Hans Stalder

Role of Nasopharyngeal Culture in Antibiotic Prescription for Patients with Common Cold or Acute Sinusitis

Abstract The aim of the present study was to assess the hypothesis that, when present in nasopharyngeal secretions, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis play a pathogenic role early in the course of an upper respiratory tract infection. Adults with a clinical diagnosis of acute sinusitis or common cold were enrolled. Participants were randomly assigned in a double-blind manner to receive azithromycin 500 mg daily or placebo for 3 days. The effect of treatment on symptom evolution in the predefined subset of patients with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis in their nasopharyngeal secretions was assessed. Of 265 patients enrolled, 132 received placebo and 133 azithromycin. Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis was identified in nasopharyngeal secretions of 77 patients (29%). In this predefined subgroup of patients with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, resolution of symptoms by day 7 occurred in 73% of those treated with azithromycin compared with 47% of those who received placebo (P=0.007). The median time before resolution of symptoms was 5 days in the azithromycin group compared to 7 days in the placebo group. Respiratory complications requiring antibiotic treatment occurred in 19% of patients in the placebo group and in 3% of the azithromycin group (P=0.025). In the remaining 188 patients without Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, resolution of symptoms by day 7 was similar in both groups (69% in the placebo group vs. 64% in the azithromycin group [P=0.75]). Antibiotic treatment is of clinical benefit for patients with acute sinusitis or common cold when Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis is present in nasopharyngeal secretions. This observation provides new insights into the pathogenic role of these bacteria in the early stage of the common cold.

Symptoms and Clinical and Radiological Signs Predicting the Presence of Pathogenic Bacteria in Acute Rhinosinusitis

A minority of patients with upper respiratory tract infections (URTI) have a bacterial infection and may benefit from antibiotherapy. In previous investigations we showed that in patients suffering from acute rhinosinusitis associated with the presence of Streptococcus pneumoniae , Haemophilus influenzae or Moraxella catarrhalis in their nasopharygeal secretions, resolution of symptoms was significantly improved by antibiotic treatment. The present analysis was performed to determine whether specific clinical symptoms or signs observed during careful endoscopic examination of the nasal cavities could help the clinician to identify a subset of patients with moderate forms of acute rhinosinusitis infected with pathogenic bacteria. Detailed clinical histories were obtained and medical examinations performed in 265 patients (138 females, 127 males; mean age 35 years) presenting with a< 4-week history of URTI symptoms but who did not require immediate antibiotic therapy for severe rhinosinusitis. The presence of three pathogenic bacteria ( S. pneumoniae , H. influenzae and M. catarrhalis ) was determined in all patients by culture of nasopharyngeal secretions. Azithromycin (500 mg day for 3 days; n =133) or placebo ( n =132) were randomly given to all patients in a double-blind manner. Pathogenic bacteria were found in 77 patients (29%). The clinical signs and symptoms significantly associated in a multivariate model with the presence of bacteria included colored nasal discharge ( p <0.003), facial pain ( p <0.032) and radiologically determined maxillary sinusitis (complete opacity, air-fluid level or mucosal thickening>10 mm) ( p <0.001). This best predictive model had a sensitivity of 69% and a specificity of 64% and therefore could not be used either as a screening tool or as a diagnostic criterion for bacterial rhinosinusitis. In the group of patients with positive bacterial cultures, resolution of symptoms at Day 7 was observed in 73% of patients treated with azithromycin and in 47% of patients in the placebo group ( p <0.007). We conclude that signs and symptoms of acute rhinosinusitis in patients with mild-to-moderate clinical presentations are poor predictors of the presence of bacteria.

Counselling overweight and obese patients in primary care: a prospective cohort study:

Background Primary care physicians are well positioned to provide counselling for overweight and obese patients, but no prospective study has assessed the effectiveness of this counselling in primary care. We aimed to evaluate weight reduction counselling by primary care physicians, and its relationship with weight change and patients’ behaviour to control weight. Design A prospective cohort study. Methods We enrolled 523 consecutive overweight and obese patients from two Swiss academic primary care clinics. Physicians and patients were blinded to the study aims. We assessed the use of 10 predefined counselling strategies for weight reduction, and weight change and behaviour to control weight after 1 year. Results Sixty-five per cent of patients received some form of weight reduction counselling whereas 35% received no counselling. A total of 407 patients completed the 1-year follow-up. Those who received counselling lost on average (SD) 1.0 (5.0) kg after 1 year, whereas those who were not advised gained 0.3 (5.0) kg (P= 0.02). In multivariate analysis, each additional counselling strategy was associated with a mean weight loss of 0.2 kg (95% confidence interval 0.03–0.4, P = 0.02). Patients counselled by their physician had more favourable behaviour to control weight than those not counselled, such as setting a target weight (56 versus 36%) or visiting a dietician (23 versus 10%, both P< 0.001). Conclusions Weight reduction counselling by primary care physicians is associated with a modest weight loss and favourable behaviour to control weight. However, many obese and overweight patients receive no advice on weight loss during primary care visits.

Post-migration dietary changes among African refugees in Geneva: a rapid assessment study to inform nutritional interventions

Summary.Objectives: To conduct an assessment of perceived dietary changes and problems by African asylum seekers, in order to develop appropriate nutritional education interventions.Methods: A cross-sectional qualitative study among a convenience sample. Analysis compared and contrasted reported dietary changes and migration-related difficulties.Results: Nineteen interviews were analysed. After migration, main dietary changes were the decrease in different fruits and vegetables consumed weekly from 10 to 2 and 17 to 10 respectively. The number of respondents drinking sweetened beverages more than 3 times a week increased from 3 to 18. Reasons for changes were related to prices, taste, choice and accessibility.Conclusion: These dietary changes may have serious health consequences. Future remedial interventions based on suggestions of the respondents could easily be implemented.Zusammenfassung.Ernährungsveränderungen von afrikanischen Flüchtlingen nach deren Migration nach Genf: eine kurze Ernährungserhebung zur Entwicklung von ErnährungsinterventionenFragestellung: Erhebung von individuell wahrgenommenen Ernährungsveränderungen und -problemen bei afrikanischen Asylsuchenden, um zielgruppenspezifische Ernährungserziehungsmassnahmen entwickeln zu können.Methoden: Eine qualitative Querschnittstudie in einer zweckbestimmten Stichprobe. In den Analysen wurden berichtete Ernährungsveränderungen den migrationsbedingten Schwierigkeiten vergleichend gegenübergestellt.Ergebnisse: Neunzehn Interviews wurden analysiert. Nach der Migration nahm die Anzahl der verschiedenen wöchentlich verzehrten Früchte und Gemüse von 10 auf zwei bzw. von 17 auf 10 ab. Die Zahl der Studienteilnehmer, die häufiger als dreimal pro Woche Süssgetränke konsumieren, stieg von drei auf 18. Gründe die mit diesen Veränderungen in Zusammenhang stehen sind Preis, Geschmack, Produktangebot und Verfügbarkeit.Schlussfolgerung: Diese Ernährungsveränderungen könnten ernsthafte gesundheitliche Folgen nach sich ziehen. Hilfsmassnahmen, die den Vorschlägen der Studienteilnehmer Rechnung tragen, könnten problemlos eingeführt werden.Résumé.Changements alimentaires chez des réfugiés africains à Genève: une évaluation brève afin d’orienter des interventions nutritionnellesObjectifs: Evaluer les changements et problèmes alimentaires perçus par des réfugiés africains, dans le but de développer des interventions d’éducation nutritionnelle appropriées.Méthodes: Etude transversale qualitative au sein d’un échantillon de convenance. Les modifications de l’alimentation rapportées comme liées à la migration ont été recensées, groupées et comparées.Résultats: Dix-neuf interviews ont été analysées. Après la migration, les principaux changements alimentaires étaient la réduction du nombre de fruits et légumes différents consommés hebdomadairement de 10 à 2, et de 17 à 10 respectivement. Le nombre de répondants consommant des boissons sucrées plus de 3 fois par semaine est passé de 3 à 18. Des raisons de prix, de goût et d’accessibilité étaient évoquées pour expliquer ces changements.Conclusion: Ces changements alimentaires pourraient avoir des conséquences sanitaires sérieuses. Des interventions simples basées sur les suggestions des répondants devraient être envisagées.