News & Analysis Medical News & Perspectives .........p2135 Excessive Antibiotic Prescribing for Sore Throat and Acute Bronchitis Remains Common
Clinical Trials Update ..............................p2139 Depression, Diabetes, and Cognitive Decline
FDA Questions Effectiveness of Measures to Reduce or Prevent Illness From Eating Imported Spices
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news@JAMA: From JAMA's Daily News Site
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NIAID Expands
Medical News & Perspectives
Excessive Antibiotic Prescribing for Sore Throat and Acute Bronchitis Remains Common Bridget M. Kuehn, MSJ
Heinz F. Eichenwald, MD/Centers for Disease Control and Prevention
M
any physicians continue to overprescribe antibiotics to patients with a sore throat or acute bronchitis despite a lack of benefit for most cases, accordingtoresearchpresentedinOctoberat IDWeek 2013, a joint meeting of the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. Inappropriate antibiotic prescribing is among several factors contributing to a growing epidemic of antibiotic resistance in the United States, according to a report published in September by the US Centers for Disease Control and Prevention (CDC) (http: //jama.md/1dYmAz7). The report estimates that each year, more than 2 million US individuals develop bacterial infections that are resistant to antibiotics, resulting in 23 000 deaths. Despite the urgency of the situation, a pair of Harvard University researchers found that most patients who present with a sore throat or acute bronchitis receive an antibiotic, even though it is unlikely to help them and may contribute to the emergence of resistance.
Persistent Behavior Only about 10% of adults with a sore throat— individuals with group A Streptococcus infections—are expected to require antibiotics for their care, explained Jeffrey A. Linder, MD, MPH, of Harvard Medical School and Brigham and Women’s Hospital in Boston. Yet Linder and his colleague Michael L. Barnett, MD, using data from the CDC’s National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical
Care Survey collected from 1997 through 2010, found that in 2010 about 60% of adults received a prescription for antibiotics for a sore throat.
Physicians often prescribe antibiotics for adults with a sore throat, though only about 10% (those with group A Streptococcus) are likely to benefit.
These new findings also were published in JAMA Internal Medicine on the day of the presentation(BarnettMLandLinderJA.JAMA Intern Med. doi:10.1001/jamainternmed.2013 .11673 [published online October 3, 2013]). Although there has been a small decline since the late 1990s in prescribing antibiotics to adults presenting with a sore throat, when about 70% of adult patients with sore throats received prescriptions, “We are still far away from the ideal rate of antibiotic prescribing for adult sore throat,” Linder said. The percentage of visits at which clinicians prescribed penicillin, the preferred antibiotic for strep throat infections, stayed steady during the same period, at about 9%
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of visits. But prescribing of azithromycin, a broad-spectrum antibiotic, increased substantially from a rate that was too small to measure in 1997-1998 to 15% in 20092010. Linder said this trend was concerning because streptococcus A bacteria have remained susceptible to treatment with penicillin but are often resistant to these newer classes of drugs, meaning patients are even less likely to benefit from their use. Ed Septimus, MD, of the Texas A&M Health Science Center in Houston, who moderatedthepressconferenceatIDWeek,noted that the IDSA does not recommend azithromycin for sore throat and that using this broad-spectrum antibiotic for this purpose could weaken its effectiveness over time by promoting resistance. “We are using up valuable drugs because of overuse,” he said. An even greater proportion of adult patients presenting with acute bronchitis received antibiotics, the researchers discovered when they examined the same data sources. They found that increasing numbers of patientswereseekingcareforthiscondition,with an estimated 3.4 million visits in 2010 comparedwith1.1millionin1996,accordingtodata they presented at the meeting. Overall about three-quarters of these patients were prescribed antibiotics, a rate that has remained fairlyconstantoverthepastdecade,theysaid. As was the case for sore throat, prescribers often selected a broad-spectrum antibiotic for patients with acute bronchitis. Prescriptions for extended-spectrum macrolides foracutebronchitisincreasedfrom25%ofvisits in 1996 to 41% of visits in 2010, while use of other classes of antibiotics for this indication remained constant. JAMA November 27, 2013 Volume 310, Number 20
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Western Oregon University User on 05/24/2015
2135
News & Analysis
Talking About the Risks of Overuse Substantial costs and risks are associated with the largely unnecessary prescribing of antibiotics for sore throat or bronchitis. Linder estimated that the financial cost between 1997 and 2010 ranged from $500 million and $20 billion. Patients may also sufferadverseeventssuchasnausea,diarrhea,allergic reactions, or yeast infections, he noted. There is also growing recognition that antibi-
otic use may damage communities of beneficial bacteria in the body and increase the risk of developing noninfectious diseases, such as inflammatory bowel diseases, said Septimus. Linder encouraged physicians to discuss these risks with patients. “For individual patients, the compelling reason not to take antibiotics for these conditions is that they are not going to help you and they may hurt you.” He noted that physicians may
worry that patients expect to receive an antibiotic, but some studies have suggested patients aren’t as eager to take antibiotics as physicians may believe. Anaddedbenefitofdiscussingthelackof benefitandthepotentialrisksofantibioticuse with patients is that patients are often more satisfied with their care, said Septimus. “We, as physicians, need to take accountability for our actions,” he said.
FDA Questions Effectiveness of Measures to Reduce or Prevent Illness From Eating Imported Spices
A
n estimated 12% of spices imported into the United States are contaminated with filth such as insects or rodent hairs and more than 6% contain the bacteria Salmonella—nearly twice the contaminant levels found in other imported foods, said the US Food and Drug Administration (FDA) in a draft risk profile (http: //1.usa.gov/1gd8xcH). The high percentages are troubling, as an estimated 86% of US households use fresh or dried herbs, spices, and seasonings. US per capita spice use has increased about 0.5 lb per decade since 1996. In 2010, per capita annual spice consumption was 3.64 lb, excluding dehydrated garlic. The draft risk profile, issued October 30, was developed in response to 2 US outbreaks ofillnessassociatedwithtaintedspices:alarge 2008-2009 outbreak of Salmonella-related illness associated with eating contaminated
2136
ground white pepper and a subsequent outbreak associated with consumption of products containing black and red pepper. Worldwide,from1973to2010,therewere124 reported outbreaks of foodborne illnesses attributed to consumption of pathogencontaminated spices. These outbreaks resulted in 1946 reported illnesses, 128 hospitalizations, and 2 deaths. Infants and children were particularly affected by 5 of these outbreaks. The purpose of the draft risk profile is to describe the nature and extent of the health risk of eating spices, evaluate current options designed to reduce the public health risk and identify further measures to improve safety, and identify data gaps and research needs. The FDA is accepting comments on the draft risk profile (which can be sent to http://1.usa.gov/HAGSn0) through January 3, 2014.
Most of the spices used in the United States are imported, and Salmonella has been foundinawidevarietyoftheseproducts.During fiscal years 2007-2009, more than 80 different Salmonella serotypes were isolated in contaminatedspiceshipments;6.8%ofthese isolatesshowedpropertiesofantimicrobialresistance. Some contaminated shipments imported into the United States had been reported to have undergone treatment to reduce the presence of pathogens before exportation, such as steaming, irradiation, or application of ethylene oxide. As for filth contaminants, the most common types were insects or insect fragments and animal (mostly rodent) hair. Direct evidence of animal fecal and/or insect fecal contamination was found in a small number of sampled shipments. Nearly all the insects found in spice samples were storedproduct pests, suggesting inadequate packing or storage conditions. The FDA risk profile said the presence of filth contaminants in spice shipments indicates unsanitary conditions and failures to apply Current Good Manufacturing Practices. The draft risk profile authors noted that knowledge and technology are available to significantly reduce the risk of illness from eating contaminated spices. The profile concludes that failures in the farm-to-table food safety system that could have led to adulteration of spices generally arose from poor and inconsistent application of preventive controls, such as failing to limit animal access to the spice source plants during harvest or drying, failing to limit insect and rodent access to spices during storage, or failing to subject all spices to an effective pathogen reduction treatment.
JAMA November 27, 2013 Volume 310, Number 20
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Western Oregon University User on 05/24/2015
jama.com
synergee/iStock.com
Mike Mitka, MSJ
Clinical Trials Update ..............................p2139 Depression, Diabetes, and Cognitive Decline
FDA Questions Effectiveness of Measures to Reduce or Prevent Illness From Eating Imported Spices
Risks Higher for Some Estrogen Drugs
Do Flawed Data on Caloric Intake From NHANES PresentProblemsforResearchersandPolicyMakers?
Kidney Injury From Contrast Media Halted HIV Vaccine Trial
Health Agencies Update......................p2140 Sleep and the Brain
More Evidence Emerges That Bats May Have Spread SARS
Treating Batten Disease
news@JAMA: From JAMA's Daily News Site
Drugs and Devices for Rare Diseases
News From the CDC ................................p2141 More Public Health Agencies Now Get Disease Data in Electronic Reports Deaths Linked With Rapid Opioid Detox Method Using Anesthesia Flu Vaccination Increases Among US Health Care Personnel Middle East Coronavirus Infections Surpass 100; Fatality Rate is 45%
NIAID Expands
Medical News & Perspectives
Excessive Antibiotic Prescribing for Sore Throat and Acute Bronchitis Remains Common Bridget M. Kuehn, MSJ
Heinz F. Eichenwald, MD/Centers for Disease Control and Prevention
M
any physicians continue to overprescribe antibiotics to patients with a sore throat or acute bronchitis despite a lack of benefit for most cases, accordingtoresearchpresentedinOctoberat IDWeek 2013, a joint meeting of the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. Inappropriate antibiotic prescribing is among several factors contributing to a growing epidemic of antibiotic resistance in the United States, according to a report published in September by the US Centers for Disease Control and Prevention (CDC) (http: //jama.md/1dYmAz7). The report estimates that each year, more than 2 million US individuals develop bacterial infections that are resistant to antibiotics, resulting in 23 000 deaths. Despite the urgency of the situation, a pair of Harvard University researchers found that most patients who present with a sore throat or acute bronchitis receive an antibiotic, even though it is unlikely to help them and may contribute to the emergence of resistance.
Persistent Behavior Only about 10% of adults with a sore throat— individuals with group A Streptococcus infections—are expected to require antibiotics for their care, explained Jeffrey A. Linder, MD, MPH, of Harvard Medical School and Brigham and Women’s Hospital in Boston. Yet Linder and his colleague Michael L. Barnett, MD, using data from the CDC’s National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical
Care Survey collected from 1997 through 2010, found that in 2010 about 60% of adults received a prescription for antibiotics for a sore throat.
Physicians often prescribe antibiotics for adults with a sore throat, though only about 10% (those with group A Streptococcus) are likely to benefit.
These new findings also were published in JAMA Internal Medicine on the day of the presentation(BarnettMLandLinderJA.JAMA Intern Med. doi:10.1001/jamainternmed.2013 .11673 [published online October 3, 2013]). Although there has been a small decline since the late 1990s in prescribing antibiotics to adults presenting with a sore throat, when about 70% of adult patients with sore throats received prescriptions, “We are still far away from the ideal rate of antibiotic prescribing for adult sore throat,” Linder said. The percentage of visits at which clinicians prescribed penicillin, the preferred antibiotic for strep throat infections, stayed steady during the same period, at about 9%
jama.com
of visits. But prescribing of azithromycin, a broad-spectrum antibiotic, increased substantially from a rate that was too small to measure in 1997-1998 to 15% in 20092010. Linder said this trend was concerning because streptococcus A bacteria have remained susceptible to treatment with penicillin but are often resistant to these newer classes of drugs, meaning patients are even less likely to benefit from their use. Ed Septimus, MD, of the Texas A&M Health Science Center in Houston, who moderatedthepressconferenceatIDWeek,noted that the IDSA does not recommend azithromycin for sore throat and that using this broad-spectrum antibiotic for this purpose could weaken its effectiveness over time by promoting resistance. “We are using up valuable drugs because of overuse,” he said. An even greater proportion of adult patients presenting with acute bronchitis received antibiotics, the researchers discovered when they examined the same data sources. They found that increasing numbers of patientswereseekingcareforthiscondition,with an estimated 3.4 million visits in 2010 comparedwith1.1millionin1996,accordingtodata they presented at the meeting. Overall about three-quarters of these patients were prescribed antibiotics, a rate that has remained fairlyconstantoverthepastdecade,theysaid. As was the case for sore throat, prescribers often selected a broad-spectrum antibiotic for patients with acute bronchitis. Prescriptions for extended-spectrum macrolides foracutebronchitisincreasedfrom25%ofvisits in 1996 to 41% of visits in 2010, while use of other classes of antibiotics for this indication remained constant. JAMA November 27, 2013 Volume 310, Number 20
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Western Oregon University User on 05/24/2015
2135
News & Analysis
Talking About the Risks of Overuse Substantial costs and risks are associated with the largely unnecessary prescribing of antibiotics for sore throat or bronchitis. Linder estimated that the financial cost between 1997 and 2010 ranged from $500 million and $20 billion. Patients may also sufferadverseeventssuchasnausea,diarrhea,allergic reactions, or yeast infections, he noted. There is also growing recognition that antibi-
otic use may damage communities of beneficial bacteria in the body and increase the risk of developing noninfectious diseases, such as inflammatory bowel diseases, said Septimus. Linder encouraged physicians to discuss these risks with patients. “For individual patients, the compelling reason not to take antibiotics for these conditions is that they are not going to help you and they may hurt you.” He noted that physicians may
worry that patients expect to receive an antibiotic, but some studies have suggested patients aren’t as eager to take antibiotics as physicians may believe. Anaddedbenefitofdiscussingthelackof benefitandthepotentialrisksofantibioticuse with patients is that patients are often more satisfied with their care, said Septimus. “We, as physicians, need to take accountability for our actions,” he said.
FDA Questions Effectiveness of Measures to Reduce or Prevent Illness From Eating Imported Spices
A
n estimated 12% of spices imported into the United States are contaminated with filth such as insects or rodent hairs and more than 6% contain the bacteria Salmonella—nearly twice the contaminant levels found in other imported foods, said the US Food and Drug Administration (FDA) in a draft risk profile (http: //1.usa.gov/1gd8xcH). The high percentages are troubling, as an estimated 86% of US households use fresh or dried herbs, spices, and seasonings. US per capita spice use has increased about 0.5 lb per decade since 1996. In 2010, per capita annual spice consumption was 3.64 lb, excluding dehydrated garlic. The draft risk profile, issued October 30, was developed in response to 2 US outbreaks ofillnessassociatedwithtaintedspices:alarge 2008-2009 outbreak of Salmonella-related illness associated with eating contaminated
2136
ground white pepper and a subsequent outbreak associated with consumption of products containing black and red pepper. Worldwide,from1973to2010,therewere124 reported outbreaks of foodborne illnesses attributed to consumption of pathogencontaminated spices. These outbreaks resulted in 1946 reported illnesses, 128 hospitalizations, and 2 deaths. Infants and children were particularly affected by 5 of these outbreaks. The purpose of the draft risk profile is to describe the nature and extent of the health risk of eating spices, evaluate current options designed to reduce the public health risk and identify further measures to improve safety, and identify data gaps and research needs. The FDA is accepting comments on the draft risk profile (which can be sent to http://1.usa.gov/HAGSn0) through January 3, 2014.
Most of the spices used in the United States are imported, and Salmonella has been foundinawidevarietyoftheseproducts.During fiscal years 2007-2009, more than 80 different Salmonella serotypes were isolated in contaminatedspiceshipments;6.8%ofthese isolatesshowedpropertiesofantimicrobialresistance. Some contaminated shipments imported into the United States had been reported to have undergone treatment to reduce the presence of pathogens before exportation, such as steaming, irradiation, or application of ethylene oxide. As for filth contaminants, the most common types were insects or insect fragments and animal (mostly rodent) hair. Direct evidence of animal fecal and/or insect fecal contamination was found in a small number of sampled shipments. Nearly all the insects found in spice samples were storedproduct pests, suggesting inadequate packing or storage conditions. The FDA risk profile said the presence of filth contaminants in spice shipments indicates unsanitary conditions and failures to apply Current Good Manufacturing Practices. The draft risk profile authors noted that knowledge and technology are available to significantly reduce the risk of illness from eating contaminated spices. The profile concludes that failures in the farm-to-table food safety system that could have led to adulteration of spices generally arose from poor and inconsistent application of preventive controls, such as failing to limit animal access to the spice source plants during harvest or drying, failing to limit insect and rodent access to spices during storage, or failing to subject all spices to an effective pathogen reduction treatment.
JAMA November 27, 2013 Volume 310, Number 20
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Western Oregon University User on 05/24/2015
jama.com
synergee/iStock.com
Mike Mitka, MSJ
