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1701. Safety of anti-infective agents for skin preparation in premature infants

problems related to skin burns in infants. (Grade C) Alcohol based preparations have good antibacterial activity in adults and have an excellent safety profile. (Grade C) References Hibbard J S. Mulberry K G, Brady A R. A clinical study comparing the skin antisepsis and safety of chloraprep, 70% isopropyl alcohol, and 2% aqueous chlorhexidine. J Infus Nurs 2002;4:244–9. Hibbard J S. Analyses comparing the antimicrobial activity and safety of current antiseptic agents: a review. J Infus Nurs 2005;28:194 (...) source: Medline (1956–2005), MeSH terms were used. An advance search was carried out and close matches from mapping were chosen and another search was carried out using explode and major subheadings. Secondary sources: Cochrane and EMBASE. Search terms: Premature and anti-infective agents and invasive procedures and safety and complications. Search Outcome Only four hits matched all our search criteria. We further searched for trials that looked at the safety and efficacy of different antimicrobials

2007 BestBETS

1702. Silver sulphadiazine cream in burns

and undisturbed environment to allow healing. One confounding factor in these studies may be that the flamazine dressings tended to be changed 12hrly while the other dressings were left intact for longer. Clinical Bottom Line Despite evidence of the antibacterial properties of this compound no evidence was found showing a definitive improvement in outcome in terms of infection rates or healing time. Local advice should be followed. Level of Evidence Level 3 - Small numbers of small studies or great

2007 BestBETS

1703. Is lumbar puncture necessary for evaluation of early neonatal sepsis?

review, level 2b No of cases of meningitis, number of missed/partially treated cases of meningitis No cases of meningitis were found. No missed or partially treated cases were detected Uncontrolled cohort. Small study but only looking at BC positive cases. Babies were treated with antibiotic before CSF was obtained, so the early meningeal seeding could be missed. No mention about the timing of follow-up to detect missed cases Weiss et al, 1991 All infants admitted with respiratory distress

2007 BestBETS

1704. Myringotomy in traumatic haemotympanum

that this condition may be treated conservatively (Deguine and Pulec, 2003; Pulec and Deguine, 2001). Prophylactic antibiotics are recommended but a review of the evidence for this is beyond the scope of this BET. Clinical Bottom Line Patients with traumatic haemotympanum should be investigated for potential basal skull fracture. There is no published evidence of either benefit or harm with myringotomy, nor is there any evidence of harm following conservative management. Local advice should be followed

2006 BestBETS

1705. Does neonatal BCG vaccination protect against tuberculous meningitis?

August 2006 Last Modified: 30th August 2006 Status: Green (complete) Three Part Question In [children suspected of having mycobacterial meningitis] does [a history of BCG vaccination or presence of BCG scar] influence [the likelihood of tuberculous meningitis]? Clinical Scenario An 8 month old baby girl, of Eastern European parents, presents with a week long history of coryzal symptoms for which she has been taking oral antibiotics. She is pyrexial, irritable, and unwell on examination. She

2006 BestBETS

1706. How useful is C-reactive protein in detecting occult bacterial infection in young children with fever without apparent focus?

and a peripheral film negative for malarial parasites. Patients with underlying neoplastic or immunosuppressive condition or with a chronic liver, heart and renal disease and those who had already received antibiotics were excluded Exploratory prospective cohort study (level IIb) CRP, total and differential leucocyte count and ESR in children with laboratory or radiographically proven bacterial illness and non-bacterial illnesses The sensitivity of serum CRP >4 mg/dl for diagnosis of bacteraemia was 95 (...) but not proven bacterial infection (13%) were not included in statistical analysis Confidence interval of sensitivity and specificity values were not given Pulliam et al, 2001 77 children from 1 to 36 months of age with temperature >39°C and clinically undetectable source of fever. Children with acute otitis media, acute pharyngitis, clinical pneumonia, acute respiratory tract infection, acute gastroenteritis, those with a history of antibiotic use during the past 7 days, a known underlying immunologic

2006 BestBETS

1707. A simplified version of the Walsh clinical prediction rule was accurate for detecting streptococcal pharyngitis Full Text available with Trip Pro

) (table). Conclusion In adults with symptoms of upper respiratory tract infection or sore throat, the simplified version of the Walsh clinical prediction rule was accurate for detecting the presence of group A β haemolytic streptococcal pharyngitis. Commentary Although most sore throats lead only to temporary illness, streptococcal pharyngitis may have prolonged symptoms and sometimes local suppurative and serious immune complications. Antibiotic treatment decreases symptoms, reduces transmission (...) HP, et al. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981 ; 1 : 239 –46. McIsaac WJ, White D, Tannenbaum D, et al. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ 1998 ; 158 : 75 –83. Poses RM, Cebul RD, Collins M, et al. The importance of disease prevalence in transporting clinical prediction rules. The case of streptococcal pharyngitis. Ann Intern Med 1986 ; 105 : 586 –91. View this table: Likelihood ratios for GABHS

2004 Evidence-Based Medicine

1708. Review: evidence on the effectiveness of interventions to assist patient adherence to prescribed medications is limited Full Text available with Trip Pro

included simplified dosing regimens for those taking antihypertensive and lipid lowering medications and counselling about the importance of full adherence to antibiotic regimens reinforced by written instructions. Conclusion In patients with medical or mental disorders, limited evidence suggests that several interventions designed to assist patients’ adherence to prescribed medications may be effective. Commentary Healthcare providers tend to see their job as making decisions about care

2004 Evidence-Based Medicine

1709. Oral or intravenous thiamine in the emergency department

Wernickes encephalopathy] is [parental delivery of thiamine better than the oral route] at[achieving bioavailability without side effects]? Clinical Scenario A 56 year old male attends the emergency department with cellulitis in his left leg. He is unkempt and drinks heavily. The cellulitis can be treated as an out patient with oral antibiotics, but you suspect he is thiamine deficient as a result of chronic alcohol abuse. You are therefore about to prescibe an intravenous infusion of thiamine as you

2004 BestBETS

1710. Wound closure in animal bites

OR OR exp adhesives OR] LIMIT to human AND English language. Search Outcome Altogether 74 papers were found of which 1 provided the best evidence to answer the clinical question. Relevant Paper(s) Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses Maimaris C & Quinton DN, 1988, UK 96 ED patients with 169 dog bite lacerations (punctures excluded) randomised to primary closure or leaving wound open No antibiotics PRCT Infection 7 (...) versus non-closure. No antibiotics were used in this study. It excludes puncture wounds, wounds infected at presentation, wounds with other structures involved, and those requiring plastic surgery. The study concludes that there is no significant difference in infection rates between the two groups except in those wounds occurring to the hands. Significantly more hand wounds became infected than wounds elsewhere, and of all hand wounds significantly more became infected in the group treated

2004 BestBETS

1711. Full blood count and reticulocyte count in painful sickle crisis

Size No cases of aplastic anemia. Suspicion of aplastic anemia No patients were suspected to have aplastic anemia before or after reticulocyte cell count was available. Chapman JI 2004 USA 30 children with 86 presentations. A complicated presentation was defined as one that required admission, antibiotics, blood products, or resulted in acute chest syndrome within forty-eight hours. Retropective study Haematologic differences between complicated and uncomplicated patients None Retrospective Small

2006 BestBETS

1712. Administration of steroids in acute exacebations of COPD

Question In [patients with an acute exacerbation of COPD] are [steroids prior to discharge better than no steroids] at [improving outcome and hastening recovery]? Clinical Scenario A 55yr old man, known to have COPD comes to casulty more short of breath than usual and with a history of recently coughing purulent sputum. You treat him in the ED with continuous nebulised bronchodilater therapy, oral steroids as well as antibiotics. He starts to improve and on reasessing him clinically, after reviewing (...) his chest X Ray and blood tests you decide to discharge him with community follow up. You wonder whether he should also be started on course of steroids in addition to his antibiotics. Search Strategy COCHRANE LIBRARY Issue 4 2005 Ovid MEDLINE 1966-November 2005 Embase 1980–2005 Week 47 Medline:[{ or exp Pulmonary Disease, Chronic Obstructive or or chronic or exp Bronchitis, Chronic OR or exp EMPHYSEMA/ or exp PULMONARY EMPHYSEMA} AND [{

2006 BestBETS

1713. Review: data are lacking on the effect of bed rest in women with singleton pregnancies who are at high risk of preterm birth Full Text available with Trip Pro

In women with a singleton pregnancy who are at high risk of spontaneous preterm birth, data are lacking to support or refute the effect of bed rest at hospital or at home to prevent preterm birth. Commentary The incidence of preterm birth has stayed constant over the years despite all the advances in medical and social care. A variety of therapies such as bed rest in the lateral position, antibiotics, and uterine tocolytics are often recommended to prevent preterm birth. Bed rest at home may be a more

2006 Evidence-Based Medicine

1714. Continuous subglottic suction is effective for prevention of ventilator associated pneumonia

secretions in this case was an inappropriate indicator of VAP Valles et al, 1995, Spain 190 critically ill general patients requiring mechanical ventilation for >3 days. Randomised to receive continuous aspiration of subglottic secretions (CASS)(n=76) or to receive usual care (n=77) PRCT (level 1b) Duration of ventilation Subglottic suction (CASS) 13±1 day. Control group 11±1 day p>0.02. 64.4% CASS group and 58.4% of control group received an antibiotic agent at the time of randomisation Of 190 patients (...) specimens. No differences in duration of ventilation, hospital stay, or mortality Flawed randomization technique using patient birth year. Onset of VAP CASS patients mean 5.6±2.3 days. Routine care patients mean 2.9±1.2 days; (p=0.006) Pneumatikos et al, 2002, Greece 61 patients admitted to the ICU who were predicted to need ventilation for >5 days. Patients were randomly assigned to receive Selective Decontamination of Subglottic Area (SDSA) using suction and antibiotics (n=30) or placebo (n=31) SDSA

2005 BestBETS

1715. Are routine urine cultures helpful in the management of asymptomatic infants or preschool children with a previous urinary tract infection?

primary and secondary (after a previous UTI) ABU. Despite their weaknesses, which should caution about the generalisation of their findings, these studies have shown that the detection and the treatment of ABU in infants and preschool children did not decrease the risk of renal scarring. In addition, antibiotic-induced modifications of the bacterial flora may increase the risk of acute pyelonephritis, and therefore the risk of cortical damage. Therefore, the practice of routine detection

2005 BestBETS

1716. Review: ear pain and a cloudy, bulging, or distinctly immobile tympanic membrane appear to help diagnose acute otitis media in children Full Text available with Trip Pro

be difficult to teach. One reason why physicians prescribe antimicrobials for children is their assumption of parental expectations of antibiotics. Physicians often overestimate the parents’ expectations, and change in parental expectations does not change physicians’ prescribing behaviour. Providing a contingency plan to parents who expect antibiotics for their children has been shown to improve parental satisfaction without antimicrobial prescription. Thus, parents should not be blamed, and we physicians (...) urgently need to stop over prescribing antimicrobials. References Koivunen P, Alho OP, Uhari M, et al. Minitympanometry in detecting middle ear fluid. J Pediatr 1997 ; 131 : 419 –22. Mangione-Smith R, McGlynn EA, Elliott MN, et al. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med 2001 ; 155 : 800 –6. Wheeler JG, Fair M, Simpson PM, et al. Impact of a waiting room videotape message on parent attitudes toward pediatric antibiotic use

2005 Evidence-Based Medicine

1717. Symptoms and signs plus erythrocyte sedimentation rate or C-reactive protein predicted pneumonia in lower respiratory tract infection Full Text available with Trip Pro

with an LRTI. Exclusion criteria included severe clinical disease, recent antibiotic treatment, or hospital admission for respiratory disease. Description of tests: the clinical status of patients (classified as either pneumonia or other LRTI) was based on clinical symptoms and signs, and C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) blood tests. Diagnostic standard: chest radiography (lateral and postero anterior) was used as the diagnostic standard for identifying pneumonia. Outcomes (...) of the 193 antibiotic prescriptions could have been prevented. View this table: Diagnostic characteristics of C reactive protein (CRP) (mg/l) and erythrocyte sedimentation rate (ESR) (mm/h) tests for diagnosing pneumonia in lower respiratory tract infection* CONCLUSIONS In adults with a lower respiratory tract infection, classical symptoms and signs of pneumonia were not predictive of pneumonia. A model consisting of dry cough, diarrhoea, and temperature ⩾38°C plus erythrocyte sedimentation rate or C

2005 Evidence-Based Medicine

1718. Review: adjuvant corticosteroid therapy reduces death, hearing loss, and neurological sequelae in bacterial meningitis Full Text available with Trip Pro

and experts. Study selection and assessment studies in any language were selected if they were randomised controlled trials that compared any type of corticosteroid therapy adjuvant to antibiotics with placebo in patients with ABM and recorded case fatality rates. 2 reviewers independently assessed the quality of studies using the Jadad scale. Outcomes mortality, severe hearing loss (bilateral hearing loss > 60 dB or requiring bilateral hearing aids), and short term (discharge to 6 wk) or long term (6 (...) recent vaccine developments against ABM have shifted the proportion of infections to adults in developed countries, ABM continues to threaten both children and adults in developing countries. Failed treatment of ABM is rarely a bug and drug problem despite recent concerns about drug resistant pneumococci and meningococci. The fact that a host’s immune response causes the bulk of neurological morbidity in ABM (which can be attenuated by adjunctive corticosteroids before administering antibiotics) has

2005 Evidence-Based Medicine

1719. Review: the only effect for surgery plus antiobiotics in vesicoureteric reflux is fewer febrile urinary tract infections Full Text available with Trip Pro

Therapeutics Review: the only effect for surgery plus antiobiotics in vesicoureteric reflux is fewer febrile urinary tract infections Free Steven McTaggart , MD Statistics from Wheeler D, Vimalachandra D, Hodson EM, et al . Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials. Arch Dis Child 2003 ; 88 : 688 –94. Q In children with vesicoureteric reflux (VUR), which treatments reduce urinary tract infection (UTI) and renal parenchymal injury (...) ? Clinical impact ratings GP/FP/Primary care ★★★★★★★ METHODS Data sources: Medline, EMBASE/Excerpta Medica (to February 2003), and the Cochrane Controlled Trials Register; reference lists; and contact with authors. Study selection and assessment: randomised (RCTs) or quasi-randomised controlled trials that evaluated surgery (open and closed techniques), antibiotic prophylaxis, non-invasive techniques (eg, management of voiding dysfunction), or any combination of interventions in patients of any age

2005 Evidence-Based Medicine

1720. Are newer macrolides effective in eradicating carriage of pertussis?

to medications unclear. Small study group. Relapse: positive culture at 2 weeks after treatment None in either study or control groups. Comment(s) Antimicrobials are usually administered when Pertussis is suspected or confirmed .If the disease is already established (paroxysmal phase), antibiotics have little or no effect on the clinical course of the illness except to render the patient non infectious to others. This is important, so as to limit the spread of infection especially to the un immunised

2005 BestBETS

Evidence-based Synopses

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