Updates
October 15, 1999 3 minutes read
Updates
Novel Intervention Reduces Antibiotic Use
Source: Gonzales R, et al. JAMA 1999; 281:1512-1519.
Numerous studies document the lack of benefit of antimicrobial therapy for acute uncomplicated bronchitis, most of which is viral in etiology. Nevertheless, the continued excessive use of antibiotics for upper respiratory infection is fueling the growing resistance of respiratory pathogens to existing antimicrobials. Kaiser Permanente in Denver, Colorado, examined the effects on antibiotic use for acute bronchitis of a novel, educational intervention aimed at both primary care providers and 2500 households receiving services at one of its facilities. In addition, written materials placed in examining rooms and posters in waiting rooms distinguished between "bronchitis" and "chest colds," and actively discouraged the use of antibiotics for the latter. This multi-dimensional intervention was compared to the effects of standard written materials distributed to providers at two other facilities and no intervention at a fourth site. The incidence of uncomplicated acute bronchitis requiring antimicrobial therapy, as defined by ICD-9 codes and excluding cases with other respiratory illness requiring antibiotics, was compared between sites.
There was a significant reduction in the use of antibiotics (from 74% to 48%) and in the number of office visits (-28%) for acute respiratory infection during the study period at the intervention site, but not at the other sites. There was no compensatory increase in antibiotic use for other reasons, and the frequency of return visits during the next 30 days remained stable. Unfortunately, there was no evidence that prescriptions for bronchodilators, which are of benefit in acute bronchitis, and were encouraged during study, were increased by the more aggressive intervention.
The public health crisis in antimicrobial resistance of common respiratory pathogens should be first and foremost in every physician’s mind the next time an antibiotic prescription is written. Group-model HMOs and other contract organizations are perfectly poised to provide this type of aggressive community education and physician intervention.
Tropheryma Whippelii: A Normal Oral Commensal?
Source: Street S, et al. Lancet 1999; 354:1178-1179.
Tropheryma whippelii is a mys- terious organism closely related to the group B actinomycetes (family Cellulomonadaceae) that is of questionable pathogenicity. While it has been found in the blood, small intestines, and other organs of individuals with multisystemic illness and malabsorption, it has also been identified in the intestines and tissues of individuals with no evidence of disease. Roughly 13% of patients undergoing elective gastroduodenoscopy in one study were found to have T. whippelii in either gastric juices or duodenal biopsy specimens, none of whom had evidence of Whipple’s disease.
On a chance occurrence, Street and colleagues identified T. whippelii DNA in a sample of human saliva. Using primers specific for the 16s rRNA gene of T. whippelii, aliquots of saliva from 40 healthy individuals were examined. Fourteen (13.3%) were positive. Sequencing of six of these PCR products showed 100% homology for 16s rRNA T. whippelii, confirming the presence of the organism in human saliva. Additional specimens from six of the people who were initially positive were positive on one or more occasions, suggesting that not only may the organism persist in human saliva, but it also may be a part of the normal human oral flora.
Antimicrobial Residues in Food: What is too Much?
Source: Auit A. Lancet 1999;354:1190.
The increasing presence of vre and other multi-drug-resistant organisms in human intestinal flora is an increasing public health hazard. Evidence suggests that these organisms are being introduced into the human population from a number of different sources, including animal feed and possibly in the food we eat (Kemper CA. Infect Dis Alert 1999;18:128), and also as the result of frequent exposure to antimicrobials. Following prompting by a Joint Committee of the WHO and the Food and Agriculture Organization of the United Nations, which recommend acceptable daily intake and maximum residue limits of antimicrobials from meat and other dietary products, the FDA in 1996 established a policy limiting the daily exposure of Americans to no more than 1.5 mg of antimicrobial residues in food. This policy was more liberal than that of our European and Japanese counterparts. Given the public health impact of increasing bacterial resistance, the FDA is re-examining this policy as it reviews newer data on the effect of antimicrobial residues in food on intestinal flora.
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