When Are Antibiotics Needed for URI in Children? CME/CE

News Author: Norra MacReady
CME Author: Laurie Barclay, MD

CME/CE Released: 12/03/2013; Valid for credit through 12/03/2014

Clinical Context

Because most upper respiratory tract infections (URIs) are caused by viruses, antibiotic treatment is generally not needed. A clinical report describes antibiotic prescribing strategies for bacterial URIs in children, including acute otitis media (AOM), acute bacterial sinusitis, and group A streptococcal (GAS) pharyngitis.

Three principles for judicious antibiotic prescribing are using strict diagnostic criteria, considering the benefits and harms of antibiotic treatment, and understanding situations when antibiotics may not be needed. Although these principles can help guide implementation of recommendations from recent clinical guidelines regarding antibiotic prescribing strategies for bacterial URIs in children, Hersh and colleagues suggest that they may apply more broadly to antibiotic prescribing in general.

Study Synopsis and Perspective

Effective use of antibiotics to treat pediatric URIs rests on 3 basic principles: accurate diagnosis, consideration of risks vs benefits, and recognizing when antibiotics may be contraindicated, according to a clinical report by the Committee on Infectious Diseases of the American Academy of Pediatrics.

Of the nearly 50 million pediatric antibiotic prescriptions written annually, as many as 10 million of those "are directed toward respiratory conditions for which they are unlikely to provide benefit," lead author Adam L. Hersh, MD, PhD, and fellow committee members write in an article published in the December issue of Pediatrics. Often this occurs because it is hard to distinguish bacterial infections, which respond to antibiotics, from viral infections, which do not.

The report emphasizes "the importance of using stringent and validated clinical criteria when diagnosing ...AOM, acute bacterial sinusitis, and pharyngitis caused by ...GAS, as established through clinical guidelines," the authors write.

The first principle of judicious antibiotic prescribing is to determine the presence of a bacterial infection. For example, with AOM, this requires an otoscopic examination to observe characteristic inflammatory changes in the tympanic membrane plus bulging of the membrane or new-onset otorrhea not attributable to otitis externa, or mild bulging of the tympanic membrane accompanied by intense erythema or pain of recent onset. Acute bacterial sinusitis is diagnosed from persistent, worsening, or severe symptoms. Pharyngitis resulting from GAS can be diagnosed by taking a throat culture to identify the organism.

Following these diagnostic guidelines can help clinicians rule out the common cold, nonspecific URI, and bronchitis, which are viral in origin and will not respond to antibiotics, the authors write.

The second principle is to weigh the benefits against the harms of antibiotics. In the case of AOM, the evidence suggests that although at least 50% of patients may get well without antibiotics, antibiotics hasten recovery and are especially helpful for patients who are younger or have bilateral or severe disease. The evidence for using antibiotics to treat acute bacterial sinusitis is limited and mixed, and the role of the drugs in preventing complications such as orbital cellulitis or intracranial abscess also is unproven. Nevertheless, the American Academy of Pediatrics recommends antibiotics for children with clinical features of acute bacterial sinusitis, especially when the symptoms are worsening or severe. As for GAS pharyngitis, good evidence suggests that antibiotics can shorten symptom duration, although their effect on limiting fever is less clear, and they may reduce horizontal transmission. Antibiotics also may prevent suppurative complications of GAS pharyngitis such as peritonsillar abscess.

The harms of antibiotics can potentially outweigh these benefits, the authors warn. Most of the clinical trials reviewed have used amoxicillin or amoxicillin-clavulanate, which have been associated with adverse events ranging from mild (eg, diarrhea and rash), to severe (eg, Stevens-Johnson syndrome), to life-threatening cardiac and anaphylactic reactions. What is more, a growing body of evidence suggests that antibiotic use early in life may upset the normal microbial balance in the intestine and other organs, possibly setting the child up for lifelong health problems, including inflammatory bowel disease, obesity, eczema, and asthma. "Application of stringent diagnostic criteria and use of therapy only when the diagnosis and potential benefits are well established is essential to minimizing the impact of antibiotic overuse on resistance in individuals and within communities," the authors write.

Principle 3 is implementation of judicious prescribing strategies, including selection of the antibiotic most likely to eliminate the infecting organism, using an appropriate dose, and treating for the shortest duration possible. The committee suggests that clinicians consider a "wait-and-see" approach before prescribing antibiotics, especially for older patients with mild to moderate AOM or sinusitis. They also recommend an assessment of the child's overall antibiotic exposure.

These principles "can be used to amplify messages from recent clinical guidelines for local guideline development and for patient communication; they are broadly applicable to antibiotic prescribing in general," the authors conclude.

The authors have disclosed no relevant financial relationships.

Pediatrics. 2013;132:1146-1154.

Study Highlights

• The first principle of judicious antibiotic prescribing for pediatric URIs is to determine the likelihood of a bacterial infection.
  • For AOM, diagnosis of a bacterial cause requires middle ear effusion and signs of inflammation, with moderate or severe bulging of the tympanic membrane; otorrhea not the result of otitis externa; mild bulging of the tympanic membrane with ear pain; or erythema of the tympanic membrane.
  • For acute bacterial sinusitis, diagnosis of a bacterial cause requires URI symptoms that are worsening, severe, or persistent.
  • These include worsening or new-onset fever, daytime cough, or nasal discharge after improvement of viral URI.
  • Severe URI symptoms include fever of at least 39°C or purulent nasal discharge.
  • Persistent URI symptoms without improvement include nasal discharge or daytime cough lasting longer than 10 days.
  • There is no role for routine imaging in diagnosis of acute bacterial sinusitis.
  • Diagnosis of GAS pharyngitis requires confirmation by rapid testing or culture.
  • Testing for GAS pharyngitis should be done only if 2 of the following conditions are present: fever, tonsillar exudate or swelling, swollen or tender anterior cervical nodes, and absence of cough.
  • Presumed GAS pharyngitis should not be treated empirically.
• The second principle of judicious antibiotic prescribing for pediatric URIs is to consider the benefits vs the harms of antibiotics.
  • For strictly defined AOM, the number needed to treat for a reduction in symptoms is as low as 4 patients.
  • However, antibiotic treatment of AOM offers no significant benefits in preventing complications such as mastoiditis.
  • For strictly defined bacterial sinusitis, antibiotics relieve symptoms at 3 and 14 days, but no evidence exists that antibiotics prevent complications such as brain abscess.
  • For confirmed GAS pharyngitis, antibiotics shorten symptom duration, prevent rheumatic fever, and may reduce secondary transmission.
  • However, evidence is limited that antibiotics may prevent GAS complications such as peritonsillar abscess.
  • Recommended first-line therapy is amoxicillin with or without clavulanate for AOM or bacterial sinusitis, and amoxicillin or penicillin for GAS pharyngitis.
  • For all 3 conditions, the harms of antibiotics are the lack of benefit from therapy when bacterial infection is not likely; and an increased risk for adverse events, including diarrhea, dermatitis, Clostridium difficile colitis, and antibiotic resistance.
• The third principle is to implement judicious antibiotic prescribing strategies for pediatric URIs.
  • For AOM, watchful waiting may be considered for patients older than 2 years, and for those with unilateral disease and without severe symptoms.
  • For AOM, shorter-duration therapy (7 days) may also be an option.
  • For bacterial sinusitis, watchful waiting may be considered for patients with persistent symptoms only.
  • For GAS pharyngitis, treatment may be limited to once-daily dosing of amoxicillin.
  • Azithromycin and oral third-generation cephalosporins are generally not recommended for these conditions attributable to Streptococcus pneumoniaeresistance.

Gum Chewing in Kids Under-Recognized Cause of Headaches

Pauline Anderson

 January 17, 2014

Treating some headaches in children may be a simple matter of getting them to quit chewing gum.

A new study suggests that excessive gum chewing may be an important but under-recognized trigger for headaches in older children.

The researchers, led by Nathan Watemberg, MD, Child Neurology Unit and Child Development Center, Meir Medical Center, Tel Aviv University, Israel, believe that excessive gum chewing causes headache not through the ingestion of aspartame from the gum, as has been previously suggested, but by putting undue exertion on the temporomandibular joint (TMJ).

"We feel that the mechanical burden is the culprit, as the amount of aspartame in the gum is small and, as this substance is present in sodas and other diet products, one would expect aspartame to be well associated with headaches, which is not the case," Dr. Watemberg told Medscape Medical News.

He advises that doctors make a point of enquiring about the gum chewing habits of adolescents reporting daily or recurrent headaches. "If the neurological examination is normal and the habit is present, they should first of all discontinue it to see if headaches improve, before embarking on expensive diagnostic procedures, or prescribing medications for the headache," Dr. Watemberg notes.

Their findings are published in the January issue of Pediatric Neurology.

Kicking the Chewing Habit

Dr. Watemberg said he has long observed a relationship between gum chewing and headaches in his practice. For several years, he has had very good results with headache relief after patients stop chewing gum.

For this study, he and his colleagues included 30 youngsters (25 girls), ranging in age from 6 to 19 years, who had recurrent episodes or chronic headache and were daily gum chewers. Their headaches were classified as migrainous (60%) or tension-type (40%).

Patients filled out a questionnaire that included information on medical and neurologic history, headache characteristics, family history of headaches, and known headache triggers. Researchers divided the participants into 4 groups according to gum chewing duration: up to 1 hour a day, 1 to 3 hours a day, 3 to 6 hours a day, and more than 6 hours a day.

Study participants were asked to stop gum chewing for a month. After this discontinuation, 26 patients responded (19 had complete resolution of headaches and 7 had some improvement in headache frequency and intensity). No improvement occurred in 4 patients.

The duration of symptoms before stopping gum chewing did not play a role in the clinical response. Some children who reported full or significant improvement had experienced chronic headaches for up to 6 years.

Patients were then asked to renew their gum chewing habit to the same extent as before discontinuation. All 20 of the 26 patients who first reported complete or partial headache relief and who reintroduced gum chewing reported relapse, within a week, of headaches of similar intensity as before they discontinued the chewing habit.

Research shows common headache triggers include weather, stress, menstruation, frequent travel, sleep disturbances, perfume, and lights. Triggers in children appear similar to those in adults, although they may also be vulnerable to video games, environmental noise, exposure to smoke, and school book reading, said Dr. Watemberg. Specific foods, such as chocolate, alcoholic drinks, and cheese, are also associated with headaches.

Joint Involvement

Headache has been shown to be associated with and be provoked by TMJ dysfunction. Chewing gum, as well as other oral habits (such as excessive nail biting and teeth grinding), imposes a mechanical burden on the joint.

In this study, the duration of gum chewing did not appear to be as important as the habit itself because all 4 groups included a fair number of cases. The "impressive" response to gum chewing discontinuation "strongly suggest in our opinion that the habit (and the burden on the temporomandibular joint) played a major role in our patients," the authors conclude.

Dr. Watemberg said he doesn't have any clear opinion about the maximal amount of chewing, or maximal time that could be spent chewing gum without developing headaches, since in this study some children who chewed gum as little as 1 hour a day reported headaches.

"I would think that the time/amount of chewing is related to other predisposing factors affecting the individual patient, such as anatomical facial features; maybe even a genetic predisposition to migraines," he said. "Therefore, my advice is that any person who chews gum on a daily basis and starts experiencing daily or recurrent headaches, is to discontinue the habit for several weeks irrespective of the time spent chewing. If the headaches improve or subside, then the chewing habit is the reason behind the headaches."

Prophylactic Probiotics Reduce Infantile Colic and Reflux

Lara C. Pullen, PhD

 January 14, 2014

Treatment with the probiotic Lactobacillus reuteri DSM 17938 during the first 3 months of life reduced the likelihood of colic, regurgitation, and functional constipation. Prophylactic treatment also reduced the public and private costs of managing these conditions.

Flavia Indrio, MD, from University of Bari Aldo Moro, Italy, and colleagues published the results of their large randomized clinical trial online January 13 in JAMA Pediatrics. The cohort included 589 newborns born at 9 neonatal units in Italy between September 1, 2010, and October 30, 2012. The investigators included both breast-fed and formula-fed infants.

The investigators report that daily administration of the probiotic reduced the incidence of inconsolable crying (mean duration of crying time, 38 vs 71 minutes; P < .01). In addition, infants in the probiotic group regurgitated significantly less often at 3 months of age as those in the control group (2.9 vs 4.6 times per day; P <.01).

The authors note that 16.8% of the study population was lost to follow-up.

Infantile colic is common and tends to peak at approximately 6 weeks of age. It is the cause of 10% to 20% of all pediatrician visits during the first 4 months of life. The authors found the use of the probiotic drops to be cost-effective (mean savings of $118.71 per patient for the family and mean savings of $140.30 per patient for the community).

Neonatal colic is considered a self-limiting clinical condition of unknown etiology. Numerous studies have suggested, however, that early functional gastrointestinal disorders can predict different diseases later in life. For example, the research group in Italy has previously published that children diagnosed with irritable bowel syndrome had a higher percentage of neonatal functional gastrointestinal disorders than those without irritable bowel syndrome.

Although the mechanism behind the connection between neonatal colic and later diseases is not clear, the authors suggest that early pain may promote the development of long-term visceral hypersensitivity and mucosal permeability. This could then alter the balance of the enteric microflora and increase low-grade inflammation. The authors propose that prophylactic treatment with lactobacilli may drive a change in colonization that may promote an improvement in intestinal permeability.

Long-term follow-up of infants treated with probiotics should shed some light on the effect of the treatment on long-term health.

At this time, systematic reviews and meta-analyses do not support the general use of probiotics in all infants with colic. Moreover, the mechanism of action behind the benefits of probiotics is still unclear.

"Nonetheless, despite their lack of information about the mechanisms of action and some study limitations, Indrio et al lend additional support to the potential use of L. reuteri DSM 17938 for infantile colic. Perhaps there will come a time when medical providers will recommend 5 probiotic drops a day to keep infantile colic away," write Bruno P. Chumpitazi, MD, MPH, and Robert J. Shulman, MD, from Baylor College of Medicine in Houston, Texas, in an accompanying editorial.

Dr. Chumpitazi and Dr. Shulman also note that, to date, there have been no documented adverse events in the use of probiotics for the treatment of infantile colic.

Caution is still warranted, Elizabeth Marcus, MD, assistant professor in the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition in Mattel Children's Hospital, University of California, Los Angeles, said to Medscape Medical News. "[T]reating every infant with probiotics as a prophylactic measure would be a dramatic step and not without risk. It would be interesting to see if probiotics could have similar efficacy as a treatment measure targeted only toward infants who show symptoms of specific conditions. This would be a finding that could potentially change clinical practice."

Foreign Body Ingestion

Alexandra Murray, OMSIII

 January 06, 2014

Complications from foreign body ingestion affect thousands of people each year and are responsible for approximately 1,500 deaths annually. ^[1,2] Foreign bodies can create a unique set of problems depending on whether they become lodged in the airway or GI tract. The course of treatment varies depending on the type of object ingested, the size of the foreign body and the patient’s age.

Aspirated Objects

Of aspirated foreign bodies, 80-90% become lodged in the bronchi whereas larger objects tend to become lodged in the larynx or trachea. ^[3] The location of the obstruction can sometimes be deciphered by certain clinical cues. Laryngeal foreign bodies can present with hoarseness or aphonia, whereas tracheal obstructions may present with asthma-like wheezing. Patients with foreign bodies in the bronchus typically demonstrate cough, unilateral wheezing and/or decreased breath sounds.^[3]

GI Foreign Bodies

Foreign bodies that are swallowed may become lodged at any point in the GI tract. Most foreign bodies that are identified in the esophagus must be removed, as well as foreign bodies that are too large to pass through the pyloric sphincter. Objects that reach the stomach can usually pass through the rest of the GI tract spontaneously without further complication. Foreign bodies that require immediate removal include objects that are very sharp, toxic (batteries) or magnetic. Safety pins, needles and other piercing objects must be removed immediately due to risk of bowel perforation. ^[1-5] In the case of batteries, recent studies suggest that the real danger from batteries is not necessarily the leakage of alkaline material, but the development of a current through gastrointestinal tissues leading to hydrolysis of tissue fluids and production of hydroxide ions at the negative pole of the battery. ^[6] Magnetic objects can be dangerous due to formation of magnetic fields that create pressure necrosis, fistulas and bowel perforation. ^[4]

Children

Children under the age of four are the most common culprits of foreign body ingestion. Children may not present to the ED immediately if the event was unwitnessed since it may take time for complications to develop. Children with foreign body ingestion may appear asymptomatic or have vague symptoms such as dysphagia, weight loss, drooling, emesis, chest pain, sore throat, stridor, cough, altered mental status or fever. ^[1-5] Typically, ingested foreign bodies include bones (fish, chicken) and common household items such as small toys, beads, button batteries and erasers. Coins are the most common ingested object by children (70% of reported cases), whereas peanuts are the most common objects to be aspirated. ^[1-5]

Adults

Unlike children, adults tend to present to the ED immediately after foreign body ingestion since the majority of events are accidental. Obstructive lesions or motility disorders of the esophagus such as GERD, hiatal hernia, abnormal rings/strictures and eosinophilic esophagitis have been identified as risk factors for acute food impaction. ^[1,5] Individuals with these risk factors who develop obstruction have the predisposition to choke on poorly chewed meat, leading to the disorder known as “steakhouse syndrome.” ^[7] Accidental ingestion may occur in “body packers” or i“body stuffers” who have been known to ingest packaged illegal substances (heroin, cocaine) in order to avoid detection. If these packages rupture within the carrier, toxicity can occur rapidly. ^[8]

Diagnostic Testing and Treatment

Initial evaluation typically involves AP and lateral X-rays of the airway and chest. Radiopaque objects will readily appear, and radiolucent objects may be appreciated by looking for secondary signs of airway compression, atelectasis and hyperinflation. Ingestion of a small amount of contrast material may allow visualization of filling defects and confirm the presence of a radiolucent foreign body. However, this may increase the risk of aspiration and obscure endoscopy visualization and you should consult your GI specialist beforehand. Handheld metal detectors are sensitive and specific for identifying ingested metal objects. ^[1-5,9]

There are several techniques that are used to relieve obstructions. However, the most commonly used technique with the highest success rate is flexible endoscopy. The flexible endoscope has lower complication rates and higher patient comfort ratings compared to other instruments. ^[1-5] If the obstruction does not require emergent removal and a less invasive approach is desired, glucagon can be administered to promote passage of a bolus by reducing the resting pressure of the smooth muscle at the lower esophageal sphincter. ^[10]

Instruction on Infant Crying May Lower Caregiver Depression

Jenni Laidman

 January 06, 2014

Teaching caregivers about normal infant sleeping and crying patterns and providing them with information on infant settling techniques improved maternal depression scores, according to a study published online January 6 in Pediatrics. The information also improved daytime sleep problems among infants who fed at least a dozen times a day.

Harriet Hiscock, MBBS, MD, from the Centre for Community Child Health, The Royal Children’s Hospital, Parkville, Australia; Murdoch Childrens Research Institute, The Royal Children’s Hospital, Melbourne; and the Department of Paediatrics, University of Melbourne, Australia, and colleagues conducted a randomized controlled trial , to determine the effect of an intervention program targeting infant sleep and crying problems. They enrolled 770 families of 781 infants born at 32 weeks' gestation or later in 42 well-child centers in Melbourne.

The intervention began at 4 weeks, when 385 families with 388 infants were given a booklet and a DVD that covered normal sleep and crying patterns, techniques for settling infants, information on possible medical causes of crying, and parent self-care advice. At 8 weeks, the information was reinforced in a telephone conversation, and again at 13 weeks in a parent group. Caregiver-reported infant sleeping and crying and caregiver depression symptoms were compared with reports from a control group of 385 families with 393 infants who were provided standard well-infant care.

Although caregivers saw some benefit in infants behavior in the treatment group, there were no overall differences in reports of infant sleeping, crying, or feeding problems at either 4 or 6 months in either cohort. However, infants classified as frequent feeders at baseline (those feeding >11 times in 24 hours) had reduced odds of daytime sleep problems at 4 months (odds ratio [OR] 0.13; 95% confidence interval [CI], 0.03 - 0.54) and 73% lower odds of daytime crying problems (OR, 0.27; 95% CI, 0.08 - 0.86). Nighttime sleep problems were similar in frequent feeders in both the treatment and control cohorts.

There were no differences in caregiver depression at 4 months, but at 6 months, caregivers in the intervention group were less likely to score higher than 9 on the Edinburgh Postnatal Depression Scale, with 7.9% scoring higher than 9 in the intervention group vs 12.9% in the control cohort (adjusted odds ratio [AOR], 0.57; 95% CI, 0.34 - 0.94; P = .03). The researchers adjusted for infant age, sex, rating in the Socio-Economic Indexes for Areas, parent education, parenting doubt surrounding infant sleep measured at baseline, parenting self-efficacy, and parental rating of self as a tense person.

Intervention caregivers had fewer doubts about their ability to manage infant sleep at both 4 months and 6 months ( P < .02 for both periods), and at 6 months, caregivers in the intervention group were also less likely to spend 20 minutes or more attending infant wakings (41% vs 51%; AOR, 0.66; 95% CI, 0.46 - 0.95; P = .03). The intervention group was also less likely to change infant formula, with 13% of the intervention group changing formula compared with 23% in the control group (AOR, 0.41; 95% CI, 0.21 - 0.82; P = .01).

Those who received the booklet and other training also reported less difficulty setting limits (adjusted mean difference, −1.22; 95% CI, −2.03 to −0.41; P = .003) and less excessive concern about sudden infant death (adjusted mean difference, −0.38; 95% CI, −0.67 to −0.08; P = .01). At 4 months, those in the intervention group sought help more often from health professionals, but there was no difference at 6 months.

AAP Releases New Principles for URI Antibiotics

Norra MacReady

 November 18, 2013

Effective use of antibiotics to treat pediatric upper respiratory tract infections (URIs) rests on 3 basic principles: accurate diagnosis, consideration of risks vs benefits, and recognizing when antibiotics may be contraindicated, according to a clinical report by the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP).

Of the nearly 50 million pediatric antibiotic prescriptions written annually, as many as 10 million of those "are directed toward respiratory conditions for which they are unlikely to provide benefit," lead author Adam L. Hersh, MD, PhD, and fellow committee members write in an article published in the December issue of Pediatrics. Often this occurs because it is hard to distinguish bacterial infections, which respond to antibiotics, from viral infections, which do not.

The report emphasizes "the importance of using stringent and validated clinical criteria when diagnosing acute otitis media (AOM), acute bacterial sinusitis, and pharyngitis caused by group A Streptococcus (GAS), as established through clinical guidelines," the authors write.

The first principle of judicious antibiotic prescribing is to determine the presence of a bacterial infection. For example, with AOM, this requires an otoscopic examination to observe characteristic inflammatory changes in the tympanic membrane plus bulging of the membrane or new-onset otorrhea not attributable to otitis externa, or mild bulging of the tympanic membrane accompanied by intense erythema or pain of recent onset. Acute bacterial sinusitis is diagnosed from persistent, worsening, or severe symptoms. Pharyngitis resulting from GAS can be diagnosed by taking a throat culture to identify the organism.

Following these diagnostic guidelines can help clinicians rule out the common cold, nonspecific URI, and bronchitis, which are viral in origin and will not respond to antibiotics, the authors write.

The second principle is to weigh the benefits against the harms of antibiotics. In the case of AOM, the evidence suggests that although at least 50% of patients may get well without antibiotics, antibiotics hasten recovery and are especially helpful for patients who are younger or have bilateral or severe disease. The evidence for using antibiotics to treat acute bacterial sinusitis is limited and mixed, and the role of the drugs in preventing complications such as orbital cellulitis or intracranial abscess also is unproven. Nevertheless, the AAP recommends antibiotics for children with clinical features of acute bacterial sinusitis, especially when the symptoms are worsening or severe. As for GAS pharyngitis, good evidence suggests that antibiotics can shorten symptom duration, although their effect on limiting fever is less clear, and they may reduce horizontal transmission. Antibiotics also may prevent suppurative complications of GAS pharyngitis such as peritonsillar abscess.

The harms of antibiotics can potentially outweigh these benefits, the authors warn. Most of the clinical trials reviewed have used amoxicillin or amoxicillin-clavulanate, which have been associated with adverse events ranging from mild (eg, diarrhea and rash), to severe (eg, Stevens-Johnson syndrome), to life-threatening cardiac and anaphylactic reactions. What is more, a growing body of evidence suggests that antibiotic use early in life may upset the normal microbial balance in the intestine and other organs, possibly setting the child up for lifelong health problems, including inflammatory bowel disease, obesity, eczema, and asthma. "Application of stringent diagnostic criteria and use of therapy only when the diagnosis and potential benefits are well established is essential to minimizing the impact of antibiotic overuse on resistance in individuals and within communities," the authors write.

Principle 3 is implementation of judicious prescribing strategies, including selection of the antibiotic most likely to eliminate the infecting organism, using an appropriate dose, and treating for the shortest duration possible. The committee suggests that physicians consider a "wait-and-see" approach before prescribing antibiotics, especially for older patients with mild to moderate AOM or sinusitis. They also recommend an assessment of the child's overall antibiotic exposure.

These principles "can be used to amplify messages from recent clinical guidelines for local guideline development and for patient communication; they are broadly applicable to antibiotic prescribing in general," the authors conclude.

The authors have disclosed no relevant financial relationships.

Pediatrics. 2013;132:1146-1154.

Flu Vaccine Allergy May Be Attributed to Gelatin, Not Egg

Kate Johnson

 November 21, 2013

BALTIMORE — A new allergy risk to a common ingredient has been identified in a recent case study that has implications for vaccination. Gelatin, often found in lunchmeats, jellies, and gummy candies, is also used in vaccines, and allergy — though rare — can trigger anaphylaxis.

An allergy to egg is no longer considered a risk of flu vaccination, but investigators presenting here at the American College of Allergy, Asthma & Immunology (ACAAI) 2013 Annual Scientific Meeting warned that gelatin allergy can be a problem.

It is rare, and the first case reports were published in the mid-1900s, Stephanie Albin, MD, from the Jaffe Food Allergy Institute at Mount Sinai in New York, New York, told Medscape Medical News. However, it can present significant issues because many vaccines — and foods — contain gelatin.

Gelatin is a mixture of peptides and proteins produced by partial hydrolysis of collagen extracted from cow, pig, and fish, she explained. Patients with gelatin allergy do not react to meat because gelatin is derived from tendons and bones rather than the flesh. And gelatin in vaccines is more likely to cause an allergic reaction because it is concentrated, purified, and processed and has direct access to the immune system through injection.

Vaccines that contain gelatin include those against influenza; measles, mumps, and rubella (MMR); varicella; yellow fever; zoster; rabies; Japanese encephalitis; and diphtheria, tetanus, and pertussis (DTaP).

The case report involved a 4-year-old boy with a presumed egg allergy who was avoiding unbaked egg upon developing a perioral rash after eating meringue icing.

 

He had received the influenza vaccine in the past without any issue, but that year he developed diffuse hives, watery eyes, sneezing, and vomiting within 15 minutes.Dr. Stephanie Albin

 

"He had received the influenza vaccine in the past without any issue, but that year he developed diffuse hives, watery eyes, sneezing, and vomiting within 15 minutes of receiving the immunization," Dr. Albin reported.

A complete history of the patient's food reactions revealed that he had previously developed a watery mouth, abdominal pain, and weakness after eating gummy candies, gummy vitamins, and marshmallows. The patient was also avoiding peanuts, tree nuts, fish, and shellfish because of a family history of food allergy.

Skin-prick testing showed a 4-mm wheal and 21-mm flare with commercial egg extract, as well as a 13-mm wheal and 33-mm flare with fresh gelatin. Serum testing showed an IgE level of 4.76 kIU/L for egg white and 0.39 kIU/L for bovine gelatin. Positive IgE levels were also noted for salmon.

The patient was offered an oral food challenge to salmon with the idea that salmon-derived gelatin might be safe, but the family declined and preferred to defer any immunization with gelatin-containing vaccines, Dr. Albin said.

Gelatin-Free Alternatives

There are gelatin-free alternatives to some vaccines, including those against influenza and DTaP, but not to others, including those against zoster and MMR.

The patient was instructed to avoid egg, salmon, and gelatin and to introduce peanut, tree nuts, and shellfish at home one at a time. A prescription was given for an epinephrine autoinjector and an emergency action plan discussed.

The patient's previous influenza immunizations may have been administered before clinical sensitization, senior author Anna Nowak-Wegrzyn, MD, from the Icahn School of Medicine at Mount Sinai, explained to Medscape Medical News.

"There is always a sensitization period during which allergy develops. It may depend on the patient's immune system and on the amount of gelatin in the vaccines that is highly variable," she said.

The index of suspicion for gelatin allergy depends on the allergic reaction, said Dr. Albin. "If a patient had anaphylaxis after vaccination, you should consider gelatin allergy. If a patient had a large local reaction after vaccination, it is less likely to be gelatin allergy."

It's very uncommon to be allergic to gelatin, but if you see a reaction to the influenza vaccine it is probably gelatin and not egg allergy, confirmed Jay Portnoy, MD, chair of the abstract committee for ACAAI 2013.

 

Some allergists are aware of this and some are not, and I can guarantee that none of the primary care doctors are aware because they send me their egg-allergic patients. Dr. Jay Portnoy

 

A recent update from the American Academy of Allergy, Asthma & Immunology and ACAAI Joint Task Force on Practice Parameters say that patients with any severity of egg allergy can safely receive the influenza vaccine with no special precautions ( Ann Allergy Asthma Immunol. 2013;111:301-302).

Many physicians remain unaware of this update, and even current recommendations from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices do not reflect this information, Dr. Portnoy told Medscape Medical News.

"Some allergists are aware of this and some are not, and I can guarantee that none of the primary care doctors are aware because they send me their egg-allergic patients and I just give them the flu shot. I see a lot of them," he said.

A new warning may end up replacing the previous egg allergy precautions after a case report of pediatric anaphylaxis to the influenza vaccine was traced back to gelatin allergy.

The study authors have disclosed no relevant financial relationships. Dr. Portnoy reports work with Sanofi, Thermo Fisher Scientific, and Mylan.

American College of Allergy, Asthma & Immunology (ACAAI) 2013 Annual Scientific Meeting. Abstract P104. Presented November 9, 2013.