Newsletter from Penn Elm Medical Group

NEWSLETTER: November 2005

Happy Thanksgiving!

Penn Elm Medical Group
488 E. Valley Parkway
Suite 411
Escondido, CA 92025
(760) 745-2000

NEWS YOU CAN USE
Antibiotic Treatment Unnecessary for Acute Eye Infections
According to a recent trial, children with acute infective conjunctivitis don't need antibiotics. Peter W. Rose, M.D., of the University of Oxford, and colleagues reported online in The Lancet that there was no significant difference in the recovery rate between 163 children treated with antibiotic eye drops and 163 given placebo drops.

In this study of children aged six months to 12 years, 86% in the antibiotic group had healed after seven days, versus 83% in the placebo group. "About half a day was gained in time to resolution between children treated with antibiotic and those with placebo, but this gain has to be weighed against the personal and health-care costs of a condition that improves without treatment," wrote Dr. Rose, and colleagues. Relapse rates also did not differ substantially between the treatment groups, with seven (4%) of the children treated with placebo experiencing another episode of conjunctivitis within six weeks, compared with five (3%) of those given antibiotics. One child had a drug-related side effect in the antibiotic group, with swollen eyelids and face.

Dr. Rose and colleagues concluded, "Parents should be encouraged to treat children themselves (with topical lubricants) without medical consultation unless their child develops unusual symptoms or symptoms persist for more than a week." Although bacterial conjunctivitis is generally self-limited, most clinicians use topical antibiotic therapy based upon parental pressure. This can be an important issue for parents as many daycare centers and schools require 24 hours of topical therapy before allowing the children to return to school. Antibiotics typically used in the U.S. include erythromycin opthlamic ointment or sulfa ophthalmic drops.

Antibiotics Don't Shorten Cough Duration in Lower Respiratory Tract Infections
SOUTHAMPTON, England -- Antibiotics make patients happy even though the drugs don't shorten the duration of cough, congestion, or general malaise caused by lower respiratory tract infections, researchers reported recently. The only measurable effect of giving antibiotics immediately is that they may cut about a day off the tail end of sickness when symptoms such as sleep disturbance, phlegm, and feeling unwell are waning, said results of a study published in the June 22/29 issue of the Journal of the American Medical Association. This is a questionable benefit that does not outweigh the dangers of antibiotic resistance, reported Paul Little, M.D., of the University of Southampton and colleagues.

These were the conclusions derived from a randomized controlled trial that compared three antibiotic strategies—immediate, delayed offer of antibiotics, and no antibiotics—as well as the value of educational materials about lower respiratory tract infection. The study also found that educating patients about lower respiratory tract infection had no effect on outcome or on patient satisfaction. Antibiotic use did, however, predict patient satisfaction, as seen by the satisfaction of 86% of patients immediately handed a prescription for antibiotics. They reported being very satisfied, versus 77% of those who had to wait to get antibiotics and 72% of patients who were not offered antibiotics (P = 0.005). Immediately prescribing antibiotics also appears to reinforce patients' belief in the value of antibiotics because 75% of the patients who received antibiotics immediately believed the drugs were effective, versus 40% of those who waited to receive antibiotics and 47% of those who received no antibiotics.

Dr. Little and colleagues randomized 262 patients to immediate antibiotics, 272 to delayed prescription, and 273 to no antibiotics. About half of each group also received informational materials. One hundred and thirty-six patients were younger than 16, and 133 were older than 60. Patients, or patients' parents for those younger than 16, were asked to keep daily diaries and to complete satisfaction questionnaires. Symptoms, including cough, sputum production, well being, sleep disturbance, and activity disturbance were rated on a scale of 0 to 6. 562 patients returned completed diaries and 78 completed satisfaction surveys. For all patients, cough lasted a mean of 11.7 days, although 25% of patients had a cough lasting 17 days or longer.

In a pre-specified subgroup analysis, patients who produced green sputum also had no significant benefit from antibiotics, and elderly patients had less benefit from antibiotic treatment, either immediate or delayed. Among children there was no difference among the three antibiotic strategies. In an editorial that accompanied the study, Mark H. Ebell, M.D., of Michigan State University in East Lansing, said that although acute cough in healthy adults is common, the evidence in favor of the use of antibiotics is relatively limited; consisting primarily of nine studies with 750 patients, many performed a decade or more ago. Dr. Ebell wrote that there were three take home messages in the new study: 1) antibiotics have little or no benefit for patients with cough, regardless of age, low-grade fever or sputum production; 2) physicians should tell patients that cough can last as long as three weeks; and 3) by prescribing antibiotics, physicians reinforce patients' belief in the value of antibiotics.

Antibacterial Soaps are a Washout, Declares FDA Panel
SILVER SPRING, Md., Oct. 20 - Antibacterial soaps don't reduce the risk of illness any better than plain old soap, proclaimed an FDA advisory committee today in a unanimous vote. Indeed, said Alastair J.J. Wood, M.D., of Vanderbilt, chairman of the FDA's Nonprescription Drugs Advisory Committee, the members of the panel were unconvinced by testimony during the day that antibacterial soaps and disposable wipes are any more effective than regular soap and water in preventing infections in the home. In lieu of readily available soap and water, said the panel, alcohol-based hand sanitizers are a sensible alternative.

Now that the committee has taken its stand, however, it's not clear how the FDA itself will respond. Although there are allegations that antibacterial soaps may promote drug-resistant bacteria—which led to today's hearing—the likelihood of banning the products is slim. Instead, any action may take the form of squeezing marketing claims or revising the products' labels. During the day, infectious disease and drug experts called on industry to concede that bacteria-killing soaps may actually be hastening bugs' evolution towards drug-resistant "super-bugs." Stuart B. Levy, M.D., director of the Center for Adaptation Genetics and Drug Resistance at Tufts in Boston testified, "Bacteria are not going to be destroyed. They've seen dinosaurs come and go," he noted. "They will be happy to see us come and go. Any attempt to sterilize our homes is fraught with failure." The problem, Dr. Levy and others said, is that bactericidal soaps leave trace chemical residues and tend to target specific processes in the bacterial life-cycle, which can allow the bacteria to select for resistant strains. Hand soaps, in contrast, suspend bacteria and make it easier for them to be washed down the drain or wiped off on a towel, but aren't that effective at knocking off germs.

As reported in July, investigators from the CDC, and colleagues in Pakistan, conducted an ambitious randomized controlled trial of the effects of hand washing on disease reduction in Karachi, a Pakistani city of four million residents living in squatter settlements. They found that hand washing reduced the incidence of pneumonia by 50% and the incidence of diarrhea by 53%. Hand-washing and daily bathing also cut the incidence of impetigo by 34%. They also noted that antibacterial soap did not provide any significant advantage over plain soap for any of the health outcomes in the study.

"Soap companies should consider whether the funds and marketing efforts spent in the addition of antibacterial compounds to soap would be better deployed to improve the lathering and sensory experience of hand washing to make the action more pleasant, and to actively promote regular hand washing," the investigators in that study said. But it was clear at today's hearing that industry hopes the FDA will wash its hands of the whole affair. The advisory panel has said that consumer products that include antimicrobial ingredients should be required to furnish scientific evidence of efficacy against infections.

A literature search performed by FDA review staff failed to find to find a correlation between use of antiseptic hand washes and a reduction in illness rates in homes, schools, or day care centers, according to an agency briefing document."The one randomized, blinded clinical trial (Larson et al., 2004) that studied triclosan-based soap showed no reduction in symptoms of infectious disease or disease transmission," the briefing stated. "Furthermore, the literature suggests that consumer hand washing techniques may not result in a clinically significant bacterial log reduction." Other studies have shown that alcohol-based hand sanitizers can also kill bacteria, but the use of these agents has not been associated with bacteria resistance, according to infectious disease experts.

IMPORTANT ANNOUNCEMENTS
Schedule Your Physical Exam Early
The holidays are often a popular time to schedule physical exams because people have extra days off work, insurance coverage often changes on January 1, and patients are looking for current year tax deductions. If you want to get a physical before the end of 2005 please schedule it as soon as possible to avoid this last minute crunch.

WHAT’S NEW AT PENN ELM?
Flu Vaccine
Again this year there is a national distribution shortage of flu vaccine. Despite guarantees of full stock from the three major pharmaceutical companies, Penn Elm, like many medical groups, has only been receiving small shipments. Please contact our front desk each week to see if we received our full stock yet. According to the CDC, the flu shot can be given to all patients, but since we still have a limited supply we are giving priority to patients who are most likely to have serious health problems if they get the flu, including:

Children aged 6 months to 23 months.

Seniors aged 65 years and older.

People 2 years or older who have an underlying, long-term illness: heart or lung disease, metabolic disease (like diabetes), kidney disease, a blood disorder, or a weakened immune system (including people with HIV/AIDS).

Women who will be pregnant this season.

People who live in nursing homes or other chronic-care facilities.

People who are 6 months to 18 years of age and take aspirin daily.

Health-care workers who take care of patients.

People who have, or take care of, a baby under 6 months old (flu shots are not given to babies under 6 months).

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