Upper Respiratory, Head, and Neck Infections Pleuropulmonary and Bronchial Infections
Upper Respiratory, Head, and Neck Infections Itzhak Brook, MD, MSc Professor of Pediatrics, Georgetown University, 4431 Albemarle St. NW, Washington, DC 20016, USA. Uhari M, Kontiokari T, Niemela M: A novel use of xylitol sugar in preventing acute otitis media. Pediatrics 1998, 102:879–884. Significance: Prevention of recurrent otitis media is practiced through the use of antbiotics, prophylaxis, tympanostomy, and adenoidectomy. Prophylactic and frequent use of antimicrobials, especically in day care children, is responsible for the spread of nasopharyngeal carriage of penicillinresistant pneumococci. A need exists, therefore, for a simple and safe alternative approach to prevent recurrences of acute otitis media (AOM) episodes. This study offers an avenue for a new apporach to the prevention of AOM in children and could contribute to reduction of antimicrobial use. Xylitol, a commonly used sweetner, is effective in preventing dental caries and is known to inhibit the growth of Streptococcus mutans and Streptococcus pneumoniae. Evaluation was made whether xylitol could be effective in preventing AOM. Although the mechanism of action of is believed to be due to inhibition of bacterial growth, the sugar can also act through interference with bacterial adherence to nasopharygeal cells. Evidence for this mode of action in patients is lacking at present. There is, however, a practical problem in using chewing gum in young children, as the infection might mostly occur in those younger than 2 years of age. Using xylitol as syrup was also effective, but chewing gum had the greater activity. Findings: Eight hundred fifty-seven healthy children were recruited from day care centers and randomized to one of five treatment groups: control syrup (n=165), xylitol syrup (n=159), contol chewing gum (n=178), xylitol gum (n=179), or xylitol lozenge (n=176). The daily dose of xylitol varied from 8.4 g (chewing gum) to 10 g (syrup). The design was a 3-month randomized, blinded, controlled trial. The occurrence of AOM each time a child showed any symptoms of respiratory infection was the main outcome. At least one event of AOM was experienced by 68 (41%) of the 165 children who received control syrup, while only 46 (29%) of the 159 children receiving xylitol syrup were affected. Likewise, the occurrence of otitis decreased by 40% compared with control subjects in the children who received xylitol chewing gum and by 20% in the lozenge group. Thus, the occurrence of AOM during the follow-up period was significantly lower in those who received xylitol syrup or gum, and these children required antimicrobials less often than did controls. The authors concluded that xylitol sugar, when given in syrup or chewing gum, was effective in preventing AOM and decreasing the need for antimicrobials. Clement PAR, Bluestone CD, Gordts F, et al.: Management of rhinosinusitis in children: Concensus Meeting, Brussels, Belgium, September 13, 1996. Arch Otolaryngol Head Neck Surg 1998, 124:31–34. Significance: The management of rhinosinusitis in children is a controversial and rapidly evolving issue. Opinions regarding treatment vary from no therapy to extensive surgery. Even the use of antibiotics, still the mainstay of medical management, is questioned. The concensus panel guidelines provide direction regarding the indication for treatment in an illness that is difficult to diagnose and is often overdiagnosed in children. Unfortunately, the panel did not provide clear guidelines regarding criteria for diagnosis, as this topic is controversial and ill-defined. Further studies are needed to aid in establishing these diagnostic criteria. Hopefully these guidelines will reduce the over-use of antimicrobials in treating an infection that is often viral in nature with a very high rate of spontaneous recovery.
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Findings: The concensus panel discussed definitions, symptoms and signs, diagnosis, medical management, and surgery of rhinosinusitis. They recommended the use of antimicrobials in acute rhinosinusitis, severe acute rhinosinusitis, and nonsevere acute rhinosinusitis. A duration of at least 10 to 14 days of treatment is given for acute rhinosinusitis. It can be prolonged to 1 month if the symptoms have improved but have not resolved. If symptoms are unchanged at 72 hours or wosen at any time, however, reevaluation is necessary. For chronic rhinosinusitis, an intial course of 2 weeks of oral antimicrobial treatment is advised. If there is no response within 5 to 7 days, the antibiotic should be changed. If there is again no response within the same time period, a specimen of sinus secretions should be obtained for culture. If the patient responds rather slowly, a second 2-week course can be prescribed. A third course can be given before surgery is considered in severe cases. Several members of the panel recommend treatment with intranasal steroids in chronic, nonpurulent rhinosinusitis, especially for those with an established diagnosis or a strong suspicion of allergic (specific) rhinitis. Sclafani AP, Ginsburg J, Shah MK, Dolisky JN: Treatment of symptomatic chronic adenotonsillar hypertrophy with amoxicillin/clavulanate potassium: short- and long-term results. Pediatrics 1998, 101:675–681. Significance: Adenotonsillar surgery is one of the most commonly performed surgical procedures in children. Recurrent tonsillitis and obstructive adenotonsillar hypertrophy are the most common indications for surgery. An effective, nonsurgical treatment option for adenotonsillar disease is therefore of particular value. The authors of this study demonstrated a significant reduction in the need for adenotonsillectomy following 30 days of therapy with amoxicillin-clavulante compared with placebo in children with adenotonsillar hypertrophy. The effect of amoxicillin-clavulante may be due to its efficacy against aerobic and anaerobic b-lacatamase–producing bacteria, including Haemophilus influenzae and Staphylococcus aureus. These organisms can be recovered in higher numbers in the cores of hypertropic tonsils compared with nonhypertropic tonsils. Further studies are warranted, however, that would compare the efficacy of antimicrobials directed against b-lactamase–producing bacteria as compared with other antimicrobials that are not effective against these organisms in the treatment of adentonsillar hypertrophy. Such studies could help clarify the role of specific bacteria in this condition and establish the use of antimicrobials as a substitute for surgical removal of the adenoids and tonsils. Findings: In this prospective, randomized, double-blind, placebo-controlled trial of 167 children 2 to 16 years of age, the authors evaluated the short- and long-term effects of treatment of symptomatic chronic adenotonsillar hypertrophy with a 30-day course of amoxicillin–clavulanate. Patients were randomly treated with 30-day courses of either placebo (81 patients) or amoxicillin–clavulante (86 patients) in three daily divided doses of 40 mg/kg. The treatment group showed a significant reduction in the need for surgery in the short term compared with the placebo group at 1-month follow-up (37.5% vs 62.7%, respectively). The reduced need for surgery in the treatment group persisted at 3 months and 24 months compared with the placebo group (54.5% vs 85.7%, respectively, at 3 months; 83.3% vs 98.0%, respectively, at 24 months). Dowell SF, Butler JC, Giebink GS, et al.: Acute otitis media: management and surveillance in an era of pneumococcal resistance—a report from the Drug-resistant Streptococccus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J 1999, 18:1–9. Significance: Streptococcus pneumoniae is the most important cause of AOM. The recent emergence of multiple drug-resistant S. pneumoniae in the US has not only complicated empiric treatment but has led to increased numbers of treatment failures. The new recommendations for management of AOM provide general guidelines for treatment choices. The authors suggest the continuous role of amoxicillin in a high dose as the most effective and least expensive agent in the therapy of drug-resistant S. pneumoniae. They also stressed the use of tympanocentesis as a diagnostic and therapeutic tool. They warn that macrolides and trimethoprim-sulfamethoxazole may not be effective against drugresistant S. pneumoniae because of the high cross-resistance between them and penicillin. The authors chose not to suggest two popular and effective agents: the second-generation cephalosporins, cefprozil and cefpodoxime because of limited clinical trials, even though a nonplacebo control study of cefprozil and in vitro data supports their efficacy.
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Findings: In an attempt to provide guidance for the management of AOM, experts were convened by the Centers for Disease Control to respond to changes in antimicrobial susceptibility among pneumococci and provide consensus recommendations for the management of AOM and the surveillance of drug-resistant S. pneumoniae. The conclusions of the group were that oral amoxicillin should remain the first-line antimicrobial agent for treating AOM. They recommended an increase in the dosage used for empiric treatment from 40 to 45 mg/kg/d to 80 to 90 mg/kg/d. For patients with clinically defined treatment failure after 3 days of therapy, useful altenative agents include oral amoxicillin-clavulanate, cefuroxime axetil, and intramuscular ceftriaxone. They concluded that many of the 13 other Food and Drug Administration–approved otitis media drugs lack good evidence for efficacy against drug-resistant S. pneumoniae. Recommendations to improve surveillance of drug-resistant S. pneumoniae include establishing criteria for setting susceptibility breakpoints for clinically appropriate antimicrobials to ensure relevance for treating AOM, testing middle ear fluid or nasal swab isolates in addition to sterile site isolates, and testing drugs that are useful in treating AOM. Takoudes TG, Haddad J: Retropharyngeal abscess and Epstein-Barr virus infection in children. Ann Otol Rhinol Laryngol 1998, 107:1072–1075. Significance: The association between Epstein-Barr viurs (EBV) and retrophyaryngeal abscess may have diagnostic and therapeutic implications. The organisms that predominate in peritonsillar abscess are anaerobic bacteria of oral origin (eg, pigmented Prevotella and Porphyromas species and Fusobacterium species) and Streptococcus pyogenes. The pathogenic role of these organisms was highlighted by the finding of an increase in antibody levels to some of these organisms (Prevotella and Fusobacterium species) in patients with peritonsillar abscess. Oral flora anaerobes may “benefit” from the presence of EBV infection, and a true synergy between these organisms and EBV may exist. Support for this explanation comes from several observations. These observations include the recovery of more species of anaerobic bacteria from the surfaces of tonsils with EBV infection during the illness than following it. In addition, patients with infectious mononucleosis respond favorably to treatment with metronidazole that is effective only against these organisms. These findings do not suggest that antimicrobials should be routinely given to patients with EBV infection. They suggest, however, that these patients should be monitored and watched carefully, so that if a tonsillar or retropharyngeal abscess develops, immediate medical and surgical therapy may be initiated. Findings: The authors conducted a 6-year retrospective chart review of all pediatric patients with the diagnosis of retropharyngeal abscess admited to their hospital. The charts were examined for signs, symptoms, and serologic findings consistent with recent acute EBV infection. Of the seven studied patients, four had elevated immunoglobulin G antibodies that were consistent with recent actue EBV infection; three patients were not tested. The four patients with positive titers also presented with signs typical for acute EBV infection, including fever (three of four patients), lymphadenopathy (four of four patients), and pharyngitis (four of four patients). The two patients who were older than expected for retropharyngeal abscess (ages 18 and 11 years) had the most severe infections. The authors concluded that there may be a role for EBV infection in the pathogenesis of retropharyngeal abscess formation in children, and that increasing age may correlate with a more severe infection. Amir J, Yagupsky P: Invasive Kingella kingae infection associated with stomatitis in children. Pediatr Infect Dis J 1998, 17:757–758. Significance: Kingella kingae, a gram-negative bacillus normally found in the respiratory tract, is increasingly recognized as a cause of bacteremia, skeletal infections, and endocarditis in young children. This study suggests that occurrence of diffuse stomatitis in young children may be associated with a risk to develop bacteremia or focal K. kingae infections. This clinical sign should alert clinicians to the potential serious complication of K. kingae. Although the etiology of stomatitis was not thoroughly investigated in most cases, a few viral infections were identified. Conversely, a substantial number of patients with culture-proved herpes simplex infection had concommitant K. kingae bacteremia. This association does not seem to be coincidental. The authors postulate that a breach of the mucosal continuity caused by viral infection provides a portal of entry to K. kingae organisms, which colonize the tonsillar surfaces. The immunosuppressive effect of the systemic viral infection
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may contribute to the process as well. Penetration of the organism into the bloodstream may be followed by hematogenous seeding of K. kingae to remote sites and especially to the skeletal system to which the organism shows a striking and still unexplained affinity. Findings: This study described 16 children with stomatitis and bacteremia or septic arthritis caused by K. kingae out of a total of 65 children with invasive K. kingae infections diagnosed at two medical centers in Israel. These 16 children had erosions in the buccal, gingival, and/or glossal surfaces. Duration of the stomatitis before blood sampling was 2 to 6 days. K. kingae was isolated from the blood in 14 children and from the joint fluid in three (one child had positive cultures from both sites). In most cases no attempt was made to identify the cause of the stomatitis. In four children with gingivostomatitis, herpes simplex virus was isolated from oral lesions, and in an additional four children the clinical data suggested herpetic gingivostomatitis. Neeman R, Keller N, Barzilai A, et al.: Prevalence of internalization-associated gene, prtF1, among persisting group A Streptococcus strains isolated from asymptomatic carriers. Lancet 1998, 352:1974–1977. Significance: The failure of antibiotic treatment to eradicate group a streptococci (GAS) in up to 30% of patients with pharyngotonsillitis is unexplained. Some strains of GAS can enter respiratory epithelial cells, where they would be inaccessible to antibiotics unable to penetrate the cell membrane, such as penicillins. The fibronectin-binding proteins, F1 and Sfbl, are needed for this process. The authors of this study hypothesized that an intracellular reservoir of GAS could account, at least partly, for failure to eradicate throat carriage, and that the presence of a gene for fibronectin-binding protein (F1) might be linked to the ablility of a strain to persist in the throat after therapy. Findings: The frequency of prtF1-containing stains among 67 patients with pharyngotonsillitis was investigated. All patients were clinically cured, but 13 continued to carry GAS in the throat during or after therapy. To distinguish between persisting and recolonizing strains, isolates from the 13 patients were serologically tested and compared by polymorhpic DNA-amplification technique. Twelve of the 13 patients (92%) with symptomless carriage had prtF1-containing strains in the throat, compared with 16 (30%) of the 54 patients with successful eradication. Three of the 13 eradication-failure patients were recolonized with strains that differed from the pretreatment strains. Nine of the 10 (90%) persisting strains carried prtF1. The authors findings suggest that protein-F1– mediated entry to cells is involved in the causative process of the carriage state.
Pleuropulmonary and Bronchial Infections Abigail Zuger, MD Albert Einstein College of Medicine, Bronx, NY 10467, USA. Flahault A, Dias-Ferrao V, Chaberty P, et al.: FluNet as a tool for global monitoring of influenza on the Web. JAMA 1998, 280:1330–1332. Significance: A computerized surveillance system formed in 1997 now links a network of 110 influenza centers in 83 countries around the world. For the first time public health authorities will have easy access to global data depicted both graphically and in map form. These worldwide influenza patterns can be found at http://oms.b3e.jussieu.fr/flunet/. Findings: Last year information on a total of more than 13,000 viral isolates were entered into the database. This serves as an early alert tool for local influenza outbreak detection in countries without their own early detection networks. In addition, global patterns of antigenic shift are easier to monitor than in the past. By linking FluNet data with other global databases, such as weather patterns, some clues to the pathogenesis of influenza pandemics may be obtained. State-specific prevalence among adults of current cigarette smoking and smokeless tobacco use and per capita tax-paid sales of cigarettes–United States 1997. MMWR 1998, 47:922–926. Significance: Cigarette smoking, an important risk factor for virtually all lung infections, remains widely prevalent in the United States.
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Findings: Results from a nationwide telephone survey of US citizens 18 years of age or older indicated that overall about 23% of US adults were cigarette smokers during 1997, similar to findings for 1996. Among men, 25.5% were smokers and among women 21.3% were smokers. Prevalence of smoking varied among the states, from a high of 30.8% of adult residents in Kentucky, to a low of 13.7% in Utah. Per capita cigarette sales ranged from a high of 186.8 packs per person per year in Kentucky to a low of 49 packs in Hawaii. Valdes L, Alvarez D, San Jose E, et al.: Tuberculous pleurisy: a study of 254 patients. Arch Intern Med 1998, 158:2017–2021. Significance: A large series of tuberculous pleural effusions confirms that elevated concentrations of adenosine deaminase (ADA) is a characteristic finding. Findings: In a retrospective review of 254 adults with tuberculous pleurisy seen over 8 years in a hospital in Spain, most patients were under the age of 35 years and fewer than 20% had obvious risks for tuberculosis such as HIV infection or alcoholism. Tuberculin skin tests were positive in only 66%. Fewer than 20% of patients had other characteristic radiologic abnormalities of pulmonary tuberculosis. Acid-fast stain of the pleural fluid showed organisms in only 5.5% of cases and only 36.6% of fluid specimens were culture positive. However, all but one of 254 specimens had an elevated ADA level, confirming that this test may be helpful in diagnosing tuberculous pleurisy, particularly if pleural biopsy, the gold standard diagnostic test, cannot be obtained. Zwarenstein M, Schoeman JH, Vundule C, et al.: Randomised controlled trial of self-supervised and directly observed treatment of tuberculosis. Lancet 1998, 352:1340–1343. Significance: The first published randomized trial of directly observed therapy (DOT) for tuberculosis fails to show obvious benefits from this technique. Findings: Two-hundred sixteen South African adults with active drug-sensitive pulmonary tuberculosis were randomly assigned to receive medications through a DOT program or take medications on their own. Treatment success was equivalent in the two groups, although among patients who were being retreated for relapsed disease, success was significantly higher among self-supervised patients than DOT patients (74% vs 42%). Almost half the patients in both groups failed to complete treatment, raising questions about the validity of this study and emphasizing the need for others. Doern GV, Pfaller MA, Kugler K, et al.: Prevalence of antimicrobial resistance among respiratory tract isolates of Streptococcus pneumoniae in North America: 1997 results from the SENTRY antimicrobial surveillance program. Clin Infect Dis 1998, 27:764–770. Significance: Only about half the strains of Streptococcus pneumoniae tested in this nationwide 1997 survey retained full susceptibility to penicillin. Findings: In 1997 antibiotic susceptibility results for 845 isolates of S. pneumoniae were reported from 27 medical centers across the United States. Among isolates, 56.2% were fully susceptible to penicillin, 27.8% were intermediately susceptible, and 16% had high-level drug resistance, with minimum inhibitory concentrations 2.0 mg/mL or more. Resistance to second-generation cephalosporins ranged from 19.5% resistance to cefuroxime to 91.7% to cefadroxil. Macrolide resistance was seen in 10% to 15% of isolates, and resistance to trimethoprim-sulfamethoxazole was seen in 20% of isolates. More than 90% of isolates were susceptible to the third-generation cephalosporins cefotaxime and cefipime, and all isolates were susceptible to vancomycin. Chodosh S, Schreurs A, Siami G, et al., and the Bronchitis Study Group: Efficacy of oral ciprofloxacin vs. clarithromycin for treatment of acute exacerbations of chronic bronchitis. Clin Infect Dis 1998, 27:730–738. Significance: A study sponsored by the manufacturer of ciprofloxacin found that ciprofloxacin is as effective as clarithromycin in treatment of acute exacerbations of chronic bronchitis. Findings: Three hundred seventy-six adults with underlying asthma or chronic obstructive pulmonary disease and acute purulent bronchitis were enrolled in a blinded, randomized trial of oral
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ciprofloxacin versus oral clarithromycin for a 14-day course. Most patients had Haemophilus influenzae, Moraxella catarrhalis, or S. pneumoniae isolated from pretreatment sputum specimens. Rates of clinical resolution were equivalent, as were rates of drug-related adverse events. Pathogens were eradicated from posttreatment sputum specimens in 86% of ciprofloxacin recipients and 67% of clarithromycin recipients, a statistically but not clinically significant difference, since time to the development of new infection was similar in both groups. Bishai WR, Graham NMH, Harrington S, et al.: Molecular and geographic patterns of tuberculosis trransmission after 15 years of directly observed therapy. JAMA 1998, 280:1679–1684. Significance: Despite an effective program of directly observed therapy, almost half of the tuberculosis cases in Baltimore from 1994 through 1996 were probably the result of recent exposure to the disease. Findings: Bacterial isolates in 182 persons with active tuberculosis were fingerprinted with two DNA probes. In 20 patients (11%) matching DNA fingerprints and identifiable epidemiologic links suggested that disease was almost certainly the result of recent transmission. In 98 patients with no matching DNA patterns and no epidemiologic links, disease was almost certainly reactivated after remote exposure. In the remaining 64 patients (35%) DNA fingerprinting showed related strains, but no epidemiologic data linked the patients. Because these patients had so many risk factors for recently acquired disease such as HIV seropositivity and homelessness, their disease was believed to represent recently acquired infection that standard epidemiologic methods were not sensitive enough to detect. Thus, approximately half of all Baltimore tuberculosis cases were clustered, a rate similar to that found in other large US cities at the height of the tuberculosis epidemic.