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Increased bacterial resistance is caused most frequently by the widespread use of antimicrobial agents. Antimicrobial agents are often used inappropriately to treat common respiratory illnesses in children. This article discusses the judicious use of antimicrobials in the common cold, otitis media, acute sinusitis, pharyngitis, and bronchitis.
In each clinical trial the statistical evaluation of adverse events (AEs) is a major part of standard safety analyses. However, the analyses of AEs usually lack from adequately accounting for the occurrence of multiple, different AEs. Furthermore, predictive variables other than treatment such as age, sex and concomitant medication are often ignored. These issues can be addressed by the Cox regression as introduced by Andersen and Gill and Wei et al. A further issue arises from the fact that an ordered programme of studies is conducted during clinical testing of pharmaceutical drugs. In this paper, we therefore discuss a stratified multivariate Cox regression model that can be used in integrated summaries of safety. We derive partial maximum likelihood estimators of the model parameters which can be shown to be consistent and asymptotically normally distributed. Mainly based on a sandwich estimator of their covariance matrix several test statistics are proposed that can be used to test various null hypotheses on the underlying parameters. Their asymptotic null distributions are given. The benefit of this survival time approach for analysing AEs is illustrated by evaluating symptoms of common cold from the database of a clinical development project.
Upper respiratory tract infections (URTIs) are mostly caused by viruses. Antibiotic misuse for viral URTIs in children is a serious problem that not only results in selection of resistant strains of bacteria but also wastes millions of dollars each year in Taiwan. Antibiotic resistance among common respiratory bacterial pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and Moraxella catarrhalis has become a major issue for public health. The common cold, acute pharyngotonsillitis, acute otitis media, acute sinusitis, acute bronchitis, influenza and acute epiglottitis are the most frequently encountered acute URTIs in out-patient clinics. This article recommends the judicious use of antimicrobial agents for these seven common pediatric URTIs, based on local epidemiological data and the recommendations of the Infectious Disease Society of Taiwan and the American Academy of Pediatrics. With education and behavior modification, practitioners will help to reduce antibiotic overuse, and the goal of reducing antimicrobial resistance may be accomplished.
Respiratory illnesses are the commonest cause of patient visits to physicians. Although the common cold, sinusitis and bronchitis may be lacking in drama, they account for a substantial amount of morbidity among women of reproductive age and are frequently encountered by physicians caring for pregnant women. Present knowledge about the management of these common conditions and the safety of the medications often used to treat them are reviewed in this chapter. Asthma and community-acquired pneumonia are more serious respiratory illnesses that are also often encountered in pregnancy. Present evidence suggests that community-acquired pneumonia is best treated empirically, with additional investigation usually necessary only if there is a failure of initial treatment. The recognition of asthma as an inflammatory condition has led to a very specific approach to its management that can readily and safely be applied to the pregnant woman. Treatment of HIV and tuberculosis should not be withheld during pregnancy because of the life-threatening nature of these infections and the importance of preventing vertical transmission.
BACKGROUND: Widespread antibiotic use has fostered the emergence of antibiotic-resistant bacteria. Parental expectations have been cited as one reason for physicians to overprescribe antibiotics. The objective of this study was to determine parental knowledge about antibiotics and their use for common respiratory tract infections. METHODS: A survey was administered to 100 adults at a rural pediatric office. RESULTS: Many respondents had misconceptions about the etiology of common respiratory tract infections and the effects of antibiotic therapy. Only 54% knew that a virus is the usual cause of the common cold, and 33% thought that a virus causes strep throat. Almost half (46%) believed that antibiotics kill viruses, while 17% were not sure whether antibiotics kill viruses. Most respondents (60%) had never heard about antibiotic resistance. CONCLUSION: Parental knowledge about common respiratory tract infections and about antibiotic therapy is often lacking. Improved parent education may alter parents' expectations concerning antibiotic therapy for their ill children.
The epidemiology of the common cold is reviewed with the aim of providing helpful advice for patients. Future management will include limiting the spread of the cold virus by attention to the mode of transmission and the development of anti-viral drugs, of which interferon holds the most promise.
A randomized, controlled, blinded clinical trial was conducted to determine if self-care instructions, coupled with a health education program, could reduce unnecessary visits to physicians for minor respiratory illness. A symptom-based algorithm was developed for determining the necessity of a physician visit and provided, along with a brief educational package on proper care of the common cold, to a randomly selected group of 433 families attending a family practice clinic. Subsequent clinic visits by family members were monitored and evaluated in relation to the algorithm, and results were compared with those obtained from a control group of 444 families. The subsequent rate of visits for upper respiratory tract infections classified as unnecessary using the algorithm was 44% lower in the test as compared with the control group, while the rate of necessary visits was only 15% lower. No increase was seen in complications of upper respiratory tract infections.
OBJECTIVE: To determine whether over-the-counter cold medications have been shown to be effective in relieving symptoms in children, adolescents, and adults. DATA SOURCES: The MEDLINE database using the key words combined with medications and research and review articles. Articles were retrieved if they were written in English and published between January 1950 and January 1991. STUDY SELECTION: Articles were selected if they described a controlled clinical trial on the treatment of the common cold. Forty-eight percent of 106 articles met the selection criteria, and these were grouped by age into child studies (< 5 years old and < 12 years old) and adolescent (aged 12 years and older)/adult studies. DATA EXTRACTION: Each article was scored on 11 criteria to determine scientific validity. Those articles scoring above 70% were included in the final analysis. Two authors independently scored a sample of articles to determine interrater reliability. DATA SYNTHESIS: Very few studies have been performed on children. Of those, two done on preschool children demonstrated no symptom relief, whereas two done on older children showed some benefit. In the adolescent/adult studies, chlorpheniramine maleate, pseudoephedrine hydrochloride, oxymetazoline hydrochloride, phenylpropanolamine hydrochloride, ipratropium bromide, and atropine methonitrate all improved nasal symptoms. Combination therapy (using an antihistamine-decongestant mix) was shown to relieve a variety of symptoms. CONCLUSIONS: No good evidence has demonstrated the effectiveness of over-the-counter cold medications in preschool children. Further studies are required to clarify the role of these medications in children. Certain single over-the-counter medications and combinations have been shown to reduce cold symptoms in adolescents and adults.
An epidemic chain model is developed by assuming a beta distribution for the probability of being infected by contact with a given infective from the same household. This model includes, as a particular case, the epidemic chain model corresponding to the stochastic Kermack-McKendrick model and, as a limiting case, the Reed-Frost chain binomial model. The advantages of the more general model are illustrated with an application to household data for the common cold. Finally, it is shown how the coefficient of variation of the duration of the infectious period may be estimated without any direct observations on this duration.
Minor illnesses, such as colds and influenza, are frequent, widespread and a major cause of absenteeism from work and education. Yet the clinical symptoms of such illnesses may not be so great as to stop people from working or from carrying out everyday activities. It is therefore important to determine whether these viral infections alter central nervous system function and change performance efficiency. Data on this topic are almost non-existent, which in part reflects the difficulties inherent in carrying out such studies. In real life it is almost impossible to predict when such illnesses will occur, and difficult to establish which virus produced the illness. This problem was overcome by studying experimentally induced infections and illnesses at the Medical Research Centre (MRC) Common Cold Unit in Salisbury. Results from this research programme show that: (i) colds and influenza have selective effects on performance; (ii) even sub-clinical infections can produce performance impairments; (iii) performance may be impaired during the incubation period of the illness; (iv) performance impairments may still be observed after the clinical symptoms have gone. These results have strong implications for occupational safety and efficiency and it is now essential to assess the impact of naturally occurring colds and influenza on real-life activities.
We report a 19-year-old male with group A xeroderma pigmentosum who presented life-threatening vocal cord paralysis. At 3 months of age, he became sensitive to sunlight, and at the age of 4 years he was diagnosed with group A xeroderma pigmentosum. The neurologic symptoms progressed slowly thereafter. From the age of 18 years, he reported the development of occasional episodic inspiratory stridor and dyspnea, but the cause remained unknown. At the age of 19, he had a common cold and became severely dyspneic and cyanotic. Immediate examination of the glottis upon arrival by an otorhinolaryngologist using a fibroscope indicated complete paralysis of both vocal cords, and tracheal intubation resulted in marked improvement of respiration. Tracheostomy was performed thereafter. Inspiratory stridor and dyspnea are the common symptoms in this disease, and some patients with group A xeroderma pigmentosum undergo a tracheostomy, but the pathogenesis remains unknown. To our knowledge, vocal cord paralysis has never been reported in patients with group A xeroderma pigmentosum. This case is presented to illustrate the importance of fibroscopy in the examination of vocal cords in patients with group A xeroderma pigmentosum before the development of life-threatening events.
INTRODUCTION: Most visits to the primary care center are for infection and particularly respiratory tract infection. Antimicrobial administration for these clinical processes is common and these agents are often used to treat viral infections. La Fundación para el Estudio de la Infección (Foundation for the Study of Infection) designed the DIRA (Día de la Infección Respiratoria del Adulto, Adult Respiratory Infection Day) Project to investigate and assess the impact of this problem. METHODS: The study design consisted of one-day cross sections with the participation of 720 physicians belonging to Primary Health Care Centers from the 17 Autonomic Regions of Spain, establishing a one-day cross section every three months for one year. Epidemiologic, clinical and therapeutic factors were evaluated. RESULTS: The total number of visits attended was 72 929, and 14 426 patients had infectious processes (43.9%). Among these, 9145 (63.4%) had a respiratory infection. The mean age of the patients was 44.6 years and 34.1% had an underlying condition. Common cold was the most frequent diagnosis. Antibiotics were prescribed in 53.2% of patients. Results were compared to those of a previous study. DISCUSSION: Infection in general and respiratory infection in particular is frequently attended in primary care. Antibiotics are widely used in our setting and self-medication is common.
Because of their efficacy, intranasal corticosteroids (INCS) remain the cornerstone in the treatment of upper airway diseases. Although INCS are extremely efficacious, local and systemic adverse effects have been associated with their use. However, none of these effects is of sufficient frequency or magnitude to warrant a reduction in their use or any action more than careful drug and dose selection and monitoring when indicated. Recent publications focus on newer aspects of efficacy in rhinitis and on the adverse effects of growth suppression, cataract formation, and histologic effects on the nasal mucosa. Optimizing mucosal delivery of INCS is a major goal because of the need to maximize efficacy and minimize systemic bioavailability and potential risks. One recent study examined the bioavailability and metabolism of beclomethasone dipropionate. Another study examined the tendency of patients to overdose when using betamethasone drops. A third study compared the two different delivery systems of fluticasone propionate and budesonide, and their efficacy in treating perennial rhinitis. Other studies examined the effect of INCS on the treatment of nasal polyps (budesonide) and on the common cold (beclomethasone dipropionate). These studies have continued to define safety and efficacy aspects, and the important role of INCS in treating rhinitis.
In connection with grommet insertion due to secretory otitis media (SOM), the middle ear effusion was collected and studied for content of interferon and bacteria. The study material comprised a total of 47 ears in 29 children, but from 10 ears the effusion was too viscous for interferon titration, so only 24 children were ultimately included. Interferon was present in 5 ears of 3 children. A child having a low titre in both ears had recently been treated with penicillin. From the other 2 children, pneumococci were cultured. Twelve of the included children had a common cold, but of them only 2 had interferon in the middle ear. The production of interferon was presumably induced by the pneumococci, not by virus.
This study examined the role of personality in the reporting of symptoms and illness not supported by underlying pathology. After assessment of the Big Five personality factors, 276 healthy volunteers were inoculated with a common cold virus. On each of the following 5 days, objective indicators of pathology, self-reported symptoms, and self-reported illness onset were assessed. Neuroticism was directly associated with reports of unfounded (without a physiological basis) symptoms in individuals at baseline and postinoculation in those with and without colds. Neuroticism was also indirectly associated with reports of unfounded illness through reports of more symptoms. Openness to Experience was associated with reporting unfounded symptoms in those with verifiable colds, whereas Conscientiousness was associated with reporting unfounded illness in those who were not ill.
The relative bioavailability of nicotine from a nasal spray was assessed in 15 smokers suffering a common cold and rhinitis according to generally accepted criteria. The patients were given a single dose of 2 mg nicotine from the nasal spray with and without concurrent administration of a nasal vasoconstrictor decongestant, xylometazoline, in randomised order. Control session measurements were made in the disease-free state. Applying strict bioequivalence criteria, we found that common cold/rhinitis slightly reduced the bioavailability of nicotine, both in its rate and extent; the geometric mean of the ratio of Cmax, AUC and tmax were 0.81, 0.93 and 1.36, respectively. The nasal vasoconstrictor, xylometazoline, normalised the extent of the bioavailability of nicotine, but further prolonged the time for absorption to almost twice that measured in the disease-free state, increasing the tmax ratio to 1.72. The results suggest that a minor proportion of people stopping smoking with the help of a nicotine nasal spray may experience a minor reduction in the effect of the spray during common cold/rhinitis. However, the nicotine self-titration behaviour found with most smoking cessation products (except the nicotine patch) will automatically lead to an adjustment of the dosage to achieve the desired effect.
Acute sinusitis is common and usually the result of edema around the sinus ostia from the common cold. Chronic sinusitis and recurrent sinusitis are common complications of untreated or undertreated infection. Serious and life-threatening complications are uncommon but demand a high index of suspicion, accurate diagnosis, and rapid intervention by medical and surgical methods. Immediate parenteral administration of antibiotics may be necessary to prevent permanent disabilities or death, and early consultation with an otolaryngologist or neurosurgeon is prudent. Computed tomography is the imaging method of choice for detection of serious intracranial complications of acute sinusitis. Increasing numbers of immunocompromised patients and seriously ill hospitalized patients with problems related to complications of acute sinusitis are being seen.
Acute sinusitis is one of the most commonly observed entities in clinical practice. Despite the frequency of the disease, diagnosis and therapy often remain empiric. Most cases are secondary to sinus ostia obstruction associated with the common cold or allergies. Maxillary sinusitis is most common. Because of the proximity of vital anatomic structures and venous drainage systems, serious complications frequently arise from sphenoid, frontal, and ethmoid sinusitis. Clinical signs and symptoms most helpful in the diagnosis of maxillary sinusitis are the presence of a maxillary toothache, lack of improvement with decongestants, a purulent nasal discharge, cough, purulent secretions observed on nasal examination, abnormal transillumination, and sinus tenderness. Plain film radiographs are helpful, but do not adequately visualize the anterior ethmoid sinuses. Computed tomography provides superior visualization, but cost remains prohibitive for routine cases. Most maxillary sinusitis in adults is secondary to Streptococcus pneumoniae or Hemophilus influenzae. Moroxella catarrhalis is common in children. Staphylococcus aureus is observed more frequently in frontal or sphenoid disease. Most patients with acute sinusitis are treated without microbiological diagnosis and respond well to commonly used oral antimicrobials with activity against the usual pathogens. Complications of sinusitis include meningitis, periorbital infections, subdural empyema, epidural abscess, brains abscess, cavernous sinus thrombosis, and osteomyelitis.