF centres participated in CF-FAB and provided follow-up chest computed-tomography (CT) scans for children who had completed the ACFBAL study with baseline scans at age 5-years. CT scans were annotated using PRAGMA-CF scoring. Ordinal regression analysis and linear regression were used to investigate associations between PRAGMA-CF (Perth-Rotterdam Annotated Grid Morphometric Analysis for CF) outcomes at follow-up and variables measured during the ACFBAL study.99 out of 157 ACFBAL children (mean±sd age 13±1.5 years) participated in the CF-FAB study. The probability of bronchiectasis at follow-up increased with airway disease severity on the baseline CT scan. In multiple regression (retaining factors at p<0.05) the extent of bronchiectasis at follow-up was associated with baseline atelectasis (OR 7.2, 95% CI 2.4-22; p≤ 0.001), bronchoalveolar lavage (BAL) log2 interleukin (IL)-8 (OR 1.2, 95% CI 1.05-1.5; p=0.010) and body mass index z-score (OR 0.49, 95% CI 0.24-1.00; p=0.05) at age 5 years. Percentage trapped air at follow-up was associated with BAL log2 IL-8 (coefficient 1.3, 95% CI 0.57-2.1; p<0.001) at age 5 years.The extent of airway disease, atelectasis, airway inflammation and poor nutritional status in early childhood are risk factors for progressive structural lung disease in adolescence.


Assuntos
Fibrose Cística , Adolescente , Austrália , Criança , Pré-Escolar , Progressão da Doença , Seguimentos , Humanos , Pulmão/diagnóstico por imagem , Nova Zelândia
11.
J Cyst Fibros ; 19(3): 370-375, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31680041

RESUMO

BACKGROUND: Antimicrobial susceptibility testing (AST) is a cornerstone of infection management in cystic fibrosis. However, there is little evidence that AST predicts the clinical outcome of CF antimicrobial treatment. It has been suggested there is a need for careful consideration of current AST use by the CF community. METHODS: We engaged a group of experts consisting of pulmonary (adult and pediatric) and infectious disease clinicians, microbiologists, and pharmacists representing a broad international experience. We conducted an iterative systematic survey (Delphi) to determine and quantify consensus regarding key questions facing CF clinicians in the use of respiratory culture results including what tests to order, when to obtain them, and how to act upon the results of the testing. RESULTS: Consensus was reached for many questions but there was not universal agreement to the questions that were addressed. There were some differences with respect to cultures obtained for surveillance compared to when there is clinical worsening. Areas of general consensus include when and how respiratory cultures should be performed, what information should be reported, and when AST should be performed. A key finding is that clinical response to treatment is used to guide treatment decisions rather than AST results. CONCLUSIONS: Recommendations are presented regarding questions related to microbiology testing for patients with CF. We have also offered recommendations for priority research questions.


Assuntos
Antibacterianos/uso terapêutico , Fibrose Cística , Farmacorresistência Bacteriana , Testes de Sensibilidade Microbiana/métodos , Utilização de Procedimentos e Técnicas , Adulto , Antibacterianos/classificação , Criança , Consenso , Procedimentos Clínicos/normas , Fibrose Cística/tratamento farmacológico , Fibrose Cística/microbiologia , Técnica Delfos , Humanos , Cooperação Internacional , Seleção de Pacientes , Resultado do Tratamento
12.
Lancet Respir Med ; 8(1): 65-124, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31570318

RESUMO

The past six decades have seen remarkable improvements in health outcomes for people with cystic fibrosis, which was once a fatal disease of infants and young children. However, although life expectancy for people with cystic fibrosis has increased substantially, the disease continues to limit survival and quality of life, and results in a large burden of care for people with cystic fibrosis and their families. Furthermore, epidemiological studies in the past two decades have shown that cystic fibrosis occurs and is more frequent than was previously thought in populations of non-European descent, and the disease is now recognised in many regions of the world. The Lancet Respiratory Medicine Commission on the future of cystic fibrosis care was established at a time of great change in the clinical care of people with the disease, with a growing population of adult patients, widespread genetic testing supporting the diagnosis of cystic fibrosis, and the development of therapies targeting defects in the cystic fibrosis transmembrane conductance regulator (CFTR), which are likely to affect the natural trajectory of the disease. The aim of the Commission was to bring to the attention of patients, health-care professionals, researchers, funders, service providers, and policy makers the various challenges associated with the changing landscape of cystic fibrosis care and the opportunities available for progress, providing a blueprint for the future of cystic fibrosis care. The discovery of the CFTR gene in the late 1980s triggered a surge of basic research that enhanced understanding of the pathophysiology and the genotype-phenotype relationships of this clinically variable disease. Until recently, available treatments could only control symptoms and restrict the complications of cystic fibrosis, but advances in CFTR modulator therapies to address the basic defect of cystic fibrosis have been remarkable and the field is evolving rapidly. However, CFTR modulators approved for use to date are highly expensive, which has prompted questions about the affordability of new treatments and served to emphasise the considerable gap in health outcomes for patients with cystic fibrosis between high-income countries, and low-income and middle-income countries (LMICs). Advances in clinical care have been multifaceted and include earlier diagnosis through the implementation of newborn screening programmes, formalised airway clearance therapy, and reduced malnutrition through the use of effective pancreatic enzyme replacement and a high-energy, high-protein diet. Centre-based care has become the norm in high-income countries, allowing patients to benefit from the skills of expert members of multidisciplinary teams. Pharmacological interventions to address respiratory manifestations now include drugs that target airway mucus and airway surface liquid hydration, and antimicrobial therapies such as antibiotic eradication treatment in early-stage infections and protocols for maintenance therapy of chronic infections. Despite the recent breakthrough with CFTR modulators for cystic fibrosis, the development of novel mucolytic, anti-inflammatory, and anti-infective therapies is likely to remain important, especially for patients with more advanced stages of lung disease. As the median age of patients with cystic fibrosis increases, with a rapid increase in the population of adults living with the disease, complications of cystic fibrosis are becoming increasingly common. Steps need to be taken to ensure that enough highly qualified professionals are present in cystic fibrosis centres to meet the needs of ageing patients, and new technologies need to be adopted to support communication between patients and health-care providers. In considering the future of cystic fibrosis care, the Commission focused on five key areas, which are discussed in this report: the changing epidemiology of cystic fibrosis (section 1); future challenges of clinical care and its delivery (section 2); the building of cystic fibrosis care globally (section 3); novel therapeutics (section 4); and patient engagement (section 5). In panel 1, we summarise key messages of the Commission. The challenges faced by all stakeholders in building and developing cystic fibrosis care globally are substantial, but many opportunities exist for improved care and health outcomes for patients in countries with established cystic fibrosis care programmes, and in LMICs where integrated multidisciplinary care is not available and resources are lacking at present. A concerted effort is needed to ensure that all patients with cystic fibrosis have access to high-quality health care in the future.


Assuntos
Fibrose Cística/terapia , Atenção à Saúde/tendências , Progressão da Doença , Qualidade de Vida , Fibrose Cística/genética , Regulador de Condutância Transmembrana em Fibrose Cística/administração & dosagem , Terapia Genética/métodos , Saúde Global , Humanos , Transplante de Pulmão/métodos
13.
Lancet Respir Med ; 7(9): 791-801, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31427252

RESUMO

BACKGROUND: Bronchiectasis guidelines recommend antibiotics for the treatment of acute respiratory exacerbations, but randomised placebo-controlled trials in children are lacking. We hypothesised that oral amoxicillin-clavulanate and azithromycin would each be superior to placebo in achieving symptom resolution of non-severe exacerbations in children by day 14 of treatment. METHODS: In this multicentre, three-arm, parallel, double-dummy, double-blind, randomised placebo-controlled trial at four paediatric centres in Australia and New Zealand, we enrolled children aged 1-18 years with CT-confirmed bronchiectasis unrelated to cystic fibrosis, who were under the care of a respiratory physician and who had had at least two respiratory exacerbations in the 18 months before study entry. Participants were allocated (1:1:1) at exacerbation onset to receive oral suspensions of amoxicillin-clavulanate (45 mg/kg per day) plus placebo azithromycin, azithromycin (5 mg/kg per day) plus placebo amoxicillin-clavulanate, or both placebos for 14 days. An independent statistician prepared a computer-generated, permuted-block (size 2-8) randomisation sequence, stratified by centre, age, and cause. Participants, caregivers, study coordinators, and investigators were masked to treatment assignment until data analysis was completed. The primary outcome was the proportion of children with exacerbation resolution by day 14 in the intention-to-treat population. Treatment groups were compared using generalised linear models. Statistical significance was set at p<0·0245 to account for multiple comparisons. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000011886) and is completed. FINDINGS: Between April 17, 2012, and March 1, 2017, 604 children were screened and 252 were enrolled. Between July 31, 2012, and June 26, 2017, 197 children were allocated at the start of an exacerbation (63 to the amoxicillin-clavulanate group, 67 to the azithromycin group, and 67 to the placebo group). Respiratory viruses were identified in 82 (53%) of 154 children with available nasal swabs on day 1 of treatment. Primary outcome data were available for 196 (99%) children (one child with missing data [placebo group] was recorded as non-resolved according to criteria defined a priori). By day 14, exacerbations had resolved in 41 (65%) children in the amoxicillin-clavulanate group, 41 (61%) in the azithromycin group, and 29 (43%) in the placebo group. Compared with placebo, relative risk for resolution by day 14 was 1·50 (95% CI 1·08-2·09, p=0·015; number-needed-to-treat [NNT] 5 [95% CI 3-20]) in the amoxicillin-clavulanate group and 1·41 (1·01-1·97, p=0·042; NNT 6 [3-79]) in the azithromycin group. Adverse events were recorded in 19 (30%) children in the amoxicillin-clavulanate group, 20 (30%) in the azithromycin group, and 14 (21%) in the placebo group, but no events were severe or life-threatening. INTERPRETATION: Amoxicillin-clavulanate treatment is beneficial in terms of resolution of non-severe exacerbations of bronchiectasis in children, and should remain the first-line oral antibiotic in this setting. FUNDING: National Health and Medical Research Council (Australia), Cure Kids (New Zealand).


Assuntos
Amoxicilina/uso terapêutico , Antibacterianos/uso terapêutico , Azitromicina/uso terapêutico , Bronquiectasia/tratamento farmacológico , Bronquiectasia/fisiopatologia , Ácido Clavulânico/uso terapêutico , Administração Oral , Amoxicilina/administração & dosagem , Antibacterianos/administração & dosagem , Austrália , Azitromicina/administração & dosagem , Criança , Pré-Escolar , Ácido Clavulânico/administração & dosagem , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Humanos , Pulmão/efeitos dos fármacos , Pulmão/fisiopatologia , Masculino , Nova Zelândia , Resultado do Tratamento
14.
BMC Health Serv Res ; 19(1): 561, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31409413

RESUMO

BACKGROUND: Bronchiectasis in children is an important, but under-researched, chronic pulmonary disorder that has negative impacts on health-related quality of life. Despite this, it does not receive the same attention as other chronic pulmonary conditions in children such as cystic fibrosis. We measured health resource use and health-related quality of life over a 12-month period in children with bronchiectasis. METHODS: We undertook a prospective cohort study of 85 children aged < 18-years with high-resolution chest computed-tomography confirmed bronchiectasis undergoing management in three pediatric respiratory medical clinics in Darwin and Brisbane, Australia and Auckland, New Zealand. Children with cystic fibrosis or receiving cancer treatment were excluded. Data collected included the frequency of healthcare attendances (general practice, specialists, hospital and/or emergency departments, and other), medication use, work and school/childcare absences for parents/carers and children respectively, and both parent/carer and child reported quality of life and cough severity. RESULTS: Overall, 951 child-months of observation were completed for 85 children (median age 8.7-years, interquartile range 5.4-11.3). The mean (standard deviation) number of exacerbations was 3.3 (2.2) per child-year. Thirty of 264 (11.4%) exacerbation episodes required hospitalization. Healthcare attendance and antibiotic use rates were high (30 and 50 per 100 child-months of observation respectively). A carer took leave from work for 53/236 (22.5%) routine clinic visits. Absences from school/childcare due to bronchiectasis were 24.9 children per 100 child-months. Quality of life scores for both the parent/carer and child were highly-correlated with one another, remained stable over time and were negatively associated with cough severity. CONCLUSIONS: Health resource use in this cohort of children is high, reflecting their severe disease burden. Studies are now needed to quantify the direct and societal costs of disease and to evaluate interventions that may reduce disease burden, particularly hospitalizations.


Assuntos
Antibacterianos/uso terapêutico , Bronquiectasia/terapia , Hospitalização/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde , Qualidade de Vida , Antibacterianos/economia , Bronquiectasia/economia , Bronquiectasia/epidemiologia , Criança , Pré-Escolar , Progressão da Doença , Feminino , Necessidades e Demandas de Serviços de Saúde , Hospitalização/economia , Humanos , Masculino , Projetos Piloto , Estudos Prospectivos
15.
BMJ Open ; 9(4): e026411, 2019 04 24.
Artigo em Inglês | MEDLINE | ID: mdl-31023759

RESUMO

INTRODUCTION: Early childhood pneumonia is a common problem globally with long-term complications that include bronchiectasis and chronic obstructive pulmonary disease. It is biologically plausible that these long-term effects may be minimised in young children at increased risk of such sequelae if any residual lower airway infection and inflammation in their developing lungs can be treated successfully by longer antibiotic courses. In contrast, shortened antibiotic treatments are being promoted because of concerns over inducing antimicrobial resistance. Nevertheless, the optimal treatment duration remains unknown. Outcomes from randomised controlled trials (RCTs) on paediatric pneumonia have focused on short-term (usually <2 weeks) results. Indeed, no long-term RCT-generated outcome data are available currently. We hypothesise that a longer antibiotic course, compared with the standard treatment course, reduces the risk of chronic respiratory symptoms/signs or bronchiectasis 24 months after the original pneumonia episode. METHODS AND ANALYSIS: This multicentre, parallel, double-blind, placebo-controlled randomised trial involving seven hospitals in six cities from three different countries commenced in May 2016. Three-hundred-and-fourteen eligible Australian Indigenous, New Zealand Maori/Pacific and Malaysian children (aged 0.25 to 5 years) hospitalised for community-acquired, chest X-ray (CXR)-proven pneumonia are being recruited. Following intravenous antibiotics and 3 days of amoxicillin-clavulanate, they are randomised (stratified by site and age group, allocation-concealed) to receive either: (i) amoxicillin-clavulanate (80 mg/kg/day (maximum 980 mg of amoxicillin) in two-divided doses or (ii) placebo (equal volume and dosing frequency) for 8 days. Clinical data, nasopharyngeal swab, bloods and CXR are collected. The primary outcome is the proportion of children without chronic respiratory symptom/signs of bronchiectasis at 24 months. The main secondary outcomes are 'clinical cure' at 4 weeks, time-to-next respiratory-related hospitalisation and antibiotic resistance of nasopharyngeal respiratory bacteria. ETHICS AND DISSEMINATION: The Human Research Ethics Committees of all the recruiting institutions (Darwin: Northern Territory Department of Health and Menzies School of Health Research; Auckland: Starship Children's and KidsFirst Hospitals; East Malaysia: Likas Hospital and Sarawak General Hospital; Kuala Lumpur: University of Malaya Research Ethics Committee; and Klang: Malaysian Department of Health) have approved the research protocol version 7 (13 August 2018). The RCT and other results will be submitted for publication. TRIAL REGISTRATION: ACTRN12616000046404.


Assuntos
Antibacterianos/uso terapêutico , Hospitalização/estatística & dados numéricos , Pneumonia/tratamento farmacológico , Austrália/epidemiologia , Pré-Escolar , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Incidência , Lactente , Malásia/epidemiologia , Masculino , Nova Zelândia/epidemiologia , Pneumonia/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
17.
Lancet ; 392(10154): 1197-1206, 2018 10 06.
Artigo em Inglês | MEDLINE | ID: mdl-30241722

RESUMO

BACKGROUND: Although amoxicillin-clavulanate is the recommended first-line empirical oral antibiotic treatment for non-severe exacerbations in children with bronchiectasis, azithromycin is also often prescribed for its convenient once-daily dosing. No randomised controlled trials involving acute exacerbations in children with bronchiectasis have been published to our knowledge. We hypothesised that azithromycin is non-inferior to amoxicillin-clavulanate for resolving exacerbations in children with bronchiectasis. METHODS: We did this parallel-group, double-dummy, double-blind, non-inferiority randomised controlled trial in three Australian and one New Zealand hospital between April, 2012, and August, 2016. We enrolled children aged 1-19 years with radiographically proven bronchiectasis unrelated to cystic fibrosis. At the start of an exacerbation, children were randomly assigned to oral suspensions of either amoxicillin-clavulanate (22·5 mg/kg, twice daily) and placebo or azithromycin (5 mg/kg per day) and placebo for 21 days. We used permuted block randomisation (stratified by age, site, and cause) with concealed allocation. The primary outcome was resolution of exacerbation (defined as a return to baseline) by 21 days in the per-protocol population, with a non-inferiority margin of -20%. We assessed several secondary outcomes including duration of exacerbation, time to next exacerbation, laboratory, respiratory, and quality-of-life measurements, and microbiology. This trial was registered with the Australian/New Zealand Registry (ACTRN12612000010897). FINDINGS: We screened 604 children and enrolled 236. 179 children had an exacerbation and were assigned to treatment: 97 to amoxicillin-clavulanate, 82 to azithromycin). By day 21, 61 (84%) of 73 exacerbations had resolved in the azithromycin group versus 73 (84%) of 87 in the amoxicillin-clavulanate group. The risk difference showed non-inferiority (-0·3%, 95% CI -11·8 to 11·1). Exacerbations were significantly shorter in the amoxicillin-clavulanate group than in the azithromycin group (median 10 days [IQR 6-15] vs 14 days [8-16]; p=0·014). Adverse events were attributed to the trial medication in 17 (21%) of 82 children in the azithromycin group versus 23 (24%) of 97 in the amoxicillin-clavulanate group (relative risk 0·9, 95% CI 0·5 to 1·5). INTERPRETATION: By 21 days of treatment, azithromycin is non-inferior to amoxicillin-clavulanate for resolving exacerbations in children with non-severe bronchiectasis. In some patients, such as those with penicillin hypersensitivity or those likely to have poor adherence, azithromycin provides another option for treating exacerbations, but must be balanced with risk of treatment failure (within a 20% margin), longer exacerbation duration, and the risk of inducing macrolide resistance. FUNDING: Australian National Health and Medical Research Council.


Assuntos
Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Antibacterianos/uso terapêutico , Azitromicina/uso terapêutico , Bronquiectasia/tratamento farmacológico , Inibidores de beta-Lactamases/uso terapêutico , Administração Oral , Adolescente , Combinação Amoxicilina e Clavulanato de Potássio/efeitos adversos , Antibacterianos/efeitos adversos , Azitromicina/efeitos adversos , Criança , Pré-Escolar , Progressão da Doença , Método Duplo-Cego , Estudos de Equivalência como Asunto , Feminino , Humanos , Lactente , Masculino , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem , Inibidores de beta-Lactamases/efeitos adversos
18.
Respirology ; 23(11): 1006-1022, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30207018

RESUMO

Interest in bronchiectasis has increased over the past two decades, as shown by the establishment of disease-specific registries in several countries, the publication of management guidelines and a growing number of clinical trials to address evidence gaps for treatment decisions. This review considers the evidence for defining and treating pulmonary exacerbations, the approaches for eradication of newly identified airway pathogens and the methods to prevent exacerbations through long-term treatments from a pragmatic practice-based perspective. Areas for future studies are also explored. Watch the video abstract.


Assuntos
Antibacterianos , Infecções Bacterianas , Bronquiectasia , Antibacterianos/classificação , Antibacterianos/farmacologia , Infecções Bacterianas/microbiologia , Infecções Bacterianas/fisiopatologia , Infecções Bacterianas/prevenção & controle , Bronquiectasia/diagnóstico , Bronquiectasia/microbiologia , Bronquiectasia/fisiopatologia , Bronquiectasia/terapia , Tomada de Decisão Clínica , Protocolos Clínicos , Progressão da Doença , Humanos , Exacerbação dos Sintomas
19.
Front Pediatr ; 3: 32, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25954737

RESUMO

BACKGROUND: Bronchiolitis is a major health burden in infants globally, particularly among Indigenous populations. It is unknown if 3 weeks of azithromycin improve clinical outcomes beyond the hospitalization period. In an international, double-blind randomized controlled trial, we determined if 3 weeks of azithromycin improved clinical outcomes in Indigenous infants hospitalized with bronchiolitis. METHODS: Infants aged ≤24 months were enrolled from three centers and randomized to receive three once-weekly doses of either azithromycin (30 mg/kg) or placebo. Nasopharyngeal swabs were collected at baseline and 48 h later. Primary endpoints were hospital length of stay (LOS) and duration of oxygen supplementation monitored every 12 h until judged ready for discharge. Secondary outcomes were: day-21 symptom/signs, respiratory rehospitalizations within 6 months post-discharge and impact upon nasopharyngeal bacteria and virus shedding at 48 h. RESULTS: Two hundred nineteen infants were randomized (n = 106 azithromycin, n = 113 placebo). No significant between-group differences were found for LOS (median 54 h for each group, difference = 0 h, 95% CI: -6, 8; p = 0.8), time receiving oxygen (azithromycin = 40 h, placebo = 35 h, group difference = 5 h, 95% CI: -8, 11; p = 0.7), day-21 symptom/signs, or rehospitalization within 6 months (azithromycin n = 31, placebo n = 25 infants, p = 0.2). Azithromycin reduced nasopharyngeal bacterial carriage (between-group difference 0.4 bacteria/child, 95% CI: 0.2, 0.6; p < 0.001), but had no significant effect upon virus detection rates. CONCLUSION: Despite reducing nasopharyngeal bacterial carriage, three large once-weekly doses of azithromycin did not confer any benefit over placebo during the bronchiolitis illness or 6 months post hospitalization. Azithromycin should not be used routinely to treat infants hospitalized with bronchiolitis. CLINICAL TRIAL REGISTRATION: The trial was registered with the Australian and New Zealand Clinical Trials Register: Clinical trials number: ACTRN1261000036099.

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