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Antibiotics for preventing complications in children with measles.

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Antibiotics for preventing complications in children with measles.

Cochrane Database Syst Rev. 2013 Aug 14;8:CD001477

Authors: Kabra SK, Lodha R

Abstract
BACKGROUND: Measles is the leading killer among vaccine-preventable diseases; it is responsible for an estimated 44% of the 1.7 million vaccine-preventable deaths among children annually.
OBJECTIVES: To assess the effects of antibiotics given to children with measles to prevent complications and reduce pneumonia, other morbidities and mortality.
SEARCH METHODS: We searched CENTRAL 2013, Issue 4, MEDLINE (1966 to May week 4, 2013) and EMBASE (1980 to May 2013).
SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs comparing antibiotics with placebo or no treatment, to prevent complications in children with measles.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed trial quality.
MAIN RESULTS: Seven trials with 1263 children were included. The methodological quality of most studies was poor. Only two studies were randomized, double-blind trials. There was variation in antibiotics used, their doses, schedule and evaluation of outcome. Pooled study data showed that the incidence of pneumonia was lower in the treatment group compared to the control group. However, the difference was not statistically significant. Of the 654 children who received antibiotics, 27 (4.1%) developed pneumonia; while out of 609 children in the control group, 59 (9.6%) developed pneumonia (odds ratio (OR) 0.35; 95% confidence interval (0.12 to 1.01). The one trial that showed an increase in the rate of pneumonia with antibiotics was conducted in 1942 and compared oral sulfathiazole with symptomatic treatment. If the results of this trial are removed from the meta-analysis, there is a statistically significant reduction in the incidence of pneumonia in children receiving antibiotics (OR 0.26; 95% CI 0.12 to 0.60). The incidence of other complications was significantly lower in children receiving antibiotics: purulent otitis media (OR 0.34; 95% CI 0.16 to 0.73) and tonsillitis (OR 0.08; 95% CI 0.01 to 0.72). There was no difference in the incidence of conjunctivitis (OR 0.39; 95% CI 0.15 to 1.0), diarrhea (OR 0.53; 95% CI 0.23 to 1.22) or croup (OR 0.16; 95% CI 0.01 to 4.06). No major adverse effects attributable to antibiotics were reported.
AUTHORS' CONCLUSIONS: The studies reviewed were of poor quality and used older antibiotics. This review suggests a beneficial effect of antibiotics in preventing complications such as pneumonia, purulent otitis media and tonsillitis in children with measles. On the basis of this review, it is not possible to recommend definitive guidelines on the type of antibiotic, duration or the day of initiation. There is a need for more evidence from high-quality RCTs to answer these questions.

PMID: 23943263 [PubMed - as supplied by publisher]

Azithromycin for prevention of exacerbations in non-cystic fibrosis bronchiectasis

This randomised, double-blind placebo control trial from New Zealand looked at the use of azithromycin in non-cystic fibrosis bronchiectasis and aimed to assess its effect on exacerbation frequency, lung function and health-related quality of life.

The trial enrolled 141 participants and randomly assigned them to receive either azithromycin 500 mg three times a week for 6 months, or placebo, with a follow up period of 1 year. Groups were well matched in terms of baseline characteristics. The co-primary endpoints were rate of exacerbations, change in forced expiratory volume in 1 s (FEV1) and change in total score on a St Georges Respiratory questionnaire (SGRQ).

The azithromycin group experienced a statistically significant decrease in the rate of exacerbations requiring antibiotic therapy over the treatment period (relative risk reduction 62%); this reduction was sustained over the 6 month period after cessation of treatment (relative risk reduction of 42% over 1 year). Time to first exacerbation requiring antibiotics...

Incremental value of T-SPOT.TB for diagnosis of active pulmonary tuberculosis in children in a high-burden setting: a multivariable analysis

Introduction

Interferon release assays (IGRAs) are increasingly used for tuberculosis (TB) infection, but their incremental value beyond patient demographics, clinical signs and conventional tests for active disease has not been evaluated in children.

 Methods

The incremental value of T-SPOT.TB was assessed in 491 smear-negative children from two hospitals in Cape Town, South Africa. Bayesian model averaging was used to select the optimal set of patient demographics and clinical signs for predicting culture-confirmed TB. The added value of T-SPOT.TB over and above patient characteristics and conventional tests was measured using statistics such as the difference in the area under the receiver operating characteristic curve (AUC), the net reclassification improvement (NRI) and the integrated discrimination improvement (IDI).

 Results

Cough longer than 2 weeks, fever longer than 2 weeks, night sweats, malaise, history of household contact and HIV status were the most important predictors of culture-confirmed TB. Binary T-SPOT.TB results did not have incremental value when added to the baseline model with clinical predictors, chest radiography and the tuberculin skin test. The AUC difference was 3% (95% CI 0% to 7%). Using risk cut-offs of <10%, 10–30% and >30%, the NRI was 7% (95% CI –8% to 31%) but the CI included the null value. The IDI was 3% (95% CI 0% to 11%), meaning that the average predicted probability across all possible cut-offs improved marginally by 3%.

 Conclusions

In a high-burden setting, the T-SPOT.TB did not have added value beyond clinical data and conventional tests for diagnosis of TB disease in smear-negative children.

Idiopathic pulmonary fibrosis or not: antibiotic prophylaxis for all patients on immunosuppressants

Shulgina et al1 reported the effects of co-trimoxazole on outcomes in fibrotic idiopathic interstitial pneumonia (IIP). We have some concerns about their conclusions and the emphasis of their findings.

With nearly half (43%) of subjects taking ≥10 mg of prednisolone daily, a dose that increases infection risk,2 and over 30% taking a steroid-sparing agent, a valid alternate explanation for their results is that the beneficial effects of co-trimoxazole were due to prevention of adverse effects of immunosuppressive drugs. The occurrence of fewer pneumonias in the treated group supports this alternate hypothesis, as does the observation that the main driver of the between-groups mortality difference in the so-called per protocol analysis was the large proportion of deaths (12 of 17) among subjects in the placebo group on immunosuppression. It would be helpful to see a similar between-groups breakdown in the intention to treat (ITT) analysis....

SKUP3 randomised controlled trial: polysomnographic results after uvulopalatopharyngoplasty in selected patients with obstructive sleep apnoea

Objective

To assess the 6-month efficacy of uvulopalatopharyngoplasty (UPPP) compared with expectancy in selected patients with obstructive sleep apnoea syndrome (OSAS).

 Design

A prospective single-centre randomised controlled trial with two parallel arms stratified by Friedman stage and body mass index (BMI).

 Participants

65 consecutive patients with moderate to severe OSAS (apnoea-hypopnoea index (AHI) ≥15 events/h sleep), BMI <36 kg/m2, Epworth sleepiness scale ≥8, Friedman stage I or II.

 Intervention

Surgical treatment with UPPP. The control group underwent UPPP after a delay of 6 months.

 Outcomes

Changes in AHI and other polysomnography parameters at baseline compared with the 6-month follow-up.

 Results

All patients (32 in the intervention group and 33 in the control group) completed the trial. The mean (SD) AHI in the intervention group decreased significantly (p<0.001) by 60% from 53.3 (19.7) events/h to 21.1 (16.7) events/h . In the control group the mean AHI decreased by 11% from 52.6 (21.7) events/h to 46.8 (22.8) events/h, with a significant difference between the groups (p<0.001). The mean time in the supine position and the BMI were unchanged in both groups. Subgroup analyses for Friedman stage, BMI group and tonsil size all showed significant reductions in AHI in the intervention group compared with controls. There were no severe complications after surgery.

 Conclusions

This trial demonstrates the efficacy of UPPP in treating selected patients with OSAS with a mean reduction in AHI of 60% compared with 11% in controls, a highly significant and clinically relevant difference between the groups.

 Trial registration number

NCT01659671.

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