Pneumonia Study Leads Top 10 Journal Articles on Pediatric Infectious Diseases
ASPEN, COLO. — A World Health Organization study conducted in eight developing countries tops an expert's annual list of the most important journal articles for physicians treating pediatric infectious diseases.
“Basically, what it showed was, in a child with pneumonia who is not toxic, you never need to treat with an IV. You can treat orally,” Michael Radetsky, M.D., said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.
The nonblinded study (Lancet 2004;364:1141–8) randomized 1,702 children, aged 3–59 months, who were hospitalized with severe pneumonia. About half received oral amoxicillin for 48 hours; the rest were given parenteral penicillin.
Both regimens in the study—oral and injectable—had the same rate of treatment failure: 19% at 48 hours.
Emmanuel Addo-Yobo, M.D., of the Amoxicillin Penicillin Pneumonia International Study group interpreted the outcome as evidence that oral amoxicillin is equivalent to injectable penicillin.
Dr. Radetsky, a consultant in pediatric infectious diseases and clinical professor at the University of New Mexico in Albuquerque, also recommended the following articles:
Sensitivity of Rapid Strep Tests
M. Bruce Edmonson, M.D., and Kathryn R. Farwell at the University of Wisconsin Medical School in Madison reviewed 1,184 consecutive Rapid Antigen Detection Tests in a single pediatric clinic (Pediatrics 2005;115:280–5).
Their study compared test results to the pretest clinical likelihood of group A streptococcal pharyngitis, as calculated in a blinded chart review.
The investigators found the test's sensitivity reflected the likelihood that a patient had a group A infection. Sensitivity was high in patients younger than 15 years of age who had tonsillar exudate without a cough. It was low in patients with a McIsaac score of 2 or less.
“The accuracy of a rapid strep test goes up when you think they have strep throat. The accuracy goes down when you don't think it is strep. So it's not a good test to do in the in-between child,” Dr. Radetsky said, advising physicians to skip the test and order a culture when they are wavering or responding to circumstances, such as a sibling infected the previous week.
Infant Hyperpyrexia
Hyperpyrexia is a rare event that might be a risk factor for serious bacterial infection in infants less than 3 months old, according to Rachel Stanley, M.D. (Pediatr. Emerg. Care 2005;21:291–4).
Dr. Stanley of the University of Michigan, Ann Arbor, and her coauthors from Children's Hospital, Boston, reviewed 5,279 infants younger than 3 months who were brought to an urban emergency department with triage temperatures of 38° C or higher. Only 98 patients (1.7%) had hyperpyrexia, which was defined as a rectal temperature of 40° C or greater. More than a third of that group, 35 infants, was diagnosed with serious bacterial infections, the most common of which was urinary tract infections in 24 infants.
The authors suggested that future management algorithms might list high fever as a risk factor for serious infection. Managing high fevers in young infants is a challenge that keeps physicians awake at night, according to Dr. Radetsky. “I love this article because it takes this fear and gives body to the fear,” he said. “It says, yes, you should be concerned about it … and, yes, children can be seriously ill, but it's very rare.”
New Acute Otitis Media Paradigm
Because 80% of acute otitis media infections respond spontaneously, some physicians have called on their colleagues to delay antibiotics for 3 days in selected children who are assured clinical follow-up. Thomas F.X. Fisher, M.D., of the State University of New York at Stony Brook, and his coauthors surveyed 654 parents and 84 pediatricians about the proposed paradigm (Pediatr. Emerg. Care 2005;21:170–2).
The researchers found 53% of the parents and 73% of the physicians were “somewhat comfortable to very comfortable” with deferring antibiotics. Comfort levels increased with knowledge of the evidence, but 61% of parents did not know antibiotics could have adverse effects; 72% did not know research supported selective use of antibiotics.
Although many physicians and parents appeared open to the new recommendations, the authors noted that half the pediatricians routinely prescribed antibiotics for all cases of acute otitis media.
“What this means is, we have some work to do,” Dr. Radetsky said, calling for greater effort to educate physicians and parents. Nonetheless, he described himself as heartened by the level of physician acceptance: “It's miraculous.”
Antipyretic Effects on Measured Fever
Febrile infants often receive antipyretics at home before being brought to the emergency department, according to a prospective study that enrolled 474 infants with fever or a history of fever from Aug. 24, 2000 to Dec. 31, 2001 (Arch. Pediatr. Adolesc. Med. 2004;158:972–6).