Rapid Responses to:
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lactam antibiotic use in children on pneumococcal resistance to penicillin: prospective cohort study
Rapid Responses: Rapid Responses published:
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Reduction of antibiotic prescribing in children in general practice
- Michael D Nissen, Chris Del Mar (29 January 2002)
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Clarification of results and findings
- Michael D Nissen (3 February 2002)
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Which antibiotic in preschool children?
- Nicola Petrosillo, Annalisa Pantosti (affiliation: Bacteriology and Medical Mycology Laboratory, ISS, Rome) (12 February 2002)
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Michael D Nissen, Director of Infectious Diseases Royal Children's Hospital-Brisbane, Herston Qld 4029, Australia, Chris Del Mar
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Dear Editor; Reduction of antibiotic prescribing in children in general practice Evidence continues to accumulate to suggest the benefits of antibiotics in childhood upper respiratory tract illnesses are distressingly modest.1,2,3 Nasrin et al. have shown that antibiotics used in this way increases the prevalence of antimicrobial resistance in the children,4 providing yet more urgency to reduce the use antibiotics in general practice for acute respiratory infections. But how this can be achieved? Doctors do not necessarily share this skeptical approach to the use of antibiotics.5 The barriers to the implantation of best evidence are being explored and described.6 For example, GPs are more influenced by certain clinical signs and symptoms to use antibiotics for acute respiratory infections than the evidence suggests is effective.7 Is the sort of public campaigns initiated in Europe to reduce antibiotic use the best approach? 8,9 Doctors maybe placed in an ethical dilemma to chose between what they think is best for their individual patient, and what is deemed best for the community, now or in the future. Another problem is the replacement of ‘something that can be done for the patient’ by a sort of nihilism: ‘well, antibiotics provide such a weak benefit they are hardly worth the bother. Oh, and then there’s all the resistance worry…’ There are alternative treatments for acute respiratory infections that are just as effective. Of course they do not have the same ring to them as ‘curative’ ones: killing bacteria has a more satisfying sounding objective than the palliative alternatives, but does this matter? For spontaneously remitting diseases, anything that reduces the symptoms is just as effective as anything else, bactericidal or not. We therefore suggest wider dissemination of alternative therapies (evidence-based of course). These include the greater promotion of short acting agents such as analgesics, non-steroidal anti-inflammatory drugs, steroids, vaccination against the pneumococcus and influenza, xylitol liquid and chewing gum, better communication skills and anything else found to be effective empirically.10,11 It should be easier to sell the replacement of a less effective treatment with a more effective one, than harping on about the possible future catastrophe that seems remote from the patient before one. 1. Del Mar CB, Glasziou PP, Spinks P. Antibiotics for sore throat. Cochrane Database Syst Rev 2000:CD000023. 2. Glasziou PP, Del Mar CB, Hayem M, Sanders SL. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2000:CD000219. 3. Becker L, Glazier R, McIsaac W, Smucny J. Antibiotics for acute bronchitis. Cochrane Database Syst Rev 2000:CD000245. 4. Nasrin D, Collignon PJ, Roberts L, Wilson EJ, Pilotto LS, Douglas RM. Effect of b lactam antibiotic use in children on pneumococcal resistance to penicillin: prospective cohort study. BMJ 2002;324:28-30. 5. Tomlin Z, Humphrey C, Rogers S. General practitioners’ perceptions of effective health care. BMJ 1999;318:532-5. 6. Freeman AC, Sweeney K. Why general practitioners do not implement evidence: qualitative study. BMJ 2001;323:1-5. 7. Murray S, Del Mar C, O’Rourke P. Predictors of an antibiotic prescription by GP’s for respiratory tract infections: a pilot. Fam Pract 2000;17:386-8. 8. House of Lords Select Committee on Science and Technology. Third report on resistance to antibiotics, 2001 (last accessed January 29, 2002). http://www.parliament.the-stationery- office.co.uk/pa/ld200001/ldselect/ldsctech/56/5602.htm 9. Bauraind I, Goossens H, Tulkens PM, DeMeyere M, DeMol T, and Verhist L. A public campaign for a more rational use of antibiotics. Clin Microbiol Infect 2001;7(supp 1):1-394. (Abstract #143 presented at 11th European Congress of Clinical Microbiology and Infectious Diseases 1-4 April 2001, Istanbul, Turkey). 10. Thomas M, Del Mar C, Glasziou P. How effective are treatments other than antibiotics for acute sore throat? Br J Gen Pract 2000;50:817-20. 11. O'Neill P. Acute otitis media. In Clinical evidence, Issue 6, 2001. BMJ Publishing Group. Michael Nissen*
Chris Del Mar
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Michael D Nissen, Director of Infectious Diseases Royal Children's Hospital-Brisbane, Herston Qld 4029, Australia
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Dear Editors, In response to the article by Nasrin et al. (BMJ 2002; 324: 28), I wish to ask the authors the following questions to clarify their results and findings: 1. What were the predominant medical conditions associated with the prescription of the beta-lactam antibiotics in their cohort of children? 2. Whether any children were noted to lose their carriage of a resistant strain of pneumococcus during the course of the study, and over what time period was the carriage lost? 3. The current scientific evidence and/or duration of time for loss of carriage of a resistant strain of pneumococcus following cessation of antibiotics?, and it's implications to their opinion for a dramatic reduction in antibiotic prescribing in general practice? Yours faithfully, Dr. Michael Nissen BMedSc MBBS FRACP FRCPA Director of Infectious Diseases,Senior Lecturer in Paediatrics-
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Nicola Petrosillo, Director, 2nd Infectious Diseases Division National Institute for Infectious Diseases, "L. Spallanzani" IRCCS, Via Portuense, 292 -00149 Rome,, Annalisa Pantosti (affiliation: Bacteriology and Medical Mycology Laboratory, ISS, Rome)
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EDITOR-- Nasrin and co-workers in their prospective cohort study on pneumococcal nasal carriage among preschool Australian children found that the use of beta-lactam antibiotics in the last two months before swab collection was significantly associated with isolation of penicillin-resistant S.pneumoniae (1). These authors recommended the reduction of beta-lactam antibiotic use in preschool children as a mean to reduce carriage of penicillin-resistant pneumococci. The association between recent antibiotic exposure and nasopharyngeal colonization by antibiotic resistant S. pneumoniae has been evaluated in other studies. We recently examined pneumococcal nasopharingeal carriage in 610 children attending day care centres in Rome, Italy, and found that 220 children (36.6%) had a history of antibiotic exposure in the previous month (2). The antibiotics used included cephalosporins (37.2%), macrolides (28.7%), and aminopenicillins (25.5%). We did not find a statistically significant association between history of beta-lactam antibiotic exposure in the previous month and carriage of penicillin- resistant S. pneumoniae. On the contrary, we found an association between history of macrolide use and carriage of erythromycin- resistant strains [Odds ratio (OR) 3.76, 95% confidence intervals (CI) 1.72-8.14]. More interestingly, macrolide use was associated with carriage of S. pneumoniae resistant to both penicillin and erythromycin (OR= 6, 95%CI 1.38-24.88). Similar results were reported by Varon and co-workers, who evaluated the change in carriage of penicillin-resistant S. pneumoniae after antimicrobial therapy, and found that macrolides selected both macrolide- and penicillin-resistant strains (3). These findings might be explained by the co-selection of S.pneumoniae strains carrying both penicillin and erythomycin resistance determinants. Erythromycin resistance in S. pneumoniae is rapidly increasing world-wide, and macrolide consumption is considered a major contributory factor to resistance. Macrolides are frequently used to treat respiratory tract infections in children. In a study performed in a region in north-east Italy, macrolides accounted for 27% of all antibiotics prescribed to children (4) Moreover, treatment failures and break-through macrolide- resistant S.pneumoniae infection during macrolide treatment have been reported (5). We believe that in the community practice, prescribing policies for minimizing the risk of antibiotic resistant S. pneumoniae strains should take into account the need to reduce also macrolide use in preschool children. It is important to stress that, especially in children, antibiotics of any class should be used judiciously and exclusively to treat conditions that benefit from them. References 1.Nasrin D, Collignon PJ, Roberts L, Wilson EJ, Pilotto LS, Douglas RM. Effect of ß lactam antibiotic use in children on pneumococcal resistance to penicillin: prospective cohort study. BMJ 2002; 324: 28-30. 2.Petrosillo N, Pantosti A, Bordi E, Spanò A, Del Grosso M, Tallarida B, et al. Prevalence and determinants of Streptococcus pneumoniae nasopharyngeal colonization and molecular epidemiology of the isolates from healthy children in Rome. Eur J Clin Microbiol Infect Dis 2002 (in press). 3.Varon E, Levy C, De La Rocque, Boucherat M, Deforche D, Podglajen I, et al. Impact of antimicrobial therapy on nasopharyngeal carriage of Streptocuccus pneumoniae, Haemophilus influenzae, and Branhamella catarrhalis in children with respiratory tract infections. Clin Infect Diseases 2000; 31:477-481. 4.Borgnolo G, Simon G, Francescutti C, Lattuada L, Zanier L. Antibiotic prescription in Italian children: a population based study in Friuli Venezia Giulia, north-east Italy. Acta Pediatr 2001; 90: 1316-20. 5.Jackson MA, Burry VF, Olson LC, Duthie SE, Kearns GL. Breakthrough sepsis in macrolide-resistant pneumococcal infection. Pediatr Infect Dis J 1996; 15: 1049-51. |
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