Do we need antibiotics in acute rhinosinusitis?

This is a major question to be answered. In the US, one out of every five antibiotic prescriptions is for rhinosinusitis. However, results of studies are inconsistent and clinical benefit with antibiotic treatment is at best small due to the high rate of spontaneous improvement. The vast majority of patients are seen in primary care. The recent study by Garbutt et al (JAMA 2012;307:685-692) is therefore of major interest since it attempts to find the incremental effect of amoxicillin over symptomatic treatment on quality of life in 166 adults clinically diagnosed with acute bacterial rhinosinusitis (7 to 28 days of symptoms). They found that antibiotic treatment was not better than placebo for the control of symptoms after 3 days of treatment whereas some benefit was found after 7 days. Although a true diagnosis of sinusitis was not made, this study reflects primary care practice. Since antibiotic resistance is common, the authors propose "to avoid routine antibiotic treatment for patients with uncomplicated acute rhinosinusitis." What do you think based on your experience?

How Best to Care for Children with Allergies

The journal Archives of Disease in Childhood has recently published a supplement containing a series of articles focused on developing care pathways for children with allergies. The articles represent an attempt by the Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department to develop national care pathways for these children, as requested by the UK Department of Health. The articles each focus on a different condition:

• Anaphylaxis
• Asthma and/or rhinitis
• Drug allergies
• Eczema
• Food allergy
• Latex allergies
• Urticaria, angioedema, or mastocytosis
• Venom allergies

Each article presents a pathway algorithm and a set of competences that are required to deliver high-quality care. They are intended as “a guide for training and development of services to facilitate improvements in delivery as close to the patient's home as possible.” The authors note that the pathways should be implemented by a multidisciplinary team, at a local level, and with an eye to establishing connections between primary, secondary, and tertiary care.

How Best to Care for Children with Allergies

The journal Archives of Disease in Childhood has recently published a supplement containing a series of articles focused on developing care pathways for children with allergies. The articles represent an effort by the Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department to develop national care pathways for these children, as requested by the UK Department of Health. The articles each focus on a different condition:

• Anaphylaxis
• Asthma and/or rhinitis
• Drug allergies
• Eczema
• Food allergy
• Latex allergies
• Urticaria, angioedema, or mastocytosis
• Venom allergies

Each article presents a pathway algorithm and a set of competences that are required to deliver high-quality care. They are intended as “a guide for training and development of services to facilitate improvements in delivery as close to the patient's home as possible.” The authors note that the pathways should be implemented by a multidisciplinary team, at a local level, and with an eye to establishing connections between primary, secondary, and tertiary care.

Council of the European Union adopts conclusions on chronic respiratory diseases in children

On December 2, the Council of the European Union adopted a set of conclusions regarding "Prevention, early diagnosis and treatment of chronic respiratory diseases in children." This topic had been identified by the Polish Presidency of the EU as one of its public health priorities. According to the press release, the conclusions urge member states “to give appropriate consideration to the prevention, early diagnosis and treatment of chronic respiratory diseases in children in their health programmes” and “to increase public awareness of these diseases, strengthen smoking prevention and cessation programmes for pregnant women and follow the Council recommendation on smoke-free environment.” In addition, the Council asks the Commission “to support member states in developing and implementing effective policies on the prevention of chronic respiratory diseases in children, improving networking among institutions responsible for the implementation of member states' programmes, and strengthening cooperation of national centres and reinforcing existing international research networks.”

Can we predict montelukast treatment failure in step-down therapy for controlled asthma?

Although many physicians and patients want to replace low dose inhaled steroids with montelukast in controlled patients with mild asthma, there are insufficient data to predict montelukast failure. A study by Drummond et al (J Asthma 2011 Oct 27 [Epub ahead of print]) provides a piece of the puzzle. Using the 165 participants in the Leukotriene or Corticosteroid or Corticosteroid-Salmeterol Study (LOCCS) trial who were stepped down from low-dose ICS to montelukast, the authors attempted to predict the risk of montelukast treatment failure during step-down. Characteristics independently associated with montelukast treatment failure included early asthma onset (<10 years), need for steroid burst in the last year, and low pre-bronchodilator FEV₁. They constructed a montelukast failure index that may prove to be helpful for clinical practice, but it needs further validation.

Another piece to the LABA debate in asthma: The age of the patient

The US Food and Drug Administration assessed the risks of LABAs in asthma using a meta-analysis of controlled clinical trials in patients 4 to 11, 12 to 17, 18 to 64, and older than 64 years old (McMahon AW et al., Pediatrics 2011;128:e1147-e1154). They studied how age affected a composite index of asthma-related deaths, intubations, and hospitalizations, as well as the effects of concomitant inhaled corticosteroid (ICS) use. For all ages, the composite event incidence difference was 6.3 events per 1000 patient-years when patients using LABAs were compared to those not using LABAs. The greatest difference in serious asthma-related events attributable to LABAs was observed among children — 30.4 events per 1000 patient-years [95% CI: 5.7-55.1] in the 4- to 11-year age group. In all age groups, results for the subgroup of patients with concomitant ICS use were similar to the overall results. The authors conclude that “Additional data are needed to assess risks of LABA use for children with simultaneous ICS use.”

Do we have biomarkers to improve control of asthma in children?

The level of asthma control incorporates current clinical control and exacerbations. Traditionally asthma treatments have been individualized using symptoms and spirometry or peak flow. Biomarkers hold promise for capturing complementary information, but need to be validated with regard to control. Two studies published online ahead of print in Thorax may help to give some guidance in clinical practice.

First, a systematic review evaluated the efficacy of tailoring asthma interventions based on inflammatory markers (sputum analysis and FeNO) as compared to clinical symptoms with or without pulmonary function tests in children and adults (Petsky et al. Thorax, 11 Oct 2010, epub ahead of print). The authors concluded that “tailoring of asthma treatment based on sputum eosinophils (3 studies in adults) is effective in decreasing asthma exacerbations in adults. However, tailoring of asthma treatment based on FeNO levels (2 studies in adults and 4 in children) has not been shown to be effective in improving asthma outcomes in children and adults.”

In the second article, a study was undertaken to investigate whether a strategy based on sputum eosinophils would be successful in 55 children with severe asthma (Fleming et al. Thorax, 8 August 2011, epub ahead of print). “Incorporating the control of sputum eosinophils into the management algorithm,” the authors concluded, “did not significantly reduce overall exacerbations or improve asthma control. Exacerbations were reduced in the short term, suggesting that more frequent measurements would be needed for a clinically useful effect and that controlling inflammation may have a role to play in subgroups of children with severe asthma.”

Do you agree that biomarkers are either not readily available or unavailable in most practice settings?