Pediatricians
24 years of experience

Central Harlem
The Children’s AID Society Milbank Medical Group
14 W 118th St
New York, NY 10026
212-369-8339
Locations and availability (1)

Education ?

Medical School Score Rankings
University of Pennsylvania (1986)
  • Currently 4 of 4 apples
Top 25%
Residency
Johns Hopkins Hosp (1990) *
Pediatrics
* This information was reported to Vitals by the doctor or doctor's office.

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Respiratory Tract Infections
Bridges to Excellence Recognition
Bridges to Excellence Medical Home Recognition (2014 - 2017)
Level III
NCQA Physician Practice Connections - Patient Centered Medical Home (2014 - 2017)
Appointments
Emory University School of Medicine
Faculty
University of California, San Diego School of Medicine
Faculty
Centers for Disease Control and Prevention
Acting Director
Agency for Toxic Substances and Disease Registry
Acting Administrator
Associations
American Board of Pediatrics

Publications & Research

Dr. Besser has contributed to 49 publications.
Title Urine C-peptide Creatinine Ratio is an Alternative to Stimulated Serum C-peptide Measurement in Late-onset, Insulin-treated Diabetes.
Date November 2011
Journal Diabetic Medicine : a Journal of the British Diabetic Association
Excerpt

Serum C-peptide measurement can assist clinical management of diabetes, but practicalities of collection limit widespread use. Urine C-peptide creatinine ratio may be a non-invasive practical alternative. The stability of C-peptide in urine allows outpatient or community testing. We aimed to assess how urine C-peptide creatinine ratio compared with serum C-peptide measurement during a mixed-meal tolerance test in individuals with late-onset, insulin-treated diabetes.

Title Urine C-peptide Creatinine Ratio is a Noninvasive Alternative to the Mixed-meal Tolerance Test in Children and Adults with Type 1 Diabetes.
Date June 2011
Journal Diabetes Care
Excerpt

Stimulated serum C-peptide (sCP) during a mixed-meal tolerance test (MMTT) is the gold standard measure of endogenous insulin secretion, but practical issues limit its use. We assessed urine C-peptide creatinine ratio (UCPCR) as an alternative.

Title Improving Cross-sectoral and Cross-jurisdictional Coordination for Public Health Emergency Legal Preparedness.
Date June 2008
Journal The Journal of Law, Medicine & Ethics : a Journal of the American Society of Law, Medicine & Ethics
Title Impact of a Child Care Educational Intervention on Parent Knowledge About Appropriate Antibiotic Use.
Date June 2007
Journal Wmj : Official Publication of the State Medical Society of Wisconsin
Excerpt

BACKGROUND: Parent education is an integral component to promoting judicious antibiotic use. Opportunities to educate parents directly are limited. Child care providers are in a position to relay information to parents. METHODS: A group-randomized trial assessed the impact of a child care center staff intervention on parental knowledge and attitudes regarding appropriate antibiotic use. A 9-point knowledge score and 3 attitude items were measured. RESULTS: Surveys were returned by 151 (51%) of 298 intervention center parents and 150 (42%) of 361 control center parents. Intervention center respondents were significantly more likely than control center respondents to be college graduates, non-Hispanic white, and insured. Among college graduates, the median knowledge score was 7.0 at intervention centers and 6.5 at control centers (P<0.01). No significant differences were found in knowledge scores among noncollege educated parents (P=0.11). After adjusting for clustering within child care centers, multivariate analysis demonstrated high knowledge score was associated with white race (P=0.02), being a college graduate (P=0.02), and being in the intervention group (P=0.06). CONCLUSION: An appropriate antibiotic use program for child care providers promotes better knowledge among parents of children aged <5 years, particularly among highly educated parents.

Title Reducing Legionella Colonization in Water Systems with Monochloramine.
Date July 2006
Journal Emerging Infectious Diseases
Excerpt

Monochloramine disinfection of municipal water supplies is associated with decreased risk for Legionnaires' disease. We conducted a 2-year, prospective, environmental study to evaluate whether converting from chlorine to monochloramine for water disinfection would decrease Legionella colonization of hot water systems. Water and biofilm samples from 53 buildings were collected for Legionella culture during 6 intervals. Prevalence ratios (PRs) comparing Legionella colonization before and after monochloramine disinfection were adjusted for water system characteristics. Legionella colonized 60% of the hot water systems before monochloramine versus 4% after conversion (PR 0.07, 95% confidence interval 0.03-0.16). The median number of colonized sites per building decreased with monochloramine disinfection. Increased prevalence of Legionella colonization was associated with water heater temperatures <50 degrees C, buildings taller than 10 stories, and interruptions in water service. Increasing use of monochloramine in water supplies throughout the United States may reduce Legionella transmission and incidence of Legionnaires' disease.

Title Clinicians' Management of Children and Adolescents with Acute Pharyngitis.
Date June 2006
Journal Pediatrics
Excerpt

OBJECTIVE: Sore throat is a common complaint in children and adolescents. With increasing antimicrobial resistance because of antimicrobial overuse, accurate diagnosis is imperative. Appropriate management of acute pharyngitis depends on proper use and interpretation of clinical findings, rapid antigen-detection tests, and throat cultures. We surveyed pediatricians and family physicians to evaluate their management strategies for children and adolescents with acute pharyngitis and to assess the availability and use of diagnostic tests in office practice. METHODS: In 2004, surveys were mailed to a random sample of 1000 pediatrician members of the American Academy of Pediatrics and 1000 family physician members of the American Academy of Family Physicians. We assessed factors associated with physicians using an appropriate management strategy for treating acute pharyngitis. RESULTS: Of 948 eligible responses, 42% of physicians would start antimicrobials before knowing diagnostic test results and continue them despite negative results, with 27% doing this often or always. When presented with clinical scenarios of patients with acute pharyngitis, < or =23% chose an empirical approach, 32% used an inappropriate strategy for a child with pharyngitis suggestive of group A Streptococcus, and 81% used an inappropriate strategy for a child with findings consistent with viral pharyngitis. Plating cultures in the office was associated with an appropriate management strategy, although not statistically significant. Solo/2-person practice and rural location were both independent factors predicting inappropriate strategies. CONCLUSIONS: There is much room for improvement in the management of acute pharyngitis in children and adolescents. Most physicians use appropriate management strategies; however, a substantial number uses inappropriate ones, particularly for children with likely viral pharyngitis. Efforts to help physicians improve practices will need to be multifaceted and should include health policy and educational approaches.

Title Raynaud Phenomena and Migraine in Two Children: Inclusion Within a Family of Related Disorders.
Date April 2006
Journal Acta Paediatrica (oslo, Norway : 1992)
Excerpt

We report a case of two siblings with Raynaud phenomena and migraine, whose symptoms were successfully treated with pizotifen. CONCLUSION: To our knowledge, this is the first case documenting the association between Raynaud phenomena and migraine in two siblings with a family history of Raynaud phenomena and ischaemic heart disease.

Title Introduction of Monochloramine into a Municipal Water System: Impact on Colonization of Buildings by Legionella Spp.
Date February 2006
Journal Applied and Environmental Microbiology
Excerpt

Legionnaires' disease (LD) outbreaks are often traced to colonized potable water systems. We collected water samples from potable water systems of 96 buildings in Pinellas County, Florida, between January and April 2002, during a time when chlorine was the primary residual disinfectant, and from the same buildings between June and September 2002, immediately after monochloramine was introduced into the municipal water system. Samples were cultured for legionellae and amoebae using standard methods. We determined predictors of Legionella colonization of individual buildings and of individual sampling sites. During the chlorine phase, 19 (19.8%) buildings were colonized with legionellae in at least one sampling site. During the monochloramine phase, six (6.2%) buildings were colonized. In the chlorine phase, predictors of Legionella colonization included water source (source B compared to all others, adjusted odds ratio [aOR], 6.7; 95% confidence interval [CI], 2.0 to 23) and the presence of a system with continuously circulating hot water (aOR, 9.8; 95% CI, 1.9 to 51). In the monochloramine phase, there were no predictors of individual building colonization, although we observed a trend toward greater effectiveness of monochloramine in hotels and single-family homes than in county government buildings. The presence of amoebae predicted Legionella colonization at individual sampling sites in both phases (OR ranged from 15 to 46, depending on the phase and sampling site). The routine introduction of monochloramine into a municipal drinking water system appears to have reduced colonization by Legionella spp. in buildings served by the system. Monochloramine may hold promise as community-wide intervention for the prevention of LD.

Title Knowledge, Attitudes, and Reported Practices Among Obstetrician-gynecologists in the Usa Regarding Antibiotic Prescribing for Upper Respiratory Tract Infections.
Date August 2005
Journal Infectious Diseases in Obstetrics and Gynecology
Excerpt

BACKGROUND: Knowledge, attitudes, and practices regarding antibiotic prescribing for upper respiratory tract infections (URIs) have not been well described among obstetrician-gynecologists (OB/GYNs). This information is useful for determining whether an OB/GYN-specific program promoting appropriate antibiotic use would significantly contribute to the efforts to decrease inappropriate antibiotic use among primary care providers. METHODS: An anonymous questionnaire asking about the treatment of URIs was sent to 1031 obstetrician-gynecologists. RESULTS: The overall response rate was 46%. The majority of respondents (92%) were aware of the relationship between antibiotic use and antibiotic resistance, and respondents estimated that 5% of their patients had URI symptoms at their office visits. Overall, 56% of respondents reported that they would prescribe an antibiotic for uncomplicated bronchitis and 43% for the common cold. OB/GYNs with the fewest years of experience were less likely than those with the most years of experience to report prescribing for uncomplicated bronchitis (Odds ratio (OR) 0.46, 95% confidence interval (CI) 0.23 to 0.91) or the common cold (OR 0.44, CI 0.22 to 0.89). The majority of respondents (60%) believed that most patients wanted an antibiotic for URI symptoms, with male OB/GYNs being more likely than female OB/GYNs (OR 2.1, CI 1.2 to 3.8) to hold this belief. Both male OB/GYNs (OR 1.9, CI 1.1 to 3.4) and rural practitioners (OR 2.1, CI 1.1 to 4.0) were more likely to believe that it was hard to withhold antibiotics for URI symptoms because other physicians prescribe antibiotics for these symptoms. OB/GYNs who believed that postgraduate training prepared them well for primary care management were more likely than those who did not (OR 2.1, CI 1.1 to 4.2) to believe that they could reduce antibiotic prescribing without reducing patient satisfaction. CONCLUSION: Multiple demographic factors affect attitudes and reported practices regarding antibiotic prescribing. However, in view of the low proportion of office visits for URIs, an OB/GYN-specific program is not warranted.

Title Clinician Knowledge and Beliefs After Statewide Program to Promote Appropriate Antimicrobial Drug Use.
Date July 2005
Journal Emerging Infectious Diseases
Excerpt

In 1999, Wisconsin initiated an educational campaign for primary care clinicians and the public to promote judicious antimicrobial drug use. We evaluated its impact on clinician knowledge and beliefs; Minnesota served as a control state. Results of pre- (1999) and post- (2002) campaign questionnaires indicated that Wisconsin clinicians perceived a significant decline in the proportion of patients requesting antimicrobial drugs (50% in 1999 to 30% in 2002; p<0.001) and in antimicrobial drug requests from parents for children (25% in 1999 to 20% in 2002; p = 0.004). Wisconsin clinicians were less influenced by nonpredictive clinical findings (purulent nasal discharge [p = 0.044], productive cough [p = 0.010]) in terms of antimicrobial drug prescribing. In 2002, clinicians from both states were less likely to recommend antimicrobial agent treatment for the adult case scenarios of viral respiratory illness. For the comparable pediatric case scenarios, only Wisconsin clinicians improved significantly from 1999 to 2002. Although clinicians in both states improved on several survey responses, greater overall improvement occurred in Wisconsin.

Title Impact of Statewide Program to Promote Appropriate Antimicrobial Drug Use.
Date July 2005
Journal Emerging Infectious Diseases
Excerpt

The Wisconsin Antibiotic Resistance Network (WARN) was launched in 1999 to educate physicians and the public about judicious antimicrobial drug use. Public education included radio and television advertisements, posters, pamphlets, and presentations at childcare centers. Physician education included mailings, susceptibility reports, practice guidelines, satellite conferences, and presentations. We analyzed antimicrobial prescribing data for primary care physicians in Wisconsin and Minnesota (control state). Antimicrobial prescribing declined 19.8% in Minnesota and 20.4% in Wisconsin from 1998 to 2003. Prescribing by internists declined significantly more in Wisconsin than Minnesota, but the opposite was true for pediatricians. We conclude that the secular trend of declining antimicrobial drug use continued through 2003, but a large-scale educational program did not generate greater reductions in Wisconsin despite improved knowledge. State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development to promote careful antimicrobial drug use.

Title Demand for Prophylaxis After Bioterrorism-related Anthrax Cases, 2001.
Date April 2005
Journal Emerging Infectious Diseases
Excerpt

Media reports suggested increased public demand for anthrax prophylaxis after the intentional anthrax cases in 2001, but the magnitude of anthrax-related prescribing in unaffected regions was not assessed. We surveyed a random sample of 400 primary care clinicians in Minnesota and Wisconsin to assess requests for and provision of anthrax-related antimicrobial agents. The survey was returned by 239 (60%) of clinicians, including 210 in outpatient practice. Fifty-eight (28%) of those in outpatient practice received requests for anthrax-related antimicrobial agents, and 9 (4%) dispensed them. Outpatient fluoroquinolone use in both states was also analyzed with regression models to compare predicted and actual use in October and November 2001. Fluoroquinolone use as a proportion of total antimicrobial use was not elevated, and anthrax concerns accounted for an estimated 0.3% of all fluoroquinolone prescriptions. Most physicians in Minnesota and Wisconsin managed anthrax-related requests without dispensing antimicrobial agents.

Title Promoting Appropriate Antibiotic Use for Pediatric Patients: a Social Ecological Framework.
Date October 2004
Journal Seminars in Pediatric Infectious Diseases
Excerpt

During the 1990s, the number of prescriptions for antibiotics for children and adolescents finally decreased after more than a decade of alarming increases. The Centers for Disease Control and Prevention (CDC) and many other groups have designed and implemented interventions to promote appropriate prescribing of antibiotics, and these efforts appear to have contributed to recent decreases in rates of such prescribing. In this article, we describe the various types of interventions that the CDC and others are using to encourage appropriate use of antibiotics. A social ecological framework is used to describe the various factors contributing to prescribing and using antibiotics, as well as the interventions used for targeting these factors. Although most efforts promoting appropriate use of antibiotics have focused on reducing such use for viral infections, future efforts also should include a focus on ensuring the use of targeted agents when antibiotics are indicated.

Title Responding to Detection of Aerosolized Bacillus Anthracis by Autonomous Detection Systems in the Workplace.
Date June 2004
Journal Mmwr. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports / Centers for Disease Control
Excerpt

Autonomous detection systems (ADSs) are under development to detect agents of biologic and chemical terror in the environment. These systems will eventually be able to detect biologic and chemical hazards reliably and provide approximate real-time alerts that an agent is present. One type of ADS that tests specifically for Bacillus anthracis is being deployed in hundreds of postal distribution centers across the United States. Identification of aerosolized B. anthracis spores in an air sample can facilitate prompt on-site decontamination of workers and subsequent administration of postexposure prophylaxis to prevent inhalational anthrax. Every employer who deploys an ADS should develop detailed plans for responding to a positive signal. Responding to ADS detection of B. anthracis involves coordinating responses with community partners and should include drills and exercises with these partners. This report provides guidelines in the following six areas: 1) response and consequence management planning, including the minimum components of a facility response plan; 2) immediate response and evacuation; 3) decontamination of potentially exposed workers to remove spores from clothing and skin and prevent introduction of B. anthracis into the worker's home and conveyances; 4) laboratory confirmation of an ADS signal; 5) steps for evaluating potentially contaminated environments; and 6) postexposure prophylaxis and follow-up.

Title Antimicrobial Prescribing for Otitis Externa in Children.
Date March 2004
Journal The Pediatric Infectious Disease Journal
Excerpt

We describe the patterns of antimicrobial prescribing and trends in disease occurrence among children with otitis externa using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 1995 to 2000. Oral antimicrobial therapy for otitis externa is more likely to contribute to antimicrobial resistance than is topical antimicrobial therapy and is rarely indicated. Thirty-nine percent of visits resulted in a prescription for topical antibiotics, and 25% of visits resulted in a prescription for oral antibiotics. Inappropriate antimicrobial prescribing for otitis externa occurs frequently.

Title Consumer Attitudes and Use of Antibiotics.
Date November 2003
Journal Emerging Infectious Diseases
Excerpt

Recent antibiotic use is a risk factor for infection or colonization with resistant bacterial pathogens. Demand for antibiotics can be affected by consumers' knowledge, attitudes, and practices. In 1998-1999, the Foodborne Diseases Active Surveillance Network (FoodNet( conducted a population-based, random-digit dialing telephone survey, including questions regarding respondents' knowledge, attitudes, and practices of antibiotic use. Twelve percent had recently taken antibiotics; 27% believed that taking antibiotics when they had a cold made them better more quickly, 32% believed that taking antibiotics when they had a cold prevented more serious illness, and 48% expected a prescription for antibiotics when they were ill enough from a cold to seek medical attention. These misguided beliefs and expectations were associated with a lack of awareness of the dangers of antibiotic use; 58% of patients were not aware of the possible health dangers. National educational efforts are needed to address these issues if patient demand for antibiotics is to be reduced.

Title Promoting the Appropriate Use of Oral Antibiotics: There is Some Very Good News.
Date June 2003
Journal Pediatrics
Title Antimicrobial Drug Prescription in Ambulatory Care Settings, United States, 1992-2000.
Date May 2003
Journal Emerging Infectious Diseases
Excerpt

During the 1990s, as antimicrobial resistance increased among pneumococci, many organizations promoted appropriate antimicrobial use to combat resistance. We analyzed data from the National Ambulatory Medical Care Survey, an annual sample survey of visits to office-based physicians, and the National Hospital Ambulatory Medical Care Survey, an annual sample survey of visits to hospital emergency and outpatient departments, to describe trends in antimicrobial prescribing from 1992 to 2000 in the United States. Approximately 1,100-1,900 physicians reported data from 21,000-37,000 visits; 200-300 outpatient departments reported data for 28,000-35,000 visits; approximately 400 emergency departments reported data for 21,000-36,000 visits each year. In that period, the population- and visit-based antimicrobial prescribing rates in ambulatory care settings decreased by 23% and 25%, respectively, driven largely by a decrease in prescribing by office-based physicians. Antimicrobial prescribing rates changed as follows: amoxicillin and ampicillin, -43%; cephalosporins, -28%; erythromycin, -76%; azithromycin and clarithromycin, +388%; quinolones, +78%; and amoxicillin/clavulanate, +69%. This increasing use of azithromycin, clarithromycin, and quinolones warrants concern as macrolide- and fluoroquinolone-resistant pneumococci are increasing.

Title Legionnaires' Disease Outbreak in an Automobile Engine Manufacturing Plant.
Date April 2003
Journal The Journal of Infectious Diseases
Excerpt

We investigated 4 cases of legionnaires' disease (LD) reported among workers at an Ohio automotive plant in March 2001. A "confirmed" case of LD was defined as x-ray-confirmed pneumonia and a confirmatory laboratory test. A "possible" case of LD was defined as elevated titers of antibody and respiratory symptoms. Legionella pneumophila serogroup 1 (LP1) was isolated from 1 case patient. Legionella was isolated from 18 (9%) of 197 environmental samples; 3 isolates were LP1 but did not match the case isolate. We conducted a case-control study; 17 case patients with confirmed or possible LD and 86 control subjects (workers with low antibody titers and without symptoms) were enrolled. Visiting a specific cleaning line (odds ratio, [OR], 7.29; 95% confidence interval [CI], 2.31-23.00) and working in the cleaning region of the plant (OR, 3.22; 95% CI, 1.11-9.38) were associated with LD. LD can be transmitted in industrial settings in which aerosols are produced. Clinicians should consider LD when treating persons from these settings for pneumonia.

Title Antimicrobial Prescribing in the United States: Good News, Bad News.
Date April 2003
Journal Annals of Internal Medicine
Title Trends in Legionnaires Disease, 1980-1998: Declining Mortality and New Patterns of Diagnosis.
Date November 2002
Journal Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
Excerpt

New diagnostic tests and empirical therapy for pneumonia may have important ramifications for the identification, treatment, and control of legionnaires disease (LD). To determine trends in the epidemiology of LD, we analyzed data for 1980-1998 from the passive surveillance system of the Centers for Disease Control and Prevention. During this time period, there were 6757 confirmed cases of LD (median annual number, 360 cases/year). Diagnosis by culture and by direct fluorescent antibody and serologic testing decreased significantly; diagnosis by urine antigen testing increased from 0% to 69%. The frequency of isolates other than Legionella pneumophila serogroup 1 (LP1) decreased from 38% to 4% (P=.003). The case-fatality rate decreased significantly, from 34% to 12% (P<.001) for all cases, from 46% to 14% (P<.0001) for nosocomial cases, and from 26% to 10% (P=.05) for community-acquired cases. LD-related mortality has decreased dramatically. The decrease in culture-based diagnosis limits the recognition of non-LP1 disease and impairs outbreak investigation, because fewer Legionella isolates are provided for further examination.

Title Legionella and Legionnaires' Disease: 25 Years of Investigation.
Date August 2002
Journal Clinical Microbiology Reviews
Excerpt

There is still a low level of clinical awareness regarding Legionnaires' disease 25 years after it was first detected. The causative agents, legionellae, are freshwater bacteria with a fascinating ecology. These bacteria are intracellular pathogens of freshwater protozoa and utilize a similar mechanism to infect human phagocytic cells. There have been major advances in delineating the pathogenesis of legionellae through the identification of genes which allow the organism to bypass the endocytic pathways of both protozoan and human cells. Other bacteria that may share this novel infectious process are Coxiella burnetti and Brucella spp. More than 40 species and numerous serogroups of legionellae have been identified. Most diagnostic tests are directed at the species that causes most of the reported human cases of legionellosis, L. pneumophila serogroup 1. For this reason, information on the incidence of human respiratory disease attributable to other species and serogroups of legionellae is lacking. Improvements in diagnostic tests such as the urine antigen assay have inadvertently caused a decrease in the use of culture to detect infection, resulting in incomplete surveillance for legionellosis. Large, focal outbreaks of Legionnaires' disease continue to occur worldwide, and there is a critical need for surveillance for travel-related legionellosis in the United States. There is optimism that newly developed guidelines and water treatment practices can greatly reduce the incidence of this preventable illness.

Title Trends in Antimicrobial Prescribing Rates for Children and Adolescents.
Date June 2002
Journal Jama : the Journal of the American Medical Association
Excerpt

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.

Title Antibiotic Use and Upper Respiratory Infections: a Survey of Knowledge, Attitudes, and Experience in Wisconsin and Minnesota.
Date May 2002
Journal Preventive Medicine
Excerpt

BACKGROUND: Public attitudes and expectations contribute to inappropriate antibiotic prescribing and antibiotic resistance. This study assessed knowledge, attitudes, and experiences regarding antibiotic use for respiratory infection or illness. METHODS: Random-digit-dialing telephone surveys of adults and parents of children <5 years old were conducted in Wisconsin and Minnesota during 1999. RESULTS: The survey was completed by 405 adults and 275 parents of children <5 years old. The median age was 32 years for parents and 50 years for adults. Seven percent of parents and 17% of adults believed that antibiotics are never or almost never necessary for bronchitis. More than 70% in each group believed that antibiotics are needed for green or yellow nasal drainage, and nearly half of respondents believed that they knew whether an antibiotic was needed before seeing a physician. Exposure to multiple information sources on antibiotic resistance in the past 6 months was independently associated with a knowledge score greater than or equal to the median for nine questions. CONCLUSIONS: The general public has misconceptions regarding indications for antibiotic use, and this may contribute to inappropriate prescribing. Providing multiple and varied antibiotic-related informational messages may increase knowledge of appropriate antibiotic prescribing and decrease patient demand for antibiotics.

Title An Outbreak of Travel-associated Legionnaires Disease and Pontiac Fever: the Need for Enhanced Surveillance of Travel-associated Legionellosis in the United States.
Date February 2002
Journal The Journal of Infectious Diseases
Excerpt

Travel-associated outbreaks of legionnaires disease (LD) and combined outbreaks of LD and Pontiac fever (PF) are rarely identified. During one travel-associated combined outbreak at a hotel, a cohort study of potentially exposed persons and an environmental investigation were performed. Two LD and 22 PF cases were identified. Legionella pneumophila serogroup 6 (Lp6) isolates from the index patient and the hotel whirlpool spa were found to be identical by amplified fragment-length polymorphism typing. Disease occurred in 10 of 26 guests who were exposed to the spa versus 2 of 29 guests who were exposed only to the pool area (38% vs. 7%; P=.005). Immunoglobulin M (IgM) antibody to the outbreak Lp6 strain was more common among persons with PF (4 of 9) than among non-ill persons (2 of 32) (44% vs. 6%; P=.02). Spa exposure correlated with disease (P=.001) and IgM seropositivity (P=.007). New laboratory techniques facilitate outbreak investigation; to expedite outbreak interruption and measure the impact of travel-associated legionellosis, surveillance must be improved.

Title Group A Streptococcal Puerperal Sepsis Preceded by Positive Surveillance Cultures.
Date December 2001
Journal Obstetrics and Gynecology
Excerpt

BACKGROUND: Screening of pregnant women for vaginal and rectal carriage of group B streptococci may also identify group A streptococcal carriers. The clinical significance of prenatal group A streptococcal carriage is unknown. CASES: Two women developed group A streptococcal puerperal sepsis after delivery at one hospital 15 months apart. The first patient required hysterectomy and suffered complications including subcapsular hepatic hematoma, pleural effusion, and prolonged ileus. She recovered after a 35-day hospitalization. The second patient had endometritis and recovered. Both had had group A streptococci isolated from vaginal and rectal cultures taken for prenatal group B streptococcal screening. The acute sepsis isolates were both M-type 28, but pulsed-field gel electrophoresis determined that the strains were unrelated. CONCLUSIONS: Finding group A streptococci on prenatal culture may presage serious postpartum infection.

Title Risk Factors for Positive Mantoux Tuberculin Skin Tests in Children in San Diego, California: Evidence for Boosting and Possible Foodborne Transmission.
Date October 2001
Journal Pediatrics
Excerpt

OBJECTIVES: Source case finding in San Diego, California, rarely detects the source for children with tuberculosis (TB) infection or disease. One third of all pediatric TB isolates in San Diego are Mycobacterium bovis, a strain associated with raw dairy products. This study was conducted to determine risk factors for TB infection in San Diego. DESIGN: Case-control study of children </=5 years old screened for TB as part of routine health care visit. Asymptomatic children with a positive (>/=10 mm) Mantoux skin test (TST) were matched by age to 1 to 2 children with negative TST from the same clinic. We assessed risk factors for TB infection through parental interview and chart review. RESULTS: A total of 62 cases and 97 controls were enrolled. Eleven cases and 25 controls were excluded from analysis because of previous positive skin tests. Compared with controls, cases were more likely to have received BCG vaccine (73% vs 7%, odds ratio [OR] 44), to be foreign born (35% vs 11%, OR 4.3), and to have eaten raw milk or cheese (21% vs 8%, OR 3.76). The median time between the most recent previous TST and the current test was 12 months for cases and 25 months for controls. Other factors associated with a positive TST included foreign travel, staying in a home while out of the country, and having a relative with a positive TST. There was no association between contact with a known TB case. In a multivariable model, receipt of BCG, contact with a relative with a positive TST, and having a previous TST within the past year were independently associated with TB infection. CONCLUSIONS: We identified several new or reemerging associations with positive TST including cross border travel, staying in a foreign home, and eating raw dairy products. The strong associations with BCG receipt and more recent previous TST may represent falsely positive reactions, booster phenomena, or may be markers for a population that is truly at greater risk for TB infection. Unlike studies conducted in nonborder areas, we found no association between positive TB skin tests and contact with a TB case or a foreign visitor. Efforts to control pediatric TB in San Diego need to address local risk factors including consumption of unpasteurized dairy products and cross-border travel. The interpretation of a positive TST in a young child in San Diego who has received BCG is problematic.

Title Effect of Short-course, High-dose Amoxicillin Therapy on Resistant Pneumococcal Carriage: a Randomized Trial.
Date July 2001
Journal Jama : the Journal of the American Medical Association
Excerpt

CONTEXT: Emerging drug resistance threatens the effectiveness of existing therapies for pneumococcal infections. Modifying the dose and duration of antibiotic therapy may limit the spread of resistant pneumococci. OBJECTIVE: To determine whether short-course, high-dose amoxicillin therapy reduces risk of posttreatment resistant pneumococcal carriage among children with respiratory tract infections. DESIGN AND SETTING: Randomized trial conducted in an outpatient clinic in Santo Domingo, Dominican Republic, October 1999 through July 2000. PARTICIPANTS: Children aged 6 to 59 months who were receiving antibiotic prescriptions for respiratory tract illness (n = 795). INTERVENTIONS: Children were randomly assigned to receive 1 of 2 twice-daily regimens of amoxicillin: 90 mg/kg per day for 5 days (n = 398) or 40 mg/kg per day for 10 days (n = 397). MAIN OUTCOME MEASURES: Penicillin-nonsusceptible Streptococcus pneumoniae carriage, assessed in nasopharyngeal specimens collected at days 0, 5, 10, and 28; baseline risk factors for nonsusceptible pneumococcal carriage; and adherence to regimen, compared between the 2 groups. RESULTS: At the day 28 visit, risk of penicillin-nonsusceptible pneumococcal carriage was significantly lower in the short-course, high-dose group (24%) compared with the standard-course group (32%); relative risk (RR), 0.77; 95% confidence interval (CI), 0.60-0.97; P =.03; risk of trimethoprim-sulfamethoxazole nonsusceptibility was also lower in the short-course, high-dose group (RR, 0.77; 95% CI, 0.58-1.03; P =.08). The protective effect of short-course, high-dose therapy was stronger in households with 3 or more children (RR, 0.72; 95% CI, 0.52-0.98). Adherence to treatment was higher in the short-course, high-dose group (82% vs 74%; P =.02). CONCLUSION: Short-course, high-dose outpatient antibiotic therapy appears promising as an intervention to minimize the impact of antibiotic use on the spread of drug-resistant pneumococci.

Title Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults: Background, Specific Aims, and Methods.
Date June 2001
Journal Annals of Emergency Medicine
Excerpt

The need to decrease excess antibiotic use in ambulatory practice has been fueled by the epidemic increase in antibiotic-resistant Streptococcus pneumoniae. The majority of antibiotics prescribed to adults in ambulatory practice in the United States are for acute sinusitis, acute pharyngitis, acute bronchitis, and nonspecific upper respiratory tract infections (including the common cold). For each of these conditions--especially colds, nonspecific upper respiratory tract infections, and acute bronchitis (for which routine antibiotic treatment is not recommended)--a large proportion of the antibiotics prescribed are unlikely to provide clinical benefit to patients. Because decreasing community use of antibiotics is an important strategy for combating the increase in community-acquired antibiotic-resistant infections, the Centers for Disease Control and Prevention convened a panel of physicians representing the disciplines of internal medicine, family medicine, emergency medicine, and infectious diseases to develop a series of "Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults." These principles provide evidence-based recommendations for evaluation and treatment of adults with acute respiratory illnesses.This paper describes the background and specific aims of and methods used to develop these principles. The goal of the principles is to provide clinicians with practical strategies for limiting antibiotic use to the patients who are most likely to benefit from it. These principles should be used in conjunction with effective patient educational campaigns and enhancements to the health care delivery system that facilitate nonantibiotic treatment of the conditions in question.

Title Principles of Appropriate Antibiotic Use for Treatment of Nonspecific Upper Respiratory Tract Infections in Adults: Background.
Date June 2001
Journal Annals of Emergency Medicine
Excerpt

The following principles of appropriate antibiotic use for adults with nonspecific upper respiratory tract infections apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease. 1. The diagnosis of nonspecific upper respiratory tract infection or acute rhinopharyngitis should be used to denote an acute infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent. 2. Antibiotic treatment of adults with nonspecific upper respiratory tract infection does not enhance illness resolution and is not recommended. Studies specifically testing the impact of antibiotic treatment on complications of nonspecific upper respiratory tract infections have not been performed in adults. Life-threatening complications of upper respiratory tract infection are rare. 3. Purulent secretions from the nares or throat (commonly observed in patients with uncomplicated upper respiratory tract infection) predict neither bacterial infection nor benefit from antibiotic treatment.

Title Principles of Appropriate Antibiotic Use for Acute Rhinosinusitis in Adults: Background.
Date June 2001
Journal Annals of Emergency Medicine
Excerpt

The following principles of appropriate antibiotic use for adults with acute rhinosinusitis apply to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in adults who are not immunocompromised.Most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especially when unilateral) and purulent nasal secretions. Patients with rhinosinusitis symptoms that last less than 7 days are unlikely to have bacterial infection, although rarely some patients with acute bacterial rhinosinusitis present with dramatic symptoms of severe unilateral maxillary pain, swelling, and fever. Sinus radiography is not recommended for diagnosis in routine cases. Acute rhinosinusitis resolves without antibiotic treatment in most cases. Symptomatic treatment and reassurance is the preferred initial management strategy for patients with mild symptoms. Antibiotic therapy should be reserved for patients with moderately severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis and for those with severe rhinosinusitis symptoms-especially those with unilateral facial pain-regardless of duration of illness. For initial treatment, the most narrow-spectrum agent active against the likely pathogens, Streptococcus pneumoniae and Haemophilus influenzae, should be used.

Title Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background.
Date June 2001
Journal Annals of Emergency Medicine
Excerpt

The following principles of appropriate antibiotic use for adults with acute pharyngitis apply to immunocompetent adults without complicated comorbid conditions, such as chronic lung or heart disease, and history of rheumatic fever. They do not apply during known outbreaks of group A streptococcus. 1. Group A beta-hemolytic streptococcus (GABHS) is the causal agent in approximately 10% of adult cases of pharyngitis. The large majority of adults with acute pharyngitis have a self-limited illness, for which supportive care only is needed. 2. Antibiotic treatment of adult pharyngitis benefits only those patients with GABHS infection. All patients with pharyngitis should be offered appropriate doses of analgesics and antipyretics, as well as other supportive care. 3. Limit antibiotic prescriptions to patients who are most likely to have GABHS infection. Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria: history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy (lymphadenitis). Do not test or treat patients with none or only one of these criteria, since these patients are unlikely to have GABHS infection. For patients with two or more criteria the following strategies are appropriate: (a) Test patients with two, three, or four criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results; (b) test patients with two or three criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results or patients with four criteria; or (c) do not use any diagnostic tests, and limit antibiotic therapy to patients with three or four criteria. 4. Throat cultures are not recommended for the routine primary evaluation of adults with pharyngitis or for confirmation of negative results on rapid antigen tests when the test sensitivity exceeds 80%. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for monitoring the development and spread of antibiotic resistance, or when such pathogens as gonococcus are being considered. 5. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin in a penicillin-allergic patient.

Title Principles of Appropriate Antibiotic Use for Treatment of Uncomplicated Acute Bronchitis: Background.
Date June 2001
Journal Annals of Emergency Medicine
Excerpt

The following principles of appropriate antibiotic use for adults with acute bronchitis apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease.The evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out serious illness, particularly pneumonia. In healthy, nonelderly adults, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds, and chest radiography is usually not indicated. In patients with cough lasting 3 weeks or longer, chest radiography may be warranted in the absence of other known causes. Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. If pertussis infection is suspected (an unusual circumstance), a diagnostic test should be performed and antimicrobial therapy initiated. Patient satisfaction with care for acute bronchitis depends most on physician--patient communication rather than on antibiotic treatment.

Title Azithromycin Prophylaxis During a Hospital Outbreak of Mycoplasma Pneumoniae Pneumonia.
Date April 2001
Journal The Journal of Infectious Diseases
Excerpt

Outbreaks of Mycoplasma pneumoniae (MP) in closed communities can have a high attack rate and can last several months. Azithromycin chemoprophylaxis has not been evaluated as a means of limiting transmission. This randomized, double-blinded placebo-controlled trial of azithromycin was conducted among asymptomatic hospital employees during an MP outbreak. Oropharyngeal swabs were obtained for detection of MP by polymerase chain reaction, and questionnaires were administered to assess clinical illness. Of the 147 employees who were enrolled, 73 received azithromycin and 74 received placebo. Carriage was similar within and between groups at weeks 1 and 6 (9.6% vs. 6.7% and 10.3% vs. 13.2%, respectively). Four episodes of clinically significant respiratory illness occurred in the azithromycin group versus 16 episodes in the placebo group (protective efficacy, 75%; 95% confidence interval, 28%-91%). Use of azithromycin prophylaxis in asymptomatic persons during an MP outbreak in a closed setting may be of value in reducing clinical illness.

Title Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults: Background, Specific Aims, and Methods.
Date March 2001
Journal Annals of Internal Medicine
Excerpt

The need to decrease excess antibiotic use in ambulatory practice has been fueled by the epidemic increase in antibiotic-resistant Streptococcus pneumoniae. The majority of antibiotics prescribed to adults in ambulatory practice in the United States are for acute sinusitis, acute pharyngitis, acute bronchitis, and nonspecific upper respiratory tract infections (including the common cold). For each of these conditions-especially colds, nonspecific upper respiratory tract infections, and acute bronchitis (for which routine antibiotic treatment is not recommended)-a large proportion of the antibiotics prescribed are unlikely to provide clinical benefit to patients. Because decreasing community use of antibiotics is an important strategy for combating the increase in community-acquired antibiotic-resistant infections, the Centers for Disease Control and Prevention convened a panel of physicians representing the disciplines of internal medicine, family medicine, emergency medicine, and infectious diseases to develop a series of "Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults." These principles provide evidence-based recommendations for evaluation and treatment of adults with acute respiratory illnesses.This paper describes the background and specific aims of and methods used to develop these principles. The goal of the principles is to provide clinicians with practical strategies for limiting antibiotic use to the patients who are most likely to benefit from it. These principles should be used in conjunction with effective patient educational campaigns and enhancements to the health care delivery system that facilitate nonantibiotic treatment of the conditions in question.

Title Principles of Appropriate Antibiotic Use for Treatment of Nonspecific Upper Respiratory Tract Infections in Adults: Background.
Date March 2001
Journal Annals of Internal Medicine
Excerpt

The following principles of appropriate antibiotic use for adults with nonspecific upper respiratory tract infections apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease.1. The diagnosis of nonspecific upper respiratory tract infection or acute rhinopharyngitis should be used to denote an acute infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent. 2. Antibiotic treatment of adults with nonspecific upper respiratory tract infection does not enhance illness resolution and is not recommended. Studies specifically testing the impact of antibiotic treatment on complications of nonspecific upper respiratory tract infections have not been performed in adults. Life-threatening complications of upper respiratory tract infection are rare.3. Purulent secretions from the nares or throat (commonly observed in patients with uncomplicated upper respiratory tract infection) predict neither bacterial infection nor benefit from antibiotic treatment.

Title Principles of Appropriate Antibiotic Use for Acute Rhinosinusitis in Adults: Background.
Date March 2001
Journal Annals of Internal Medicine
Excerpt

The following principles of appropriate antibiotic use for adults with acute rhinosinusitis apply to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in adults who are not immunocompromised.1. Most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections. 2. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especially when unilateral) and purulent nasal secretions. Patients with rhinosinusitis symptoms that last less than 7 days are unlikely to have bacterial infection, although rarely some patients with acute bacterial rhinosinusitis present with dramatic symptoms of severe unilateral maxillary pain, swelling, and fever.3. Sinus radiography is not recommended for diagnosis in routine cases. 4. Acute rhinosinusitis resolves without antibiotic treatment in most cases. Symptomatic treatment and reassurance is the preferred initial management strategy for patients with mild symptoms. Antibiotic therapy should be reserved for patients with moderately severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis and for those with severe rhinosinusitis symptoms-especially those with unilateral facial pain-regardless of duration of illness. For initial treatment, the most narrow-spectrum agent active against the likely pathogens, Streptococcus pneumoniae and Haemophilus influenzae, should be used.

Title Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background.
Date March 2001
Journal Annals of Internal Medicine
Excerpt

The following principles of appropriate antibiotic use for adults with acute pharyngitis apply to immunocompetent adults without complicated comorbid conditions, such as chronic lung or heart disease, and history of rheumatic fever. They do not apply during known outbreaks of group A streptococcus.1. Group A beta-hemolytic streptococcus (GABHS) is the causal agent in approximately 10% of adult cases of pharyngitis. The large majority of adults with acute pharyngitis have a self-limited illness, for which supportive care only is needed.2. Antibiotic treatment of adult pharyngitis benefits only those patients with GABHS infection. All patients with pharyngitis should be offered appropriate doses of analgesics and antipyretics, as well as other supportive care.3. Limit antibiotic prescriptions to patients who are most likely to have GABHS infection. Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria: history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy (lymphadenitis). Do not test or treat patients with none or only one of these criteria, since these patients are unlikely to have GABHS infection. For patients with two or more criteria the following strategies are appropriate: a) Test patients with two, three, or four criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results; b) test patients with two or three criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results or patients with four criteria; or c) do not use any diagnostic tests, and limit antibiotic therapy to patients with three or four criteria. 4. Throat cultures are not recommended for the routine primary evaluation of adults with pharyngitis or for confirmation of negative results on rapid antigen tests when the test sensitivity exceeds 80%. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for monitoring the development and spread of antibiotic resistance, or when such pathogens as gonococcus are being considered.5. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin in a penicillin-allergic patient.

Title Principles of Appropriate Antibiotic Use for Treatment of Uncomplicated Acute Bronchitis: Background.
Date March 2001
Journal Annals of Internal Medicine
Excerpt

The following principles of appropriate antibiotic use for adults with acute bronchitis apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease.1. The evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out serious illness, particularly pneumonia. In healthy, nonelderly adults, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds, and chest radiography is usually not indicated. In patients with cough lasting 3 weeks or longer, chest radiography may be warranted in the absence of other known causes.2. Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. If pertussis infection is suspected (an unusual circumstance), a diagnostic test should be performed and antimicrobial therapy initiated.3. Patient satisfaction with care for acute bronchitis depends most on physician-patient communication rather than on antibiotic treatment.

Title Lack of Association Between Kawasaki Syndrome and Chlamydia Pneumoniae Infection: an Investigation of a Kawasaki Syndrome Cluster in San Diego County.
Date March 2000
Journal The Pediatric Infectious Disease Journal
Excerpt

BACKGROUND: The etiology of Kawasaki syndrome (KS), the leading cause of acquired coronary artery disease in children, is unknown. Recent studies have suggested that Chlamydia pneumoniae, a common respiratory pathogen associated with an increased risk of heart disease, might lead to KS. OBJECTIVE: To assess whether KS was associated with an elevated risk of having a current or antecedent infection with C. pneumoniae. METHODS: Blood, urine and pharyngeal specimens from KS patients in San Diego County, CA, during a period of high KS incidence were analyzed for evidence of recent C. pneumoniae infection by culture, PCR and serology. Specimens collected from two control groups, family members of KS patients and age-matched children attending outpatient clinics for well child visits, were similarly analyzed. RESULTS: Thirteen cases were identified. Forty-five outpatient controls and an average of three family members per patient were enrolled in the study. All specimens tested negative for the presence of C. pneumoniae by PCR and culture except for one blood specimen from the mother of a case-patient. Serologic analysis of patients and a subset of outpatient and family controls revealed no evidence of current C. pneumoniae infection; 4 of 13 adult family controls had IgG titers consistent with past exposure to C. pneumoniae. Case patients were no more likely than outpatient controls to have had a respiratory illness in the preceding 2 months (11 of 13 patients vs. 35 of 45 controls; odds ratio, 1.57; 95% confidence interval, 0.3 to 11.9). CONCLUSIONS: We found no evidence that C. pneumoniae infection was associated with KS.

Title Escherichia Coli O157:h7 Gastroenteritis and the Hemolytic Uremic Syndrome: an Emerging Infectious Disease.
Date April 1999
Journal Annual Review of Medicine
Excerpt

Escherichia coli O157:H7 is an increasingly common cause of a variety of illnesses, including bloody diarrhea and the hemolytic uremic syndrome. This emerging infectious agent was first identified in 1982 and has been isolated with increasing frequency since then. This chapter reviews the epidemiology, clinical spectrum, diagnosis, treatment, and prevention of infections with E. coli O157:H7.

Title Tuberculosis Screening at 2 San Diego High Schools with High-risk Populations.
Date July 1998
Journal Archives of Pediatrics & Adolescent Medicine
Excerpt

BACKGROUND: High immigration rates contribute to the high incidence of pediatric tuberculosis (TB) in San Diego, Calif. Adolescents frequently have poor access to health care and may not receive appropriate TB screening. School-based screening has been ineffective in detecting TB in other parts of the country. OBJECTIVE: To determine the prevalence of TB infection and disease in a high-risk population of high school students through school-based screening. DESIGN AND PARTICIPANTS: Cross-sectional study of TB prevalence and an analysis of risk factors for TB infection in students attending 2 San Diego high schools with high percentages of non-US-born students. MAIN OUTCOME MEASURES: Positive induration (> or =10 mm) with Mantoux tuberculin skin test. A chest radiograph or clinical findings consistent with active TB. RESULTS: A total of 744 (36%) students at high school 1 and 860 (57%) students at high school 2 participated. Ninety-five (12.8%) and 207 (24.1%) students, respectively, had positive tuberculin skin test results. One student had a chest radiograph that showed active TB. Smear for acid-fast bacteria and culture for Mycobacterium tuberculosis had negative results. Vietnamese, Filipino, and Latino ethnic groups were significantly more likely to have positive tuberculin skin test results than the white population (P<.05). Non-US-born students were significantly more likely to have positive tuberculin skin test results than US-born students in all ethnic groups except the Latino group. CONCLUSION: Although treatment of TB coupled with aggressive public health investigation is the most cost-beneficial way of preventing TB, targeted school-based screening may be an effective way of detecting TB infection in high-risk populations with poor access to health care.

Title Passive Surveillance for Kawasaki Disease in San Diego County.
Date December 1997
Journal The Pediatric Infectious Disease Journal
Excerpt

BACKGROUND: Kawasaki disease (KD) is the most common cause of acquired heart disease in children in the United States. Epidemiologic surveillance is conducted to monitor baseline incidence of the disease and to identify epidemics. The aim of this study was to evaluate a passive surveillance system for reporting cases of KD in San Diego County to the local, state and national health authorities. METHODS: We performed a retrospective review of a 2-year period to identify the number of patients who met criteria of the Centers for Disease Control and Prevention for diagnosis of KD and who were successfully reported to the county, state and national databases. RESULTS: The total number of KD patients for 1994 and 1995 was determined by retrospective review of medical record discharge diagnosis codes. Of the 28 San Diego County residents diagnosed with KD in 1994, 24 (86%) met CDC criteria and 15 (63%) of these eligible patients were reported to the county and state health authorities. Of the 41 residents in 1995, 34 (83%) met CDC criteria and 22 (65%) were reported to the above agencies. No patient in either 1994 or 1995 was reported by local or state health authorities to the CDC. CONCLUSION: Passive surveillance for KD in San Diego County resulted in the reporting of approximately two-thirds of the eligible patients at the county and state levels but completely failed to report any documented cases to the CDC. Implementation of a sentinel hospital reporting system should be considered as a preferred alternative to national passive surveillance in the effort to track total numbers of patients and to follow disease trends over time.

Title Effect of Diarrhea on the Humoral Response to Oral Polio Vaccination.
Date December 1996
Journal The Pediatric Infectious Disease Journal
Excerpt

OBJECTIVE: The purpose of this study was to measure the effect of concurrent diarrheal illness on seroconversion to trivalent oral polio vaccine (OPV). METHODS: Six- to 16-week-old infants with acute diarrhea and age-matched controls received single doses of OPV at enrollment, 4 weeks after enrollment and 8 weeks after enrollment. Serum specimens were obtained at enrollment, before the second OPV dose and 4 weeks after the third OPV dose for measurement of antibody titers to polio virus by the microneutralization assay. RESULTS: Four weeks after the first OPV dose, the serologic responses to poliovirus types 2 and 3 in the case cohort were lower by 26 and 34%, respectively, than in the control cohort (P < 0.002 for both comparisons). Poliovirus type 2 and 3 geometric mean antibody titers in the diarrhea cohort were approximately 50% of the geometric mean antibody titers in the control cohort (235 (95% confidence interval (CI) 154 to 359) vs. 446 (95% CI 350 to 569) and 64 (95% CI 45 to 90) vs. 112 (95% CI 88 to 143), respectively, P < 0.01 for both comparisons). After the third OPV dose the seroconvertion rates to poliovirus types 2 and 3 each remained about 10% lower in the case cohort than in the control cohort, but the differences were not statistically significant. CONCLUSION: Concurrent acute diarrhea adversely affects seroconvertion rates of type 2 and 3 polioviruses among infants in Bangladesh receiving the first dose of trivalent OPV.

Title An Outbreak of Cholera from Food Served on an International Aircraft.
Date June 1996
Journal Epidemiology and Infection
Excerpt

In February 1992, an outbreak of cholera occurred among persons who had flown on a commercial airline flight from South America to Los Angeles. This study was conducted to determine the magnitude and the cause of the outbreak. Passengers were interviewed and laboratory specimens were collected to determine the magnitude of the outbreak. A case-control study was performed to determine the vehicle of infection. Seventy-five of the 336 passengers in the United States had cholera; 10 were hospitalized and one died. Cold seafood salad, served between Lima, Peru and Los Angeles, California was the vehicle of infection (odds ratio, 11.6; 95% confidence interval, 3.3-44.5). This was the largest airline-associated outbreak of cholera ever reported and demonstrates the potential for airline-associated spread of cholera from epidemic areas to other parts of the world. Physicians should obtain a travel history and consider cholera in patients with diarrhoea who have travelled from cholera-affected countries. This outbreak also highlights the risks associated with eating cold foods prepared in cholera-affected countries.

Title [prevention of Cholera Transmission: Rapid Evaluation of the Quality of Municipal Water in Trujillo, Peru]
Date November 1995
Journal Boletín De La Oficina Sanitaria Panamericana. Pan American Sanitary Bureau
Excerpt

Unboiled, unchlorinated drinking water is known to have been associated with epidemic transmission of cholera in Trujillo, Peru, in February 1991. In September of that same year, chlorination of the main water supply system was begun. Water quality in Trujillo at the central level is monitored at dams and principal distribution points, but the effects of this surveillance on the quality of the water distributed are not known. In order to evaluate water quality in the residential areas of Trujillo, water samples were collected in February 1993 from 30 systematically selected houses. The chlorine levels in the samples were measured, and cultures for coliform bacteria were done. The free chlorine concentration varied from 0 to 1.5 mg/L (median = 0.4 mg/L). No free chlorine was detected in 5 samples (17%), and in 14 (47%) the concentrations were less than 0.4 mg/L. Coliforms were found in 16 samples (53%), but none were fecal coliforms. These results demonstrate the wide variability in chlorine concentrations in the municipal water that is distributed to dwellings. This variability, together with the need to store drinking water in the house because of shortages, supports the recommendation of the Ministry of Health that residents should treat drinking water in their homes. The simple sampling framework employed in this study provided a rapid evaluation of the quality of municipal water supplied to consumers. Similar studies could be carried out easily in other metropolitan areas where water quality is suspect, in order to rapidly obtain essential information on water quality at the level of the consumer.

Title Diagnosis and Treatment of Cholera in the United States. Are We Prepared?
Date November 1994
Journal Jama : the Journal of the American Medical Association
Excerpt

OBJECTIVE--To assess cholera recognition and treatment by US health care workers in the largest cholera outbreak in the United States this century. DESIGN--We reviewed the medical records of passengers from a flight on which a cholera outbreak occurred. To determine the availability of oral rehydration solutions, we surveyed treatment facilities and referral pharmacies. SETTING--On February 14, 1992, more than 100 passengers on a flight from South America to Los Angeles, Calif, were infected with toxigenic Vibrio cholerae O1. SUBJECTS--Fifty-four of 67 passengers who sought care in California and Nevada. RESULTS--We reviewed the records of 54 passengers, including 39 with diarrhea and 15 without symptoms. All 17 persons who sought treatment before the outbreak was widely reported by the media had diarrhea. For 12 of these persons, recent travel to South America was noted, but only those four whose records listed cholera as a possible diagnosis were immediately hospitalized. Seven sought care again within 3 days; three were dehydrated, two of these three were hospitalized, and one of these two died. None of the 26 patients suspected to have cholera received appropriate fluids; severely dehydrated patients did not receive Ringer's lactate solution and those not severely dehydrated did not receive an oral rehydration solution. None of the facilities and pharmacies involved stocked World Health Organization oral rehydration salts solution, the preferred solution for treating cholera and other diarrheal diseases. CONCLUSIONS--Treatment of cholera in the United States was suboptimal. Oral fluids appropriate for the treatment of cholera and other diarrheal diseases were generally unavailable. Widespread cholera in the developing world means that US physicians should be prepared to treat "imported" cases. Physicians evaluating patients with diarrhea should obtain a travel history, should consider cholera in patients returning from countries with endemic or epidemic cholera, and should instruct patients in appropriate use of World Health Organization oral rehydration salts solution or other oral rehydration solutions containing 75 to 90 mmol/L of sodium. Pharmacies and medical facilities should stock these solutions.

Title Fate of Enterohemorrhagic Escherichia Coli O157:h7 in Apple Cider with and Without Preservatives.
Date October 1993
Journal Applied and Environmental Microbiology
Excerpt

A strain of enterohemorrhagic Escherichia coli serotype O157:H7 isolated from a patient in an apple cider-related outbreak was used to study the fate of E. coli O157:H7 in six different lots of unpasteurized apple cider. In addition, the efficacy of two preservatives, 0.1% sodium benzoate and 0.1% potassium sorbate, used separately and in combination was evaluated for antimicrobial effects on the bacterium. Studies were done at 8 or 25 degrees C with ciders having pH values of 3.6 to 4.0. The results revealed that E. coli O157:H7 populations increased slightly (ca. 1 log10 CFU/ml) and then remained stable for approximately 12 days in lots inoculated with an initial population of 10(5) E. coli O157:H7 organisms per ml and held at 8 degrees C. The bacterium survived from 10 to 31 days or 2 to 3 days at 8 or 25 degrees C, respectively, depending on the lot. Potassium sorbate had minimal effect on E. coli O157:H7 populations, with survivors detected for 15 to 20 days or 1 to 3 days at 8 or 25 degrees C, respectively. In contrast, survivors in cider containing sodium benzoate were detected for only 2 to 10 days or less than 1 to 2 days at 8 or 25 degrees C, respectively. The highest rates of inactivation occurred in the presence of a combination of 0.1% sodium benzoate and 0.1% potassium sorbate. The use of 0.1% sodium benzoate, an approved preservative used by some cider processors, will substantially increase the safety of apple cider in terms of E. coli O157:H7, in addition to suppressing the growth of yeasts and molds.

Title An Outbreak of Diarrhea and Hemolytic Uremic Syndrome from Escherichia Coli O157:h7 in Fresh-pressed Apple Cider.
Date May 1993
Journal Jama : the Journal of the American Medical Association
Excerpt

OBJECTIVE--Escherichia coli O157:H7 causes hemorrhagic colitis and the hemolytic uremic syndrome. In the fall of 1991, an outbreak of E coli O157:H7 infections in southeastern Massachusetts provided an opportunity to identify transmission by a seemingly unlikely vehicle. DESIGN--Case-control study to determine the vehicle of infection. New England cider producers were surveyed to assess production practices and determined the survival time of E coli O157:H7 organisms in apple cider. RESULTS--Illness was significantly associated with drinking one brand of apple cider. Thirteen (72%) of 18 patients but only 16 (33%) of 49 controls reported drinking apple cider in the week before illness began (odds ratio [OR], 8.3; 95% confidence interval [CI], 1.8 to 39.7). Among those who drank cider, 12 (92%) of 13 patients compared with two (13%) of 16 controls drank cider from cider mill A (lower 95% CI, 2.9; P < .01). This mill pressed cider in a manner similar to that used by other small cider producers: apples were not washed, cider was not pasteurized, and no preservatives were added. In the laboratory, E coli O157:H7 organisms survived for 20 days in unpreserved refrigerated apple cider. Addition of sodium benzoate 0.1% reduced survival to less than 7 days. CONCLUSIONS--Fresh-pressed, unpreserved apple cider can transmit E coli O157:H7 organisms, which cause severe infections. Risk of transmission can be reduced by washing and brushing apples before pressing, and preserving cider with sodium benzoate. Consumers can reduce their risk by only drinking cider made from apples that have been washed and brushed.


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