Impact of a child care educational intervention on parent knowledge about appropriate antibiotic use.

BACKGROUND: Parent education is an integral component to promoting judicious antibiotic use. Opportunities to educate parents directly are limited. Child care providers are in a position to relay information to parents. METHODS: A group-randomized trial assessed the impact of a child care center staff intervention on parental knowledge and attitudes regarding appropriate antibiotic use. A 9-point knowledge score and 3 attitude items were measured. RESULTS: Surveys were returned by 151 (51%) of 298 intervention center parents and 150 (42%) of 361 control center parents. Intervention center respondents were significantly more likely than control center respondents to be college graduates, non-Hispanic white, and insured. Among college graduates, the median knowledge score was 7.0 at intervention centers and 6.5 at control centers (P<0.01). No significant differences were found in knowledge scores among noncollege educated parents (P=0.11). After adjusting for clustering within child care centers, multivariate analysis demonstrated high knowledge score was associated with white race (P=0.02), being a college graduate (P=0.02), and being in the intervention group (P=0.06). CONCLUSION: An appropriate antibiotic use program for child care providers promotes better knowledge among parents of children aged <5 years, particularly among highly educated parents.

Responding to detection of aerosolized Bacillus anthracis by autonomous detection systems in the workplace.

Autonomous detection systems (ADSs) are under development to detect agents of biologic and chemical terror in the environment. These systems will eventually be able to detect biologic and chemical hazards reliably and provide approximate real-time alerts that an agent is present. One type of ADS that tests specifically for Bacillus anthracis is being deployed in hundreds of postal distribution centers across the United States. Identification of aerosolized B. anthracis spores in an air sample can facilitate prompt on-site decontamination of workers and subsequent administration of postexposure prophylaxis to prevent inhalational anthrax. Every employer who deploys an ADS should develop detailed plans for responding to a positive signal. Responding to ADS detection of B. anthracis involves coordinating responses with community partners and should include drills and exercises with these partners. This report provides guidelines in the following six areas: 1) response and consequence management planning, including the minimum components of a facility response plan; 2) immediate response and evacuation; 3) decontamination of potentially exposed workers to remove spores from clothing and skin and prevent introduction of B. anthracis into the worker's home and conveyances; 4) laboratory confirmation of an ADS signal; 5) steps for evaluating potentially contaminated environments; and 6) postexposure prophylaxis and follow-up.

Trends in legionnaires disease, 1980-1998: declining mortality and new patterns of diagnosis.

New diagnostic tests and empirical therapy for pneumonia may have important ramifications for the identification, treatment, and control of legionnaires disease (LD). To determine trends in the epidemiology of LD, we analyzed data for 1980-1998 from the passive surveillance system of the Centers for Disease Control and Prevention. During this time period, there were 6757 confirmed cases of LD (median annual number, 360 cases/year). Diagnosis by culture and by direct fluorescent antibody and serologic testing decreased significantly; diagnosis by urine antigen testing increased from 0% to 69%. The frequency of isolates other than Legionella pneumophila serogroup 1 (LP1) decreased from 38% to 4% (P=.003). The case-fatality rate decreased significantly, from 34% to 12% (P<.001) for all cases, from 46% to 14% (P<.0001) for nosocomial cases, and from 26% to 10% (P=.05) for community-acquired cases. LD-related mortality has decreased dramatically. The decrease in culture-based diagnosis limits the recognition of non-LP1 disease and impairs outbreak investigation, because fewer Legionella isolates are provided for further examination.

Antimicrobial prescribing for otitis externa in children.

We describe the patterns of antimicrobial prescribing and trends in disease occurrence among children with otitis externa using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 1995 to 2000. Oral antimicrobial therapy for otitis externa is more likely to contribute to antimicrobial resistance than is topical antimicrobial therapy and is rarely indicated. Thirty-nine percent of visits resulted in a prescription for topical antibiotics, and 25% of visits resulted in a prescription for oral antibiotics. Inappropriate antimicrobial prescribing for otitis externa occurs frequently.

Promoting appropriate antibiotic use for pediatric patients: a social ecological framework.

During the 1990s, the number of prescriptions for antibiotics for children and adolescents finally decreased after more than a decade of alarming increases. The Centers for Disease Control and Prevention (CDC) and many other groups have designed and implemented interventions to promote appropriate prescribing of antibiotics, and these efforts appear to have contributed to recent decreases in rates of such prescribing. In this article, we describe the various types of interventions that the CDC and others are using to encourage appropriate use of antibiotics. A social ecological framework is used to describe the various factors contributing to prescribing and using antibiotics, as well as the interventions used for targeting these factors. Although most efforts promoting appropriate use of antibiotics have focused on reducing such use for viral infections, future efforts also should include a focus on ensuring the use of targeted agents when antibiotics are indicated.

Introduction of monochloramine into a municipal water system: impact on colonization of buildings by Legionella spp.

Legionnaires' disease (LD) outbreaks are often traced to colonized potable water systems. We collected water samples from potable water systems of 96 buildings in Pinellas County, Florida, between January and April 2002, during a time when chlorine was the primary residual disinfectant, and from the same buildings between June and September 2002, immediately after monochloramine was introduced into the municipal water system. Samples were cultured for legionellae and amoebae using standard methods. We determined predictors of Legionella colonization of individual buildings and of individual sampling sites. During the chlorine phase, 19 (19.8%) buildings were colonized with legionellae in at least one sampling site. During the monochloramine phase, six (6.2%) buildings were colonized. In the chlorine phase, predictors of Legionella colonization included water source (source B compared to all others, adjusted odds ratio [aOR], 6.7; 95% confidence interval [CI], 2.0 to 23) and the presence of a system with continuously circulating hot water (aOR, 9.8; 95% CI, 1.9 to 51). In the monochloramine phase, there were no predictors of individual building colonization, although we observed a trend toward greater effectiveness of monochloramine in hotels and single-family homes than in county government buildings. The presence of amoebae predicted Legionella colonization at individual sampling sites in both phases (OR ranged from 15 to 46, depending on the phase and sampling site). The routine introduction of monochloramine into a municipal drinking water system appears to have reduced colonization by Legionella spp. in buildings served by the system. Monochloramine may hold promise as community-wide intervention for the prevention of LD.

Clinicians' management of children and adolescents with acute pharyngitis.

OBJECTIVE: Sore throat is a common complaint in children and adolescents. With increasing antimicrobial resistance because of antimicrobial overuse, accurate diagnosis is imperative. Appropriate management of acute pharyngitis depends on proper use and interpretation of clinical findings, rapid antigen-detection tests, and throat cultures. We surveyed pediatricians and family physicians to evaluate their management strategies for children and adolescents with acute pharyngitis and to assess the availability and use of diagnostic tests in office practice. METHODS: In 2004, surveys were mailed to a random sample of 1000 pediatrician members of the American Academy of Pediatrics and 1000 family physician members of the American Academy of Family Physicians. We assessed factors associated with physicians using an appropriate management strategy for treating acute pharyngitis. RESULTS: Of 948 eligible responses, 42% of physicians would start antimicrobials before knowing diagnostic test results and continue them despite negative results, with 27% doing this often or always. When presented with clinical scenarios of patients with acute pharyngitis, < or =23% chose an empirical approach, 32% used an inappropriate strategy for a child with pharyngitis suggestive of group A Streptococcus, and 81% used an inappropriate strategy for a child with findings consistent with viral pharyngitis. Plating cultures in the office was associated with an appropriate management strategy, although not statistically significant. Solo/2-person practice and rural location were both independent factors predicting inappropriate strategies. CONCLUSIONS: There is much room for improvement in the management of acute pharyngitis in children and adolescents. Most physicians use appropriate management strategies; however, a substantial number uses inappropriate ones, particularly for children with likely viral pharyngitis. Efforts to help physicians improve practices will need to be multifaceted and should include health policy and educational approaches.

Reducing Legionella colonization in water systems with monochloramine.

Monochloramine disinfection of municipal water supplies is associated with decreased risk for Legionnaires' disease. We conducted a 2-year, prospective, environmental study to evaluate whether converting from chlorine to monochloramine for water disinfection would decrease Legionella colonization of hot water systems. Water and biofilm samples from 53 buildings were collected for Legionella culture during 6 intervals. Prevalence ratios (PRs) comparing Legionella colonization before and after monochloramine disinfection were adjusted for water system characteristics. Legionella colonized 60% of the hot water systems before monochloramine versus 4% after conversion (PR 0.07, 95% confidence interval 0.03-0.16). The median number of colonized sites per building decreased with monochloramine disinfection. Increased prevalence of Legionella colonization was associated with water heater temperatures <50 degrees C, buildings taller than 10 stories, and interruptions in water service. Increasing use of monochloramine in water supplies throughout the United States may reduce Legionella transmission and incidence of Legionnaires' disease.

Demand for prophylaxis after bioterrorism-related anthrax cases, 2001.

Media reports suggested increased public demand for anthrax prophylaxis after the intentional anthrax cases in 2001, but the magnitude of anthrax-related prescribing in unaffected regions was not assessed. We surveyed a random sample of 400 primary care clinicians in Minnesota and Wisconsin to assess requests for and provision of anthrax-related antimicrobial agents. The survey was returned by 239 (60%) of clinicians, including 210 in outpatient practice. Fifty-eight (28%) of those in outpatient practice received requests for anthrax-related antimicrobial agents, and 9 (4%) dispensed them. Outpatient fluoroquinolone use in both states was also analyzed with regression models to compare predicted and actual use in October and November 2001. Fluoroquinolone use as a proportion of total antimicrobial use was not elevated, and anthrax concerns accounted for an estimated 0.3% of all fluoroquinolone prescriptions. Most physicians in Minnesota and Wisconsin managed anthrax-related requests without dispensing antimicrobial agents.

Knowledge, attitudes, and reported practices among obstetrician-gynecologists in the USA regarding antibiotic prescribing for upper respiratory tract infections.

BACKGROUND: Knowledge, attitudes, and practices regarding antibiotic prescribing for upper respiratory tract infections (URIs) have not been well described among obstetrician-gynecologists (OB/GYNs). This information is useful for determining whether an OB/GYN-specific program promoting appropriate antibiotic use would significantly contribute to the efforts to decrease inappropriate antibiotic use among primary care providers. METHODS: An anonymous questionnaire asking about the treatment of URIs was sent to 1031 obstetrician-gynecologists. RESULTS: The overall response rate was 46%. The majority of respondents (92%) were aware of the relationship between antibiotic use and antibiotic resistance, and respondents estimated that 5% of their patients had URI symptoms at their office visits. Overall, 56% of respondents reported that they would prescribe an antibiotic for uncomplicated bronchitis and 43% for the common cold. OB/GYNs with the fewest years of experience were less likely than those with the most years of experience to report prescribing for uncomplicated bronchitis (Odds ratio (OR) 0.46, 95% confidence interval (CI) 0.23 to 0.91) or the common cold (OR 0.44, CI 0.22 to 0.89). The majority of respondents (60%) believed that most patients wanted an antibiotic for URI symptoms, with male OB/GYNs being more likely than female OB/GYNs (OR 2.1, CI 1.2 to 3.8) to hold this belief. Both male OB/GYNs (OR 1.9, CI 1.1 to 3.4) and rural practitioners (OR 2.1, CI 1.1 to 4.0) were more likely to believe that it was hard to withhold antibiotics for URI symptoms because other physicians prescribe antibiotics for these symptoms. OB/GYNs who believed that postgraduate training prepared them well for primary care management were more likely than those who did not (OR 2.1, CI 1.1 to 4.2) to believe that they could reduce antibiotic prescribing without reducing patient satisfaction. CONCLUSION: Multiple demographic factors affect attitudes and reported practices regarding antibiotic prescribing. However, in view of the low proportion of office visits for URIs, an OB/GYN-specific program is not warranted.

Clinician knowledge and beliefs after statewide program to promote appropriate antimicrobial drug use.

In 1999, Wisconsin initiated an educational campaign for primary care clinicians and the public to promote judicious antimicrobial drug use. We evaluated its impact on clinician knowledge and beliefs; Minnesota served as a control state. Results of pre- (1999) and post- (2002) campaign questionnaires indicated that Wisconsin clinicians perceived a significant decline in the proportion of patients requesting antimicrobial drugs (50% in 1999 to 30% in 2002; p<0.001) and in antimicrobial drug requests from parents for children (25% in 1999 to 20% in 2002; p = 0.004). Wisconsin clinicians were less influenced by nonpredictive clinical findings (purulent nasal discharge [p = 0.044], productive cough [p = 0.010]) in terms of antimicrobial drug prescribing. In 2002, clinicians from both states were less likely to recommend antimicrobial agent treatment for the adult case scenarios of viral respiratory illness. For the comparable pediatric case scenarios, only Wisconsin clinicians improved significantly from 1999 to 2002. Although clinicians in both states improved on several survey responses, greater overall improvement occurred in Wisconsin.

Impact of statewide program to promote appropriate antimicrobial drug use.

The Wisconsin Antibiotic Resistance Network (WARN) was launched in 1999 to educate physicians and the public about judicious antimicrobial drug use. Public education included radio and television advertisements, posters, pamphlets, and presentations at childcare centers. Physician education included mailings, susceptibility reports, practice guidelines, satellite conferences, and presentations. We analyzed antimicrobial prescribing data for primary care physicians in Wisconsin and Minnesota (control state). Antimicrobial prescribing declined 19.8% in Minnesota and 20.4% in Wisconsin from 1998 to 2003. Prescribing by internists declined significantly more in Wisconsin than Minnesota, but the opposite was true for pediatricians. We conclude that the secular trend of declining antimicrobial drug use continued through 2003, but a large-scale educational program did not generate greater reductions in Wisconsin despite improved knowledge. State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development to promote careful antimicrobial drug use.

Antimicrobial drug prescription in ambulatory care settings, United States, 1992-2000.

During the 1990s, as antimicrobial resistance increased among pneumococci, many organizations promoted appropriate antimicrobial use to combat resistance. We analyzed data from the National Ambulatory Medical Care Survey, an annual sample survey of visits to office-based physicians, and the National Hospital Ambulatory Medical Care Survey, an annual sample survey of visits to hospital emergency and outpatient departments, to describe trends in antimicrobial prescribing from 1992 to 2000 in the United States. Approximately 1,100-1,900 physicians reported data from 21,000-37,000 visits; 200-300 outpatient departments reported data for 28,000-35,000 visits; approximately 400 emergency departments reported data for 21,000-36,000 visits each year. In that period, the population- and visit-based antimicrobial prescribing rates in ambulatory care settings decreased by 23% and 25%, respectively, driven largely by a decrease in prescribing by office-based physicians. Antimicrobial prescribing rates changed as follows: amoxicillin and ampicillin, -43%; cephalosporins, -28%; erythromycin, -76%; azithromycin and clarithromycin, +388%; quinolones, +78%; and amoxicillin/clavulanate, +69%. This increasing use of azithromycin, clarithromycin, and quinolones warrants concern as macrolide- and fluoroquinolone-resistant pneumococci are increasing.

Trends in antimicrobial prescribing rates for children and adolescents.

CONTEXT: Annual rates of antimicrobial prescribing for children by office-based physicians increased from 1980 through 1992. The development of antimicrobial resistance, which increased for many organisms during the 1990s, is associated with antimicrobial use. To combat development of antimicrobial resistance, professional and public health organizations undertook efforts to promote appropriate antimicrobial prescribing. OBJECTIVE: To assess changes in antimicrobial prescribing rates overall and for respiratory tract infections for children and adolescents younger than 15 years. DESIGN, SETTING, AND PARTICIPANTS: National Ambulatory Medical Care Survey data provided by 2500 to 3500 office-based physicians for 6500 to 13 600 pediatric visits during 2-year periods from 1989-1990 through 1999-2000. MAIN OUTCOME MEASURES: Population- and visit-based antimicrobial prescribing rates overall and for respiratory tract infections (otitis media, pharyngitis, bronchitis, sinusitis, and upper respiratory tract infection) among children and adolescents younger than 15 years. RESULTS: The average population-based annual rate of overall antimicrobial prescriptions per 1000 children and adolescents younger than 15 years decreased from 838 (95% confidence interval [CI], 711-966) in 1989-1990 to 503 (95% CI, 419-588) in 1999-2000 (P for slope <.001). The visit-based rate decreased from 330 antimicrobial prescriptions per 1000 office visits (95% CI, 305-355) to 234 (95% CI, 210-257; P for slope <.001). For the 5 respiratory tract infections, the population-based prescribing rate decreased from 674 (95% CI, 568-781) to 379 (95% CI, 311-447; P for slope <.001) and the visit-based prescribing rate decreased from 715 (95% CI, 682-748) to 613 (95% CI, 570-657; P for slope <.001). Both population- and visit-based prescribing rates decreased for pharyngitis and upper respiratory tract infection; however, for otitis media and bronchitis, declines were only observed in the population-based rate. Prescribing rates for sinusitis remained stable. CONCLUSION: The rate of antimicrobial prescribing overall and for respiratory tract infections by office-based physicians for children and adolescents younger than 15 years decreased significantly between 1989-1990 and 1999-2000.

Legionella and Legionnaires' disease: 25 years of investigation.

There is still a low level of clinical awareness regarding Legionnaires' disease 25 years after it was first detected. The causative agents, legionellae, are freshwater bacteria with a fascinating ecology. These bacteria are intracellular pathogens of freshwater protozoa and utilize a similar mechanism to infect human phagocytic cells. There have been major advances in delineating the pathogenesis of legionellae through the identification of genes which allow the organism to bypass the endocytic pathways of both protozoan and human cells. Other bacteria that may share this novel infectious process are Coxiella burnetti and Brucella spp. More than 40 species and numerous serogroups of legionellae have been identified. Most diagnostic tests are directed at the species that causes most of the reported human cases of legionellosis, L. pneumophila serogroup 1. For this reason, information on the incidence of human respiratory disease attributable to other species and serogroups of legionellae is lacking. Improvements in diagnostic tests such as the urine antigen assay have inadvertently caused a decrease in the use of culture to detect infection, resulting in incomplete surveillance for legionellosis. Large, focal outbreaks of Legionnaires' disease continue to occur worldwide, and there is a critical need for surveillance for travel-related legionellosis in the United States. There is optimism that newly developed guidelines and water treatment practices can greatly reduce the incidence of this preventable illness.

Antibiotic use and upper respiratory infections: a survey of knowledge, attitudes, and experience in Wisconsin and Minnesota.

BACKGROUND: Public attitudes and expectations contribute to inappropriate antibiotic prescribing and antibiotic resistance. This study assessed knowledge, attitudes, and experiences regarding antibiotic use for respiratory infection or illness. METHODS: Random-digit-dialing telephone surveys of adults and parents of children <5 years old were conducted in Wisconsin and Minnesota during 1999. RESULTS: The survey was completed by 405 adults and 275 parents of children <5 years old. The median age was 32 years for parents and 50 years for adults. Seven percent of parents and 17% of adults believed that antibiotics are never or almost never necessary for bronchitis. More than 70% in each group believed that antibiotics are needed for green or yellow nasal drainage, and nearly half of respondents believed that they knew whether an antibiotic was needed before seeing a physician. Exposure to multiple information sources on antibiotic resistance in the past 6 months was independently associated with a knowledge score greater than or equal to the median for nine questions. CONCLUSIONS: The general public has misconceptions regarding indications for antibiotic use, and this may contribute to inappropriate prescribing. Providing multiple and varied antibiotic-related informational messages may increase knowledge of appropriate antibiotic prescribing and decrease patient demand for antibiotics.

An outbreak of travel-associated Legionnaires disease and Pontiac fever: the need for enhanced surveillance of travel-associated legionellosis in the United States.

Travel-associated outbreaks of legionnaires disease (LD) and combined outbreaks of LD and Pontiac fever (PF) are rarely identified. During one travel-associated combined outbreak at a hotel, a cohort study of potentially exposed persons and an environmental investigation were performed. Two LD and 22 PF cases were identified. Legionella pneumophila serogroup 6 (Lp6) isolates from the index patient and the hotel whirlpool spa were found to be identical by amplified fragment-length polymorphism typing. Disease occurred in 10 of 26 guests who were exposed to the spa versus 2 of 29 guests who were exposed only to the pool area (38% vs. 7%; P=.005). Immunoglobulin M (IgM) antibody to the outbreak Lp6 strain was more common among persons with PF (4 of 9) than among non-ill persons (2 of 32) (44% vs. 6%; P=.02). Spa exposure correlated with disease (P=.001) and IgM seropositivity (P=.007). New laboratory techniques facilitate outbreak investigation; to expedite outbreak interruption and measure the impact of travel-associated legionellosis, surveillance must be improved.