Antibiotic prescribing at NSMC Sue Neal / Steve Newell 16/5/03. Plan for the meetings:. Enough material for 2 meetings Consider some research Look at antibiotic prescribing at NSMC For respiratory illnesses For UTI in children. What are the problems?. Do antibiotics work?
An examination of antibiotic prescribing with reference to new guidelines and minor ailments
Primary-care-based randomised placebo-controlled trial of antibiotic treatment in acute maxillary sinusitis.
Lancet. 1997 May 17;349(9063):1476
van Buchem FL, Knottnerus JA, Schrijnemaekers VJ, Peeters MF
BACKGROUND: The value of antibiotics in acute rhinosinusitis is uncertain. Although maxillary sinusitis is commonly diagnosed and treated in general practice, no effectiveness studies have been done on unselected primary-care patients. We used a randomised, placebo-controlled design to test the hypothesis that there would be an improvement associated with amoxicillin treatment for acute maxillary sinusitis patients presenting to general practice.
METHODS: Adult patients with suspected acute maxillary sinusitis were referred by general practitioners for radiographs of the maxillary sinus. Those with radiographic abnormalities (n = 214) were randomly assigned treatment with amoxicillin (750 mg three times daily for 7 days; n = 108) or placebo (n = 106). Clinical course was assessed after 1 week and 2 weeks, and reported relapses and complications were recorded during the following year.
FINDINGS: After 2 weeks, symptoms had improved substantially or disappeared in 83% of patients in the study group and 77% of patients taking placebo. Amoxycillin did not influence the clinical course of maxillary sinusitis nor the frequency of relapses during the 1-year follow-up. Radiographs had no prognostic value, nor were they an effect modifier. Side-effects were recorded in 28% of patients given amoxycillin and in 9% of those taking placebo (p < 0.01). The occurrence of relapses was similar in both groups (21 vs 17%) during the follow-up year.
INTERPRETATION: Antibiotic treatment did not improve the clinical course of acute maxillary sinusitis presenting to general practice. For these patients, an initial radiographic examination is not necessary and initial management can be limited to symptomatic treatment. Whether antibiotics are necessary in more severe cases warrants further study.
- 12 post URTI
- 22 pain
- 23 tenderness
- congestion / discharge / fever
- less than 1 week = 8
- 2 weeks to 1 year
- Amoxicillin / Ampicillin / Erythromycin
- Trimethoprim & Doxycycline
For - 3 days
- 5 days
- 7 days ( 35)
- 10 days
- Other regimes
BMJ 1996;312:961-964 (13 April) Education and debate: ABC of Urology: URINARY INCONTINENCE AND URINARY INFECTION
Chris Dawson, Hugh Whitfield
Urinary tract infection: Management in children
Collecting urine specimens to confirm the diagnosis of
urinarytract infection is [..] difficult in children. A
midstream samplecan be collected from older children,
but in younger childrena sterile bag placed over the
genitalia to catch the urine maybe needed. Suprapubic
aspiration of the bladder is seldom required.
..1% of boys aged under 11 years develop a urine
infection, but the incidence is three times as high in girls.
Most such infections occur in the first 12 months of life.
The greatest danger in such children is the development
of upper tract infection and subsequent renal scarring.
Vesicoureteric reflux accompanies urinary tract infection
in children in 20-50% of cases. Although reflux may be the
cause of infection, episodes of infection may lead to
transient reflux. Vesicoureteric reflux alone is not
sufficient to cause renal cortical scarring - infection must
also be present
Treating uncomplicated infections for 3-5 days with
All children with a urinary infection shouldbe
An ultrasound scan or intravenous urogram willshow
abnormalities of the upper tracts.
A voiding cystourethrogramshould be performed to look for bladder outlet obstruction orvesicoureteric reflux.
Sexual abuse as a cause of urinary infectionin children
should not be forgotten.
Repeated infections should be treated accordingly:
Prophylacticantibiotics may be needed if more than
three infections occurduring six months.
Preventive measures [..] include adequatefluid intake
and the avoidance of constipation.
If vesicoureteric reflux is discovered then conservative
managementis appropriate initially. Higher grades of
reflux are unlikelyto settle spontaneously, but lower
grade reflux – i.e. notreaching the renal pelvis – may
settle without intervention.Surgery is likely to be needed
if repeated infections occurwhile the child is taking
prophylactic antibiotics, if antibioticcompliance is low, or
if reflux persists after lengthy surveillance.
BMJ 1999;319:1173-1175 ( 30 October )Clinical review: Clinical evidenceUrinary tract infection in children
James Larcombe, general practitioner.
Sedgefield, County Durham TS21 3BN
This review of the effects of treatment for urinary tract
infection in children and of preventive interventions is
one ofover 60 chapters in the first issue of Clinical
Evidence, publishedby the BMJ Publishing Group.
Treating symptomatic acute urinary tract infection in children with an antibiotic is accepted clinical practice and trials would be considered unethical
We found little evidence on the effects of delaying treatment while awaiting microscopy or culture results, but retrospective observational studies suggest delayed treatment may be associated with increased rates of renal scarring
One systematic review of randomised controlled trials (RCTs) has found that antibiotic treatment for seven days or longer is more effective than shorter courses
We found no convincing evidence of benefit from routine diagnostic imaging of all children with a first urinary tract infection, but subgroups at increased risk of future morbidity may benefit from investigation. Because such children cannot currently be identified clinically, investigating all young children with urinary tract infection may be warranted
Two small RCTs found that prophylactic antibiotics prevented recurrent urinary tract infection in children, particularly during the period of prophylaxis. The long term benefits of prophylaxis have not been adequately evaluated, even for children with vesicoureteric reflux. The optimum duration of treatment is unknown
One systematic review and a subsequent multicentre RCT found no difference between surgery for vesicoureteric reflux and medical management in preventing recurrence or complications from UTI
What is the problem?