JOURNAL CLUB

JOURNAL CLUB

COMMENTARIES BY MICHAEL G. BURKE, MD

GABHS reinfection: Blame the toothbrush?

Toothbrushes and removable orthodontic appliances that harbor group Ab-hemolytic streptococci (GABHS) may contribute to persistent GABHS in theoropharynx and account for the failure of penicillin therapy in some pharyngotonsillitis,a new study suggests. Investigators obtained pharyngotonsillar and toothbrushcultures from 104 children with acute GABHS pharyngotonsillitis before andafter 10 days of penicillin V potassium therapy. They also got culturesof samples from removable orthodontic appliances of 21 children. The childrenranged from 5 to 14 years of age.

After penicillin therapy was completed, investigators isolated GABHSfrom the toothbrushes of 11 (11%) of the children and from the pharynx andtonsils of 18 (17%). Of the 18 children who harbored GABHS, five (28%) hadtoothbrushes that were colonized with the organisms. In addition, four (19%)of the removable orthodontic appliances had GABHS after therapy.

Separately, the researchers studied persistence of GABHS in 20 new toothbrushesthat were dipped in a solution of GABHS. Ten of the toothbrushes were rinsedin clean water once a day and 10 were not rinsed. GABHS persisted in unrinsedtoothbrushes for up to 15 days. In rinsed toothbrushes, the organism didnot live more than three days. These findings, investigators noted, suggestthat toothbrushes and removable orthodontic appliances that are not thoroughlycleaned every day may contribute to persistence of GABHS in the oropharynxof children (Brook I et al: Arch Otolaryngol Head Neck Surg 1998;124:993).

Commentary: Where both the toothbrush and the child grew GABHSat follow up, it is hard to know if the toothbrush was reinfecting the childor vice versa. In six of 86 children with negative follow-up throat cultures,however, the toothbrushes were positive for GABHS. For your patient withrecurrent strep pharyngitis, an investment in a new toothbrush might preventa tonsillectomy.

CDC group makes AOM recommendations

Experts in the management of otitis media and the Drug-resistant Streptococcuspneumoniae Therapeutic Working Group of the Centers for Disease Controland Prevention released consensus recommendations for the management ofacute otitis media (AOM) and the surveillance of drug-resistant
S pneumoniae. The panel, which the CDC convened to respond to changes inantimicrobial susceptibility among pneumococci, includes clinicians, academicians,and public health practitioners. The group's recommendations are based onthe experience of individuals in the group and published and unpublisheddata from the scientific literature. They are intended to provide a frameworkfor clinical and public health responses to drug resistance:

• Physicians should continue using oral amoxicillin as the first-line antimicrobial agent for treating AOM. They should increase the dosage for empiric treatment from 40 to 45 mg/kg/d to 80 to 90 mg/kg/d because of increasing prevalence of drug-resistant S pneumoniae.
• For patients with clinically defined treatment failure after three days of therapy, the physician should use the following alternative agents: oral amoxicillin-clavulanate, cefuroxime axetil, or intramuscular ceftriaxone. Good evidence for efficacy against drug-resistant S pneumoniae is lacking for many of the 13 other otitis media drugs approved by the Food and Drug Administration.
• Empiric treatment of AOM should not vary by geographic region because local surveillance data for pneumococcal resistance relevant for clinical management of AOM are not available from most areas in the United States.
• To learn about resistance patterns in their patient populations, physicians can turn to local hospital microbiology laboratory records, state health department surveillance systems, occasional published surveys of nasopharyngeal swab or middle ear fluid, or annual surveillance summaries published in the Morbidity and Mortality Weekly Report. Each of these sources has potential limitations as an information source for guiding treatment of AOM, however.
• Laboratory surveillance to improve the usefulness of information for clinicians treating AOM should be improved by establishing criteria for setting susceptibility breakpoints for clinically appropriate antimicrobials; testing middle ear fluid or nasal swab isolates in addition to sterile site isolates; and testing drugs that are useful in treating AOM (Dowell SF et al: Pediatr Infect Dis J1999;18:1).

Commentary: Here is an article worth reading. We all are awareof longstanding concerns about resistant S pneumoniae and its potentialeffects. Now this consensus statementtranslates those concerns into practicaladvice on how to treat your patients with otitis media.

Urine screens best way to prevent PID

Investigators evaluated four clinical strategies in a theoretical groupof 100,000 asymptomatic sexually active young women to determine the mostcost-effective method of screening for Chlamydia and gonorrhea to preventpelvic inflammatory disease (PID). The strategies were universal screeningusing pelvic examinations, including routine cytologic tests (strategy 1),or urine tests using ligase chain reaction testing for Chlamydia and gonorrhea(strategy 2). Strategies 3 and 4 also were endocervical and urine screening,respectively, but assumed less than perfect compliance (pelvic examinationin 70% and urine screening in 90% of the group).

Analysis showed that pelvic examination screening (strategy 1) wouldprevent the most cases of PID--1,283--at a mean cost of $10,230 per case.Urine screening (strategy 2) would prevent almost as many cases as pelvicexamination--1,215--and, at a mean cost of $5,093, would be half as expensive.Strategy 3 would prevent 898 cases of PID and strategy 4 1,093 cases. Investigatorsconcluded that urine screening is the most cost-effective way of detectingchlamydial and gonorrheal infections in asymptomatic sexually active youngwomen. In addition, urine tests avoid the embarrassment associated withpelvic examinations, increasing the likelihood of compliance with preventivehealth-care visits (Shafer MB et al: Arch Pediatr Adolesc Med 1999;153;119).

Commentary: The authors restricted their analysis to screeningof asymptomatic patients. Pelvic examination is still required in youngwomen with symptoms suggesting possible PID. It certainly will be easierto get adolescent females to consent to a urine screen than to a pelvicexam at their health maintenance visits. These new techniques also willallow mass screenings away from health-care facilities.

Screen predicts hyperbilirubinemia

A new investigation indicates that universal serum bilirubin measurementsmade before hospital discharge accurately screen for risk of significanthyperbilirubinemia during the first week of life in healthy term and near-termnewborns.

Researchers obtained total serum bilirubin levels at the time of routinemetabolic screen in 13,003 newborns. The infants were racially diverse andnearly 60% were breastfed. Before discharge, 172 babies (6.1%) had totalserum bilirubin levels in the high-risk zone (>=95th percentile) at 18to 72 hours; 39.5% of these infants continued to have significant hyperbilirubinemiain the first week of life. Of 912 babies (32%) with screening bilirubinlevels in the intermediate zone (40th to 95th percentile), 58 (6.4%) movedup to the high-risk zone after discharge. Subsequent bilirubin levels innewborns in the low-risk zone (<40th percentile) also generally remainedunchanged; 6.4% moved up to the intermediate-risk zone and none jumped tothe high-risk zone (Bhutani VK et al: Pediatrics 1999;103:6).

Commentary: This article appeared with another in a series ofpieces describing use of Sn-mesoporphyrin for inhibiting bilirubin productionin high-risk infants (Martinez JC et al: Pediatrics 1999;103:1). One daywe may be screening bilirubins in all babies in the nursery, assigning riskof later hyperbilirubinemia based on the nomograms proposed by Bhutani andcolleagues, and then preemptively treating high-risk babies with Sn-mesoporphyrin.

Does sunscreen use increase melanoma?

Children who use sunscreen are more likely to develop moles--a strongpredictor of melanoma--than children who don't use sunscreen, accordingto a new report. Researchers counted nevi 2 mm or larger in 631 6- and 7-year-oldCaucasian children in four European cities and interviewed their parentsabout sun exposure, sunscreen use, and physical sun protection of theirchild. Findings were adjusted for amount of sun exposure, skin type, andeye color.

The highest nevus counts were in children with no history of sunburnwho used large quantities of sunscreens. The lowest nevus counts were amongchildren who often wore clothes while in the sun. Those who applied sunscreensused products with a median sun protection factor of 17.4. These investigatorsspeculate that sunscreen use is associated with development of nevi becausechildren who use sunscreen tend to stay out longer in the sun than childrenwithout this protection (Autier P et al: Natl Cancer Inst 1998;90:1873).

Commentary: The concern these authors and others express is thatwhile sunscreens protect against sunburn, they may not protect against nevusproduction and associated melanoma. The article does show a slightly increasedrelative risk of having a large number of moles in children who are retrospectivelyreported to be big sunscreen users. This will be an interesting issue tofollow. I think, however, that we should wait for more complete studiesbefore changing our anticipatory guidance about sun exposure and sunscreenuse.

Also of note

Does day care protect against allergies? German investigators examinedthe hypothesis that infections in early childhood may prevent allergiesin later life. Acting on the assumption that early exposure to child careoutside the home would promote cross-infection, they compared the rate ofatopy and allergy in children who attend day care beginning at a young agewith those who attend from an older age. The 2,471 East German childrenin the study were in three age groups: 5 to 7, 8 to 10, and 11 to 14 years.Of the 669 children from families of up to three people (generally one-childfamilies), those who started day care at age 6 to 11 months were less likelyto have atopy, hay fever, and irritated eyes than children who entered daycare at an older age (Krämer U et al: Lancet 1999;353:450).

Empiric chest X-rays reveal occult pneumonia. Routine chest radiographsin children with fever and leukocytosis but no identifiable major infectioncan be of value in detecting occult pneumonia, a new report suggests. Ina prospective study, investigators obtained chest radiographs in 225 childrenyounger than 5 years who presented to an emergency department over a 12-monthperiod with leukocytosis (WBC >=20,00 mL) and fever. Of 79 children withsuggestive respiratory findings, 40% had pneumonia. Of 146 children withleukocytosis and a temperature of 39° C, but no identifiable major sourceof infection, 26% had occult pneumonia (Bachur R et al: Ann Emerg Med 1999;33:166).

DR. BURKE, Section Editor for Journal Club, is Chairman of the Departmentof Pediatrics at Saint Agnes Hospital, Baltimore,
and a Contributing Editor for Contemporary Pediatrics.