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Context: Annual rates of antimicrobial prescribing for children by office-based physicians increased from 1980 through 1992. The development of antimicrobial resistance, which increased for many organisms during the 1990s, is associated with antimicrobial use. To combat development of antimicrobial resistance, professional and public health organizations undertook efforts to promote appropriate antimicrobial prescribing., Objective: To assess changes in antimicrobial prescribing rates overall and for respiratory tract infections for children and adolescents younger than 15 years., Design, Setting, and Participants: National Ambulatory Medical Care Survey data provided by 2500 to 3500 office-based physicians for 6500 to 13 600 pediatric visits during 2-year periods from 1989-1990 through 1999-2000., Main Outcome Measures: Population- and visit-based antimicrobial prescribing rates overall and for respiratory tract infections (otitis media, pharyngitis, bronchitis, sinusitis, and upper respiratory tract infection) among children and adolescents younger than 15 years., Results: The average population-based annual rate of overall antimicrobial prescriptions per 1000 children and adolescents younger than 15 years decreased from 838 (95% confidence interval [CI], 711-966) in 1989-1990 to 503 (95% CI, 419-588) in 1999-2000 (P for slope <.001). The visit-based rate decreased from 330 antimicrobial prescriptions per 1000 office visits (95% CI, 305-355) to 234 (95% CI, 210-257; P for slope <.001). For the 5 respiratory tract infections, the population-based prescribing rate decreased from 674 (95% CI, 568-781) to 379 (95% CI, 311-447; P for slope <.001) and the visit-based prescribing rate decreased from 715 (95% CI, 682-748) to 613 (95% CI, 570-657; P for slope <.001). Both population- and visit-based prescribing rates decreased for pharyngitis and upper respiratory tract infection; however, for otitis media and bronchitis, declines were only observed in the population-based rate. Prescribing rates for sinusitis remained stable., Conclusion: The rate of antimicrobial prescribing overall and for respiratory tract infections by office-based physicians for children and adolescents younger than 15 years decreased significantly between 1989-1990 and 1999-2000.

Objective: To develop consensus-based recommendations for measures to be taken by medical and public health professionals if hemorrhagic fever viruses (HFVs) are used as biological weapons against a civilian population., Participants: The Working Group on Civilian Biodefense included 26 representatives from academic medical centers, public health, military services, governmental agencies, and other emergency management institutions., Evidence: MEDLINE was searched from January 1966 to January 2002. Retrieved references, relevant material published prior to 1966, and additional sources identified by participants were reviewed., Consensus Process: Three formal drafts of the statement that synthesized information obtained in the evidence-gathering process were reviewed by the working group. Each draft incorporated comments and judgments of the members. All members approved the final draft., Conclusions: Weapons disseminating a number of HFVs could cause an outbreak of an undifferentiated febrile illness 2 to 21 days later, associated with clinical manifestations that could include rash, hemorrhagic diathesis, and shock. The mode of transmission and clinical course would vary depending on the specific pathogen. Diagnosis may be delayed given clinicians' unfamiliarity with these diseases, heterogeneous clinical presentation within an infected cohort, and lack of widely available diagnostic tests. Initiation of ribavirin therapy in the early phases of illness may be useful in treatment of some of these viruses, although extensive experience is lacking. There are no licensed vaccines to treat the diseases caused by HFVs.

Resistance is an emerging problem in human medicine and the effects of resistance are being noted on an ever-increasing scale. Whether it is treatment of nosocomial bacteremia in New York City or community-acquired dysentery in Central Africa, multiresistant organisms are diminishing our ability to control the spread of infectious diseases. Clearly, the rate at which resistant organisms develop is not solely a function of the use of antimicrobials in humans, but is also highly influenced by the use of these agents in veterinary medicine, animal husbandry, agriculture, and aquaculture, as has been emphasized at recent meetings sponsored by organizations such as Rockefeller University and the American Society for Microbiology, and in the report on bacterial resistance recently issued by the US Office of Technology Assessment. We have entered an era where both physicians and patients must take on the responsibility to use antimicrobials wisely and judiciously. Just as in the days at the turn of the century when the public was an integral part of establishing quarantines for infectious diseases, now again the public's cooperation must be sought for this latest threat to public health. The multiresistant organisms of the 1990s are a grim warning of the possibility of the postantibiotic era.

Objective: To assess changes in oral antimicrobial drug prescribing by office-based physicians from 1980 through 1992, with emphasis on the treatment of otitis media and sinusitis and on the possible impact of demographic variables on such use., Design: The National Ambulatory Medical Care Survey is a sample survey of office-based physicians in the United States conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention., Setting: Physicians' offices., Patients or Other Participants: Physicians sampled for the 1980, 1985, 1989, and 1992 National Ambulatory Medical Care Surveys, which included groups of 2959, 5032, 2540, and 3000 physicians, respectively. Sample physicians responding in 1980, 1985, 1989, and 1992 reported data for 46,081, 71,594, 38,384, and 34,606 sample office visits, respectively, including information on antimicrobial drug prescribing., Main Outcome Measure: Trends in the antimicrobial drug prescription rates., Results: From 1980 through 1992, increasing prescribing measured by the annual drug prescription rate per 1000 population, was found for the more expensive, broad-spectrum antimicrobial drugs, such as the cephalosporins; decreasing rates were observed for less expensive antimicrobial drugs with a narrower spectrum, such as the penicillins. No trend was found for trimethoprim-sulfamethoxazole, the erythromycins, or the tetracyclines. During the decade, an increasing trend in the visit rate to office-based physicians for otitis media was observed, while the visit rate for sinusitis among adults was found to be higher in 1992 than in each of the other study years., Conclusions: The increased use of broader-spectrum and more expensive antimicrobial drugs have implications for all patients because of the impact on health care costs and the potential for the emergence of antimicrobial resistance. The data suggest that the incidence of otitis media and sinusitis is increasing.

Objective: Participation in competitive sports is popular and widely encouraged throughout the United States. Reports of infectious disease outbreaks among competitive athletes and recent publicity regarding infectious disease concerns in sports underscore the need to better characterize the occurrence of these problems., Data Sources: To identify reports of infectious diseases in sports, we performed a comprehensive search of the medical literature (MEDLINE) and newspaper databases in two on-line services (NEXIS and DIALOG PAPERS)., Study Selection: Articles selected from the literature review included those describing cases or outbreaks of disease in which exposure to an infectious agent was likely to have occurred during training for competitive sports or during actual competition. Articles from the newspaper review included reports of outbreaks, exposures, or preventive measures that directly or indirectly involved teams or spectators., Data Synthesis: The literature review identified 38 reports of infectious disease outbreaks or other instances of transmission through person-to-person (24 reports), common-source (nine reports), or airborne (five reports) routes; the newspaper search identified 28 reports. Infectious agents included predominantly viruses but also a variety of fungi and gram-positive and gram-negative bacteria., Conclusions: Our findings indicate that strategies to prevent transmission of infectious diseases in sports must recognize risks at three levels: the individual athlete, the team, and spectators or others who may become exposed to infectious diseases as a result of sports-related activities. Team physicians and others who are responsible for the health of athletes should be especially familiar with the features of infectious diseases that occur in sports and measures for the prevention of these problems.

To examine maternal mortality among women aged 35 years or older, we used death certificates from the United States for 1974 through 1978. There were 425 maternal deaths, corresponding to a mortality rate of 58.3 deaths per 100,000 live births. This rate was higher than the rate for women 20 through 34 years of age (race-adjusted relative risk [RR] = 4.0; 95% confidence interval [CI], 3.6 to 4.4). The leading causes of death were obstetric hemorrhage and embolism. Black women had higher mortality rates than white women for deaths without abortive outcomes (RR = 3.3; CI, 2.7 to 4.1) and with abortive outcomes (RR = 9.4; 95% CI, 5.8 to 15.3), and the latter difference was largely due to a higher rate of deaths associated with ectopic pregnancy among black women. From 1974 through 1978, compared with 1982, maternal mortality rates for women aged 35 years or older reported by the National Center for Health Statistics declined approximately 50%. Among white women, changes in age and parity accounted for less than half of this decrease, suggesting that improvements have occurred in age- and parity-specific mortality for women aged 35 years or older.

To clarify the financial incentives for hospitals to prevent nosocomial infections, we analyzed 9423 nosocomial infections identified in 169 526 admissions selected randomly from the adult admissions to a random sample of US hospitals. By classifying each admission into a baseline diagnosis related group (DRG) (after first excluding all diagnoses of nosocomial infection) and a final DRG (after including these diagnoses), we found that only 5% to 18% of nosocomial infections would have caused the admission to be reclassified to a higher-paying DRG, depending on the extent to which physicians recorded nosocomial infection diagnoses in patients' medical records. The extra payment from the reclassification, averaged over all nosocomial infections, would have been no more than $93 per infection (in 1985 reimbursement rates), constituting only 5% of the hospitals' costs for treating these infections. Thus, at least 95% of the cost savings obtained from preventing nosocomial infections represents financial gains to the hospital.

Medical logs of 2,445 cruises taken by 38 vessels over a 20-month period beginning Jan 1, 1972, were reviewed. On 92% of the cruises, the recorded incidence of gastrointestinal illness was 1% or less; on 2% of cruises, it was 5% or greater. The actual incidence of gastrointestinal illness determined by a questionnaire survey of passengers sailing on nine cruises was found to be at least four times as high as that recorded in the medical logs. Although the cause of the illnesses was not known, there was evidence that transmission took place aboard ship. A survey of food-handling practices and water systems aboard selected ships demonstrated a significant potential for transmission of foodborne and waterborne disease.

Stool or serum specimens or both from 318 persons pertaining to 165 botulism investigations over a three-year period were examined. Botulinal toxin was detected in stools of 19 of 56 patients and in sera of 20 of 60 patients with clinical botulism; it was not detected in specimens from 246 persons with an illness other than botulism or well contacts of patients. Clostridium botulinum was identified in stools of 36 of 60 clinical botulism patients and in four of 27 asymptomatic contacts of patients with botulism victims, but not in stools of 65 persons not associated with confirmed botulism. When stool and serum samples were examined, confirmatory evidence was obtained for 72.9% of the botulism cases. Detection of botulinal toxin or C botulinum in the stool of a persons should be considered evidence supporting the clinical diagnosis of botulism.