Robert R. Wittler

Prospective randomized double blind placebo-controlled evaluation of azithromycin for treatment of cat-scratch disease

OBJECTIVE To determine the efficacy of azithromycin in the treatment of patients with typical cat-scratch disease. DESIGN Prospective, randomized, double blind, placebo-controlled clinical trial. SETTING Large military medical center and its referring clinics. PATIENTS Active duty military members and their dependents with laboratory-confirmed, clinically typical cat-scratch disease. INTERVENTION Study participants assigned by randomization to treatment with oral azithromycin or placebo for 5 days. OUTCOME MEASURES Lymph node volume was calculated using three dimensional ultrasonography at entry and at weekly intervals. The ultrasonographer was blinded to the treatment groups. Endpoint evaluations were predetermined as time in days to 80% resolution of the initial total lymph node volume. RESULTS Demographic and clinical data showed that the azithromycin and placebo treatment groups were comparable at entry although the placebo group tended to be older. Eighty percent decrease of initial lymph node volume was documented in 7 of 14 azithromycin-treated patients compared with 1 of 15 placebo-treated controls during the first 30 days of observation (P = 0.026). After 30 days there was no significant difference in rate or degree of resolution between the two groups. CONCLUSIONS Treatment of patients with typical cat-scratch disease with oral azithromycin for five days affords significant clinical benefit as measured by total decrease in lymph node volume within the first month of treatment.

A survey about management of febrile children without source by primary care physicians

BACKGROUND The management of young children with fever without source is controversial, and differences between physician specialties have been noted previously. The emergence of penicillin-resistant Streptococcus pneumoniae, the sharp decline in invasive Haemophilus influenzae infections in immunized populations and publication of practice guidelines have potentially altered physician practices. OBJECTIVE To determine the present practice preferences of pediatricians, family medicine physicians (FP) and emergency medicine physicians (EP). METHODS We mailed a checklist survey to 1600 randomly selected pediatricians, family medicine practitioners (FP) and emergency medicine physicians (EP) in the United States and replicated the methodology of a 1991/1992 survey. Physicians were asked about their evaluation and management of children of various ages (3 weeks, 7 weeks, 4 months and 16 months) with fever without source. RESULTS Most primary care physicians would admit the 3- and 7-week-old infants. For the 4-month-old infant 59% of EP, 45% of pediatricians and 28% of FP would give empiric antibiotic(s) as an outpatient (P=0.005 for FP compared with pediatricians and P=0.02 for EP compared with pediatricians). The majority of physicians would manage the 16-month-old child as an outpatient without antibiotic therapy. Ceftriaxone was the preferred antibiotic for outpatient empiric therapy. There was a 3-fold increase (28% vs. 9%) for pediatricians in the use of empiric outpatient antibiotics for the 7-week-old infant in the present survey compared with the 1991/1992 survey. CONCLUSIONS Physicians in the United States generally agree in their management of the young febrile infant, but with increasing patient age there is considerable variation. FP were the least aggressive in their evaluation and EP were the most aggressive.

Nontyphoidal Salmonella enteric infections and bacteremia

Antimicrobial treatment of nontyphoidal Salmonella gastroenteritis is usually advocated for infants younger than 3 months of age based on published data showing that infants in this age group are more prone to have bacteremia and develop extraintestinal focal infections. A review of nontyphoidal Salmonella isolates from our institution from January, 1981, through March, 1988, was undertaken to assess the role of age and specific serovar on the incidence of bacteremia. Two hundred twenty isolates were identified: one cerebrospinal fluid, 14 blood and 205 stool. The mean age of patients with bacteremia was 182 months, not significantly different from the mean age of 142 months for patients with stool isolates. Salmonella weltevreden was the most frequent isolate accounting for 23% of all isolates and all isolates of this organism were from stool cultures. Patients with S. weltevreden infections had mean and median ages of 50 and 2.5 months and were younger than patients with stool isolates from other serovars who had mean and median ages of 174 and 38 months. Infants younger than 3 or 6 months of age with positive stool cultures in whom blood cultures were obtained did not demonstrate a higher incidence of bacteremia than did older patients. We conclude that the incidence of bacteremia in patients with nontyphoidal Salmonella gastroenteritis is highly related to the invasiveness of the infecting specific Salmonella serovar.

Prospective Randomized Double-Blind Placebo-Controlled Evaluation of Azithromycin for Treatment of Cat Scratch Disease |[dagger]| 810

OBJECTIVE: To determine the efficacy of azithromycin in the treatment of patients with typical cat scratch disease (CSD).