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Objective: To assess the effect of individual compared to clinic-level feedback on guideline-concordant care for 3 acute respiratory tract infections (ARTIs) among family medicine clinicians caring for pediatric patients., Design: Cluster randomized controlled trial with a 22-month baseline, 26-month intervention period, and 12-month postintervention period., Setting and Participants: In total, 26 family medicine practices (39 clinics) caring for pediatric patients in Virginia, North Carolina, and South Carolina were selected based upon performance on guideline-concordance for 3 ARTIs, stratified by practice size. These were randomly allocated to a control group (17 clinics in 13 practices) or to an intervention group (22 clinics in 13 practices)., Interventions: All clinicians received an education session and baseline then monthly clinic-level rates for guideline-concordant antibiotic prescribing for ARTIs: upper respiratory tract infection (URI), acute bacterial sinusitis (ABS), and acute otitis media (AOM). For the intervention group only, individual clinician performance was provided., Results: Both intervention and control groups demonstrated improvement from baseline, but the intervention group had significantly greater improvement compared with the control group: URI (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.37-1.92; P < 0.01); ABS (OR, 1.45; 95% CI, 1.11-1.88; P < 0.01); and AOM (OR, 1.59; 95% CI, 1.24-2.03; P < 0.01). The intervention group also showed significantly greater reduction in broad-spectrum antibiotic prescribing percentage (BSAP%): odds ratio 0.80, 95% CI 0.74-0.87, P < 0.01. During the postintervention year, gains were maintained in the intervention group for each ARTI and for URI and AOM in the control group., Conclusions: Monthly individual peer feedback is superior to clinic-level only feedback in family medicine clinics for 3 pediatric ARTIs and for BSAP% reduction., Trial Registration: ClinicalTrials.gov identifier: NCT04588376, Improving Antibiotic Prescribing for Pediatric Respiratory Infection by Family Physicians with Peer Comparison., (© The Author(s) 2021.)

Introduction: Inappropriate prescribing of broad-spectrum antibiotics is a significant modifiable risk factor for the development of antibiotic resistance. The objective was to improve guideline-concordant care for 3 common acute respiratory tract infections (ARTIs) and to reduce broad-spectrum antibiotic prescribing in ambulatory pediatric patients., Methods: Quality measures were developed for 3 ARTIs: viral upper respiratory infection (URI), acute bacterial sinusitis (ABS), and acute otitis media (AOM). Among 22 pediatric clinics, a collaborative of 10 was identified for intervention using baseline data for each ARTI, and 3 plan-do-study-act cycles were planned and completed. Outcomes included guideline-concordant antibiotic utilization and broad-spectrum antibiotic prescribing percentage (BSAP%). Comparison in number of diagnoses for the ARTI measures and total antibiotic prescribing over time served as balancing measures., Results: Collaborative clinics had baseline medians for appropriate or first-line treatment of 70% for URI, 53% for ABS, and 36% for AOM. To reach targets for URI, ABS, and AOM required 6, 14, and 18 months, respectively. At 42 months, performance for all 3 ARTIs remained ≥90%. BSAP% decreased from a baseline of 57% to 34% at 24 months. There was a limited effect from financial incentives but a significant decrease was noted in total antibiotic utilization. Diagnosis shifting may have occurred for URI and ABS while the rates for diagnoses for AOM declined over time., Conclusions: Through education and peer comparison feedback, guideline-concordant care for 3 ARTIs in collaborative clinics improved and remained beyond above targets and was accompanied by reductions in BSAP% and total antibiotic prescribing., (Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: To evaluate the epidemiology of perineal streptococcal infection and recurrence rates following amoxicillin treatment., Study Design: We used laboratory logs in a single pediatric practice to identify patients 0-18 years of age with perineal cultures positive for group A Streptococcus (GAS) and reviewed their medical charts. We described epidemiologic features, determined recurrence rates following antibiotic treatment, and performed a case-control study to identify possible risk factors for recurrence in patients treated with amoxicillin., Results: We found a perineal streptococcal infection rate of 4.6 per 10,000 patient encounters and a recurrence rate in 157 patients with perineal streptococcal infection of 12.4% after amoxicillin. In male patients, the predominant site of involvement was the perianal region (86%), and for female patients, the perivaginal area (62%). Nearly 80% of patients were 2-7 years of age (range 18 days-12.5 years). Perineal streptococcal infection and GAS pharyngitis followed a similar seasonal pattern of occurrence with 65% of perineal streptococcal infection occurring October through March. In patients with perineal streptococcal infection, 95% had a concomitant pharyngeal culture positive for GAS. Best predictive factors for recurrence after amoxicillin were longer duration of symptoms prior to diagnosis and having a sibling with perineal streptococcal infection at some time before or after the initial episode., Conclusions: Following treatment with amoxicillin, we found a low recurrence rate of 12.4%. Amoxicillin can be expected to be reliable first-line therapy for perineal streptococcal infection., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing. Penicillin or amoxicillin remain the treatments of choice, and recommendations are made for the penicillin-allergic patient, which now include clindamycin.

The feasibility and effectiveness of a distance-based quality improvement model were examined in a cohort of Pediatric Research in Office Settings (PROS) practices, with the goal of improving immunization rates and practitioner behaviors and attitudes. Of an initially assessed 82 practices, 29 with baseline rates of < or =88% for children 8 to 15 months of age were randomized into year-long paper-based education or distance-based quality improvement intervention groups. Outcomes were utility/helpfulness of quality improvement modalities, immunization rate change, and behavior/attitude change. Quality improvement participants attended approximately 75% of monthly conference calls but used the quality improvement Listserv and Web site infrequently (mean 1.09 and 0.92 uses, respectively). Helpfulness ratings of quality improvement modalities mirrored usage. Analyses revealed a 4.9% increase in quality improvement group immunization rates (P = .061), a 0.8% education group increase (P = .752), and a 4.1% difference between groups (P = .261). More quality improvement practices adopted systems identifying children behind in immunizations. A distance-based quality improvement model is feasible and may improve immunization rates.

Background: Two relatively small previous studies comparing once-daily amoxicillin with conventional therapy for group A streptococcal (GAS) pharyngitis reported similar rates of bacteriologic success for each treatment group. The purpose of this study was to further evaluate once-daily amoxicillin for GAS pharyngitis in a larger study., Methods: In a single pediatric practice, from October through May for 2 consecutive years (2001-2003), we recruited children 3 to 18 years of age who had symptoms and signs suggestive of GAS pharyngitis. Patients with a positive rapid test for GAS were stratified by weight (<40 kg or >or=40 kg) and then randomly assigned to receive once-daily (750 mg or 1000 mg) or twice-daily (2 doses of 375 mg or 500 mg) amoxicillin for 10 days. We determined bacteriologic failure rates for GAS in the pharynx from subsequent swabs taken at 14 to 21 (visit 2) and 28 to 35 (visit 3) days after treatment initiation. We conducted a randomized, controlled, investigator-blinded, noninferiority trial to evaluate whether amoxicillin given once daily would have a bacteriologic failure rate no worse than that of amoxicillin given twice daily within a prespecified margin of 10%. GAS isolates were characterized to distinguish bacteriologic failures from new acquisitions. Adverse events were described and adherence was evaluated by review of returned daily logs and dosage bottles., Results: Of 2139 potential study patients during the 2-year period, we enrolled 652 patients, 326 into each treatment group. Children in the 2 groups were comparable with respect to all demographic and clinical characteristics except that children <40 kg more often presented with rash in each treatment group. At visit 2, failure rates were 20.1% (59 of 294) for the once-daily group and 15.5% (46 of 296) for the twice-daily group (difference, 4.53%; 90% confidence interval [CI], -0.6 to 9.7). At visit 3, failure rates were 2.8% (6 of 216) for the once-daily group and 7.1% (16 of 225) for the twice-daily group (difference, -4.33; 90% CI, -7.7 to -1.0). Gastrointestinal and other adverse events occurred in the once-daily treatment group with a frequency comparable to that in the twice-daily treatment group. Presumed allergic reactions occurred in 0.9% (6 of 635). More than 95% (516 of 541) of patients complied with 10 days of therapy with no significant differences between groups., Conclusions: We conclude that amoxicillin given once daily is not inferior to amoxicillin given twice daily. Gastrointestinal and other events did not occur significantly more often in the once-daily treatment group. From the data in this large, investigator-blinded, controlled study, once-daily amoxicillin appears to be a suitable regimen for treatment of GAS pharyngitis.

Background: Antigen tests have been well-studied and are widely used in pediatric practice for rapid detection of group A Streptococcus (GAS) infections in the throat, but they have not been examined sufficiently for the detection of infection of skin sites, such as the perineal region or impetiginous lesions., Methods: During the 3-year period 1999 to 2002, we evaluated 239 patients with suspected GAS skin infection, in 5 pediatric practices, using 3 Dacron swabs for each site. The first swab was tested in the pediatric office laboratory with an antigen detection kit. For the first 91 patients, the Abbott Test Pack Plus antigen detection test (ADT) was used. The Abbott Signify Strep A ADT was used to test subsequent patients. The second swab was tested with BD Directigen 1-2-3 ADT in the hospital laboratory. The third swab was placed in modified Stuart's transport medium for comparison of recovery of GAS from culture in broth or on agar. A positive culture served as the reference standard. Test performance and test accuracy were determined for each ADT., Results: Of the 247 ADTs and cultures performed on 239 patients, 91 with suspected skin infection were tested with the Test Pack Plus test, 149 with the Signify Strep A test and 247 with the Directigen test. Eighty-six (35%) cultures were positive, 73 from perineal sites (54 rectal, 13 vaginal, 6 penile) and 13 from impetiginous lesions. There was 100% concordance for the 86 cultures positive for GAS in a comparison between dry Dacron swabs and swabs that had been placed in modified Stuart's transport medium. Test Pack Plus and Signify Strep A ADTs had similar performance characteristics for skin infections: sensitivity, 92 and 88%; specificity, 99 and 97%; positive predictive value, 96 and 94%; and negative predictive value, 97 and 93%. Directigen ADT had sensitivity 78%, specificity 100%, positive predictive value 100% and negative predictive value 89%. Accuracy for the tests varied from 92 to 97%., Conclusion: Tests designed to detect GAS carbohydrate antigen in patients with pharyngitis can be used rapidly and accurately to detect GAS antigen in patients with cutaneous lesions suspected of GAS infection.

Congenital cutaneous candidiasis (CCC) is usually a benign condition characterized by various skin manifestations and is rarely associated with nail changes. We report a premature infant with CCC who developed dystrophy of all 20 nails at about 1 month of age. Nail dystrophy due to Candida albicans in the young infant may be differentiated from other congenital or hereditary nail malformations by appearance, recovery of the organism in nail culture, and complete resolution over a period of several months.

Objective: To compare a single-plate method for the recovery of group A streptococci with other methods that have recently been reported as being significantly more sensitive., Design: Throat swabs were allowed to dry for 2 to 6 hours before inoculating 5% sheep blood agar plates. Stabs were made into the agar, bacitracin disks were placed on the primary plates, and the cultures were incubated aerobically. Using duplicate throat swabs, the recovery rates of the above method were compared with the following ones: a carbon dioxide-enhanced incubation atmosphere, an anaerobic atmosphere with a selective blood agar medium, and a Todd-Hewitt broth medium., Setting: A five-pediatrician office., Patients: A total of 301 pediatric patients with pharyngitis were evaluated using all comparative methods. In addition, duplicate swabs from 590 pediatric patients were compared with each other using the same single-plate method., Results: There were no significant differences between any of the methods. The sensitivity of the single-plate method compared with selective plates incubated anaerobically was 96%., Conclusions: In a pediatric office setting, a single-plate method using aerobic incubation was adequately sensitive for the recovery of group A beta-hemolytic streptococci. Transport medium, selective medium, carbon dioxide enhancement, and anaerobic incubation did not significantly improve recovery. The present federal regulations that restrict the use of nonselective media and bacitracin disks on primary plates should be reevaluated.

For detecting group A beta-hemolytic streptococci in an office setting, an optical immunoassay method was compared with two culture methods. The sensitivity and specificity of OIA as compared with 5% sheep blood agar cultures were 91.4% and 95.6%, and as compared with a Todd-Hewitt broth method were 90.4% and 94.1%, respectively.

We describe a 5-month-old infant who had fever of unknown origin leading to an exhaustive evaluation during a 7-week period. Fever caused by the use of furosemide was proved; the fever resolved after discontinuation of this medication and recurred after its reintroduction.

During a three-week period, septicemia caused by group B Streptococcus, serotype III, developed in four infants born at a community hospital. The first infant had early-onset disease; late-onset disease that appeared, from epidemiologic data, to be nosocomial developed in the other three infants. Bacteriophage typing and antimicrobial susceptibility testing confirmed the relatedness of the isolates. A prospective study designed to differentiate between vertical and nosocomial transmission of group B Streptococcus showed that of 82 infants, 21 (26%) were culture-positive during their hospitalization, and nine of these infants (43%) had been culture-negative at birth. Although serotype III strains were recovered from four of nine infants with apparently nosocomial acquisition, none of the isolates displayed an antibiogram or bacteriophage type similar to that of the isolates involved in the recent cluster. Bacteriophage typing and antimicrobial susceptibility testing in addition to the use of serotyping may be helpful in epidemiologic studies of group B Streptococcus.

Periprosthetic infections due to Mycobacterium fortuitum and Mycobacterium chelonei occurred in 17 women over a 3.5-year period after implantation of prostheses for breast augmentation. The median incubation period for 16 of the women was 28 days (range, one week to over two years) after surgery; etiologic diagnosis was usually delayed for weeks to months. Odorless and serosanguineous or purulent material was found when the implants were removed, and acid-fast bacilli were often present when smears were examined. Wound infections were chronic and refractory to therapy with various antimicrobial agents. Persistent or recurrent mycobacterial infections complicated attempts to implant new prostheses. Whereas M. fortuitum isolates were susceptible to amikacin, multiple strains of M. fortuitum were distinguished by conventional antituberculous and broth microdilution susceptibility tests. Several clusters of infections were temporally and geographically related; however, sporadic cases were also reported, and no evidence of a contaminated common product or other single source of infection was found.

The role of pili and capsule was studied in neonatal infection with Escherichia coli K1. E coli strains were selectively cultured into three phases: mannose-sensitive (MS) piliated, non-mannose-sensitive (NMS) piliated, and nonpiliated. A high percentage of neonatal rats fed each phase of K1 strains developed bacteremia; there was no bacteremia with non-K1 strains or an acapsular mutant of K1 strain C94 (C94K-). Oral cavity colonization was noted in nearly 100% of rats fed K1 strains, non-K1 strains, or C94K-, regardless of the phase of piliation at feeding. Only MS piliated bacteria were found on oral cavity culture, indicating a rapid shift of NMS piliated and nonpiliated bacteria to the MS piliated phase. Conversely, only nonpiliated bacteria were found on blood culture when neonatal rats were fed piliated bacteria. Colonization of ileal epithelium was not observed. Thus, in vivo phase variation may be important in colonization and bacteremia with E coli K1.

Neisseria meningitidis is a rare cause of infection in infants younger than 2 months of age, presumably because of transplacental passage of protective maternal antibodies. In most reported cases of meningococcal disease in neonates, a relatively mild clinical course has been observed. A 25-day-old infant survived acute, severe meningococcemia due to group B N meningitidis. This organism should be considered when neonates have signs of septicemia, especially in the presence of cutaneous petechiae and purpura.

In August and September 1977 a discrete cluster of 27 serologically or pathologically confirmed cases of Legionnaires' disease, plus six highly presumptive cases were identified in the area of Kingsport, Tennessee. Three patients died. Most patients manifested severe pneumonia and fever; no mild or asymptomatic disease forms were recognized despite intensive case-finding efforts. Illness was epidemiologically associated with residing, visiting, or working in one geographic area of Kingsport, residence there being the factor most strongly associated. Although the attack rate for area residents was 0.64%, the randomly determined prevalence of serologic reactors was 5.2%, which is not significantly different from that in a nonimplicated control neighborhood. The epidemic did not correlate temporally with any identified environmental or demographic event. No source of the bacterium was found either by a detailed case-control study of area associations or by bacterial isolation from sentinel guinea pigs or environmental specimens. There was no evidence of person-to-person spread.

In a 3 1/2-year period, periprosthetic infections due to Mycobacterium fortuitum complex organisms complicated augmentation mammaplasty in at least 17 women. To determine the magnitude of the problem and to identify possible risk factors for infection, we conducted a questionnaire survey of 2062 members of the American Society of Plastic and Reconstructive Surgeons who had performed approximately 64,00 augmentation mammaplasties in 1978. Information about selected aspects of the procedures and practices in use with augmentation mammaplasty and about patients for whom augmentation mammaplasty had been performed was supplied by 67 percent of those surveyed. The estimated attack rate of wound infection after augmentation mammaplasty caused by all organisms was 0.64 percent. Only 5 cases of mycobacterial wound infection were documented after 39,455 augmentation procedures in 1978. Periprosthetic infection due to Mycobacterium fortuitum complex organisms appears, for the most part, to be a sporadic event that may occur after simple augmentation mammaplasty, subcutaneous mastectomy with augmentation, or reduction mammaplasty.

During a hospital epidemic of infections with gentamicin-resistant Serratia marcescens (GRS), we studied the relation between receiving antibiotics and acquiring GRS. In a five-month period, 22 patients acquired GRS, whereas 18 patients acquired gentamicin-sensitive Serratia (GSS). When compared with patients with nosocomial GSS infection, patients with nosocomial GRS had been in the hospital (p = 0.04) and the intensive care unit (p = 0.003) longer before infection and more had received gentamicin (p = 0.001) or ampicillin (p = 0.02) before infection. To control for the influence of underlying disease, we matched all 12 ICU patients with GRS infection and 12 patients without GRS infection for underlying illness and duration of intensive care. Use of any antibiotic (p = 0.04), or a combination of gentamicin plus ampicillin or cephalosporin (p = 0.047) was more common among patients with GRS infection. The hospital had not significantly increased the use of aminoglycosides from the previous year. We conclude that for the individual patient antimicrobial therapy, especially with gentamicin or ampicillin, creates a risk for later infection by GRS that is independent of the severity of the underlying illness.

Recovery rates of Group A beta-hemolytic streptococci in throat cultures from 300 children were studied using three different methods. The swabs were streaked onto plates immediately, streaked from the same dry swabs held at room temperature for 3 to 6 hours and streaked from swabs held in transport media at room temperature for 3 to 6 hours. The cultures were processed in a pediatric office and interpreted by a microbiologist. The recovery rates were similar for the three methods, but the cultures were easier to interpret when the swabs had been allowed to dry before streaking as a result of a decrease in the normal flora on these plates. In a separate study the recovery of Group A beta-hemolytic streptococci from 187 swabs was identical whether the swabs were streaked at 3 to 6 hours or at 18 to 24 hours.

Eikenella corrodens is a slow-growing facultative anaerobe present in the normal oral flora. Two children have been described with acute suppurative thyroiditis with E corrodens as the major pathogen. Staphylococci are the most frequently identified pathogens in acute suppurative thyroiditis. Penicillin or ampicillin are the drugs of choice for infections caused by E corrodens. Anatomic defects should be searched for in children with acute suppurative thyroiditis.

A latex agglutination test and four culture methods for the detection of group A hemolytic streptococci were compared in a pediatric office laboratory. The anaerobic (GasPak) and Detekta-Kit methods produced the highest recovery rates, but aerobic incubation of 5% blood agar plates gave very acceptable results (sensitivity 92%, or 98% if the 1+ positive cultures were eliminated; specificity 100%), and had fewer disadvantages. Delaying inoculation of plates for 2 to 6 hours resulted in significantly greater numbers of strongly positive (3+ and 4+) cultures. The group A selective sheep blood agar media as used in this study offered no advantage. The Culturette test had a sensitivity of 72% and specificity of 98%, compared with the GasPak method, and 77% and 97%, respectively, compared with standard aerobic cultures. Thus it appears too insensitive to be used alone, but might complement culture methods in selected patients.

One hundred patients with sporadic, community-acquired, serologically confirmed Legionnaires' disease were matched with control subjects known by the patients (acquaintance controls) and control subjects chosen from among patients with negative serodiagnostic tests for Legionnaires' disease (clinical controls). Each clinical control subject was also matched with an acquaintance control of his own. Legionnaires' disease patients had smoked more cigarettes, consumed more alcohol, and were more likely to have resided near excavation sites than acquaintance or clinical control subjects. Parallel differences between clinical controls and their acquaintances were not seen. Legionnaires' disease patients had traveled away from home for more time during the 2 weeks before onset of illness than had their acquaintances. The difference was of greater magnitude than that between clinical control subjects and their acquaintances. Legionnaires' disease patients were more likely to have resided near construction sites than clinical controls, and there were more construction workers among patients than among clinical control subjects.