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Top 10 articles on pediatric infectious diseases. (Expert's Picks).

ASPEN, COLO. -- Clinical sinusitis in children should not be treated with antibiotics, according to Dr. Michael Radetsky's pick for best pediatric infectious disease article of the past year.

The findings presented in the article confirm what many experts have long been saying about sinusitis: It is usually a self-limiting disease with a short duration, and outcomes are the same regardless of whether antibiotics are prescribed, Dr. Radetsky said during his annual Top 10 Articles presentation at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

There were no differences in quantitative symptom (S5) score, functional status, school days missed, relapse rate, adverse effects, or parental satisfaction among 188 children with clinical sinusitis who were randomized to receive 14 days of treatment with either amoxicillin /,amoxicilln! clavulanate, or placebo (Pediatrics 107[4]:619-25, 2001).

Here are Dr. Radetsky's other top picks for 2000-200 1:

(2.) Fever Phobia Revisited: Have Parental Misconceptions About Fever Changed in 20 Years? (Pediatrics 107[6]:1241-46, 2001).

The article's findings suggest that parents continue to have unwarranted and misguided fears about fever, and pediatricians could be doing more to change that. A total of 340 caregivers completed a 29-item questionnaire, and the results were compared with those from a study done in 1980.

Although fewer parents appear to be misinformed about the potential dangers of fever, about what is considered a high fever, and about how high an untreated fever can go, misconceptions still remain. For example, 15% of respondents in 1980 said seizure could occur from fever, compared with 32% in 2000. And 45% in 1980 said brain damage could occur, compared with 21% in 2000.

Pediatricians can do a better job educating parents and allaying fever phobia, said Dr. Radetsky, an infectious diseases specialist and chair of pediatrics at Lovelace Health Systems in Albuquerque.

(3.) The Pediatric Forum: White Blood Cell Count Likelihood Ratios for Bacteremia in Febrile Young Children (Arch. Pediatr. Adolesc. Med. 154[9]:963-64, 2000).

Likelihood ratios for bacteremia in febrile children were developed based on white blood cell counts by utilizing data from previous studies. These ratios could be more useful than using a single cutoff point, such as 15,000 WBCs, for making management decisions, Dr. Radetsky said at the meeting, which was also sponsored by the University of Colorado.

The investigators found a likelihood ratio of 0 for WBC counts of 0-5,000, 0.1 for counts of 5,000-10,000, 0.4 for counts of 10,000-15,000, 2.5 for counts of 15,000-20,000, 5 for counts of 20,000-25,000, 5.3 for counts of 25,000-30,000, and 15 for counts of 30,000-50,000.

(4.) Effect of Early or Delayed Insertion of Tympanostomy Tubes for Persistent Otitis Media on Developmental Outcomes at the Age of Three Years (N. Engl.J. Med. 344[16]:1179-87, 2001).

In this study, the rate of developmental delay did not differ between children under age 3 who received tubes and those who received tubes later. Of 6,350 newborns monitored monthly by otoscopy, 429 were found to be eligible for tubes due to 90-plus days of bilateral middle ear effusions or 135 days of unilateral middle ear infusions. The children were randomized to receive tubes immediately or to wait until age 5. At age 3, no differences were seen in cognition, receptive/expressive language, and speech.

(5.) Short-Course Antibiotic Treatment of 4,782 Culture-Proven Cases of Group A Streptococcal Tonsillopharyngitis and Incidence of Poststreptococcal Sequelae (J. Infect. Dis. 182[2]:509-16, 2000).

Tonsillopharyngitis caused by group A streptococcus can be treated just as well and as safely with 5 days of amoxicillin, cephalosporin, or a macrolide, as it can be with to days of penicillin, according to the results of this large randomized trial.

A total of 4,782 children were randomized to treatment with 10 days of penicillin, or 5 days of amoxicillin and potassium clavulanate (Augmentin), ceftibuten (Cedax), cefuroxime axetil (Ceftin), loracarbef (Lorabid), clarithromycin (Biaxin), or erythromycin.

There were no differences in clinical improvement or bacteriologic eradication rates between the 5- and 10-day treatment groups. Improvement 2-4 days after the end of therapy was about 94% in both groups, and at 7-9 days after the end of therapy it was about 88% in both groups. Bacteriologic eradication by 1 week after the end of therapy was 85% in both groups, and symptom resolution was actually faster in the 5-day treatment groups. Recurrence at 1 year follow-up was 24% in the 10-day group and 21.9% in the 5-day groups.

6. Reliability of the Urinalysis for Predicting Urinary Tract Infections in Young Febrile Children (Arch. Pediatr. Adolesc. Med. 155[1]:60-65, 2001).

Urinalysis in the evaluation of young febrile children can "restrict the use of antibiotics in a very important way,' this study showed.

Of 8,815 pediatric patients presenting to the emergency room with fever who received both urinalysis and urine culture, urinalysis bad a specificity of 92% and sensitivity of 82%. When paired with likelihood ratios of urinary tract infections (UTIs) based on age and gender, a negative urinalysis can meaningfully reduce the estimated risk of UTI in febrile infants.

7. Outpatient Treatment of Moderate Group With Dexamethasone; Intramuscular Versus Oral Dosing (Pediatrics 106[6]: 1344-48, 2000).

This randomized study of 277 patients with moderate croup aged 3 months to 12 years revealed no difference in outcome among those treated with intramuscular dexamethasone and those treated with oral dexamethasone (tablet crushed in syrup) if they were treated within 48 hours of symptom onset.

The investigators found no differences in unscheduled return visits, the need for further therapy or hospital admissions between the two groups, Dr. Radetsky said.

8. Outcome of Invasive Infections Outside the Central Nervous System Caused by Streptococcus Pneumoniae Isolates Nonsusceptible to Ceftriaxone in Children Treated with [beta]-Lactam Antibiotics (Pediatr. Infect. Dis. J. 20[4]:392-96, 2001).

Invasive pneumococcal infections outside the CNS can be treated with conventional [beta]-lactam antibiotics without concern about problems with resistance, according to the findings of this "very reassuring" study.

Of 2,100 episodes of such infection, 166 were caused by organisms thought to have some resistance to ceftriaxone; 40 of the 166 were treated with vancomycin because of concerns about the resistance, and the rest were treated with cephalosporin only. All but one of the children were treated successfully The investigators concluded that the level for defining resistance should be higher for infections outside of the CNS.

9. Efficacy and Safety of Recombinant Human Activated Protein C for Severe Sepsis (N. Engl.J. Med. 344[10]:699-709, 2001).

All patients with severe sepsis should be treated within 24 hours of hospital admission with 24 [micro]g/kg per hour of recombinant human activated protein C for 96 hours, Dr. Radetsky agreed after reading this article. In this randomized controlled trial, use of this treatment within 24 hours of admission reduced risk of death by nearly 20% at 1 month, compared with placebo.

The study of 1,690 patients was stopped early due to the treatment benefits seen. However, the incidence of serious bleeding was higher in the treatment group (3.5% vs. 2%), and there was no evidence of a reduction in risk of serious thrombosis.

10. Wet Combing Versus Traditional Scalp Inspection to Detect Head Lice in School Children: Observational Study (BMJ 321[7270]:1187-88, 2000).

It seems that the traditional approach of scalp inspection to identify the presence of head lice may not be the best approach, Dr. Radetsky said, noting that in this prospective comparative study that a wet-combing technique proved superior for accurately diagnosing head lice infestation.

In this study of 224 children, of the 14 children who were found to be negative for lice by wet-combing but positive by traditional inspection, only 1 child was found to be truly infected by natural history Scalp inspection also had a false-negative rate of 35%, and a false-positive rate of 39%.
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Author:Worcester, Sharon
Publication:Pediatric News
Geographic Code:1USA
Date:Dec 1, 2001
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