Hold Off on Antibiotics for Sinus Infection, Guidelines Urge
Between 90% and 98% of sinus infections won't respond to antibiotics, so doctors should hesitate before reaching for the prescription pad, according to new guidelines for the treatment of rhinosinusitis from the Infectious Diseases Society of America. "There is no simple test that will easily and quickly determine whether a sinus infection is viral or bacterial, so many physicians prescribe antibiotics 'just in case,'" commented Anthony Chow, MD, of the University of British Columbia in Vancouver, who chaired the panel that developed the guidelines. But, he added in a statement, "if the infection turns out to be viral -- as most are -- the antibiotics won't help and in fact can cause harm by increasing antibiotic resistance, exposing patients to drug side effects unnecessarily and adding cost."

The guidelines, published online in Clinical Infectious Diseases, offer primary care physicians 18 recommendations to help ensure appropriate treatment, ranging from how to tell bacterial from viral infections to when to call in a specialist. Although most cases are viral, the guidelines suggest suspecting a bacterial cause when:

• Symptoms or signs are persistent, lasting at least 10 days without any evidence of clinical improvement.
• The disease onset is characterized by severe symptoms or signs of high fever (of at least 39° C or 102° F) and purulent nasal discharge or facial pain lasting for at least three or four days.
• The disease gets worse with a new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection that lasted five or six days and had appeared to be improving.

Where a bacterial cause is likely, the guidelines suggest prompt treatment with an antibiotic. Many previous guidelines had suggested empiric therapy with the beta-lactam antibiotic amoxicillin, but an increasing proportion of respiratory pathogens now produce beta-lactamase, which breaks down the drug. So, the new guidelines say, initial therapy should add clavulanate, a beta-lactamase inhibitor, to the amoxicillin. The recommendation applies to both adults and children. Because of increasing rates of drug resistance, the guidelines also recommend not using other common antibiotics, including azithromycin (Zithromax), clarithromycin (Biaxin), and trimethoprim-sulfamethoxazole (Septra).

The new guidelines also say that a shorter treatment time for adults -- five to seven days, rather than 10 to 14 -- is long enough to treat a bacterial infection without encouraging resistance. Children should still be treated for 10 days to two weeks, the guidelines say. Regardless of the cause of the infection, the guidelines discourage decongestants and antihistamines, which don't help and in some cases can make symptoms worse. On the other hand, nasal steroids can help ease symptoms in people who have sinus infections and a history of allergies. Saline nasal irrigation might help relieve some symptoms, the guidelines say, although it might not be as helpful in children because of the discomfort of the therapy.

Official Food Allergy Treatment Guidelines - Protocol Designed To Aid Physicians In Diagnosis
A collaborative, government-led effort to guide and standardize diagnosis, treatment and management of food allergies has resulted in the release of an official set of recommendations for physicians.

The guidelines were published online by the Journal of Allergy and Clinical Immunology (JACI), and available online here. They were developed by the National Institutes of Health and leading researchers and clinicians, professional and patient advocacy organizations, and the American Academy of Allergy, Asthma & Immunology, among others.

Food allergies are among the most common medical conditions, believed to affect three out of 100 Americans, and the number of affected people has been steadily rising in the last 20 years for reasons not well understood, scientists say.

"Paradoxical as it may be, up until now we have lacked uniform guidelines based on hard scientific evidence about how to diagnose and treat these very common conditions that affect the lives of millions of people," said Robert Wood, M.D., one of the six lead authors on the guidelines and director of the Division of Allergy & Immunology at Johns Hopkins Children's Center.

The guidelines, available here, are designed for use by specialists, primacy-care physicians and other healthcare staff. They consolidate the latest available data into straightforward and consistent protocols for diagnosis and treatment.

"Because the guidelines will give physicians a uniform and consistent pool of information on the latest and most effective diagnostic and therapeutic approaches, patients are more likely to get the most-up-to-date care regardless of where they seek care," Wood says.

Some topics covered in the guidelines include:

• Clear-cut definitions of food allergy and food intolerance, two commonly confused, but completely different conditions
• What tests should be used for the proper diagnosis of a food allergy, including a discussion on skin-prick and blood testing vs. gold-standard oral food challenges
• Management of life-threatening and non-life-threatening allergic reactions
• Advice on management of life-threatening reactions (anaphylaxis) for patients and physicians, including an anaphylaxis emergency action plan
• Development and natural course of food allergies by type of allergy and age

Recommendations for X-rays in Low Back Pain
X-rays are unnecessary for the routine management of low back pain outside of the setting of red flags. In the setting of red flags, x-rays at the first visit are usually recommended to assist in ruling out these possible conditions (e.g., fracture, neoplasias, infection, etc.). Even when red flags are suspected, judgment is recommended and it should not be mandatory to order x-rays in all cases. In the event that there is low back pain without improvement over four to six weeks, x-rays may be recommended to rule out other possible problems. Those with subacute low back pain that is not improving or chronic low back pain should have x-rays at least once for purposes of ruling out other conditions. X-rays are non-invasive, moderately costly, and have a low risk of adverse effects, other than their considerable exposure to ionizing radiation. Thus, x-rays are recommended for certain situations. The figure below shows the radiation dosage from common medical tests.



Updated Clinical Practice Guidelines:

Pediatric Preventive Health

http://practice.aap.org/content.aspx?aid=1599

Child Immunization (Ages 0-6)

www.cdc.gov/vaccines  

www.immunize.org  

Adolescent Immunization Schedule (Ages 7-18)

www.cdc.gov/vaccines  

www.immunize.org  

Adult Immunization Schedule (over 18)

www.cdc.gov/vaccines

www.immunize.org  

Congestive Heart Failure

http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.192065

Asthma

www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Human Immune Deficiency Virus i aidsinfo.nih.gov

www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf

Adult Preventive Health

www.preventiveservices.ahrq.gov

Adult Hypertension

www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf

Chronic Kidney Disease

www.k.idney.org/Professionals/KDOQI/guidelines_ckd/pl_exec.htm

Coronary Artery Disease

www.americanheart.org/downloadable/heart/104499183808 5StableAnginaNewFigs.pdf

Chronic Obstructive Pulmonary Disease

www.goldcopd.org/Guidelineitem.asp?11=2&12=1&intld=2002

Adult Obesity

www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf

www.ahrq.gov/CLINIC/uspstf/uspsobes.htm#summary

Diabetes Mellitus

http://care.diabetesjournals.org/content/32/Supplement_1/S1.full

Child and Adolescent Obesity

http://pediatrics.aappublications.org/cgi/content/full/112/2/424

Child and Adolescent Hypertension

www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf

Intranasal Monovalent Vaccine Administration Instructions
Administration of the Intranasal Influenza A (H1N1) 2009 Monovalent Vaccine can be confusing, leading to incorrect dosing. Influenza A (H1N1) 2009 Monovalent Vaccine Live, Intranasal is indicated for the active immunization of individuals 2-49 years of age against influenza disease caused by pandemic (H1N1) 2009 virus.Dosage and administration instructions for intranasal H1N1 monovalent vaccine is available here.

FDA Okays Sixth Seasonal Flu Vaccine
The FDA has approved the seasonal influenza subtype A and B vaccine Agriflu for patients ages 18 and older. The approval was based on a demonstration that the vaccine created levels of antibodies in blood likely to be effective in flu prevention. Side effects in Agriflu's clinical trials included pain, swelling and redness of injection site, headache, muscle ache, and malaise. The drug should not be administered to patients with severe allergies to eggs or any other vaccine ingredient. The new vaccine is not approved for prevention of the 2009 H1N1 virus. seasonal flu. The drug is distributed in single dose, prefilled syringes for single injection in the upper arm. Agriflu is the sixth drug approved for vaccination against the 2009-2010 seasonal influenza virus. The drug was made available through the agency's accelerated approval pathway, which makes devices and products for serious or life-threatening diseases available sooner than usual if they demonstrate safety and efficacy.

New Guidelines on Breast Cancer Screenings Creates Controversy
New advice from the U.S. Preventive Services Task Force: biennial screening mammography for women 50 and older, saying most women in their 40s should not routinely get mammograms. They also recommending against clinicians teaching women how to perform breast self-exams. This is a reversal of previous guidelines recommending annual mammograms beginning at age 40 and promoting self-examination.  The new guidelines are sharply challenged by the American Cancer Society who will continue to recommend mammograms to women 40 and over. The American College of Obstetricians and Gynecologists also believes there is still significant benefit to women in their 40s to have routine mammograms.

Diagnostic Imaging Question: Which radiologic test should be ordered first for the evaluation of suspected urolithiasis in the pediatric age group?  
Answer: Although not as accurate as computerized tomography (CT), ultrasound (US) identified almost all clinically important renal stones in children presenting with suspected urolithiasis. The benefits of US include no ionizing radiation and lower costs. Stronger evidence from a randomized trial comparing outcomes from similar children initially undergoing either US or CT scanning is needed before setting a standard of practice.

FDA Approves HPV Vaccine for Men and Boys
The FDA approved Merck's Gardasil vaccine against human papillomavirus (HPV) for boys and men, the same day that it okayed .. Gardasil was approved for males ages 9 to 26 for prevention of genital warts. The approval did not address claims that the vaccine in this population may help prevent transmission to girls and women. The agency also approved the first competitor for Gardasil since the latter came on the market in 2006. GlaxoSmithKline's Cervarix was cleared for use in girls and women, 9 to 26 years old. Gardasil is given as three injections over a six-month period. Headache, fever, pain at the injection site, itching, redness, swelling, and bruising were the most common side effects observed in the clinical studies. 

Important Prescription Dosing for Influenza is Available - Click Here

Allergy Groups Issue Guidelines for Vaccine AEs    
New guidelines state that an adverse reaction seemingly associated with a recently-received vaccine should not automatically preclude receiving that same vaccine in the future. Patients who have a suspected allergy to a vaccine or its components should be evaluated by an allergist or immunologist. Most of these patients will eventually be able to receive the vaccine suspected of causing the problem.In many cases, patients who have had adverse reactions following vaccination have been advised to avoid future immunization. But, although there are some adverse reactions to vaccines that constitute absolute contraindications to administration of future doses, most such reactions do not preclude subsequent immunization. Future immunization would be contraindicated in patients who develop Guillan-Barré syndrome within six weeks of influenza vaccination and in those who develop encephalopathy after receiving the pertussis vaccine. Conversely, patients with mild local reactions - such as swelling, redness, and soreness - and constitutional symptoms - such as fever - should not be excluded from vaccination in the future.  

Allergic or IgE-mediated reactions to vaccines are more often caused by the components of vaccines, rather than the immunizing agent itself. The most common culprits are gelatin and egg protein, although reactions to yeast, latex from vial stoppers and syringe plungers, neomycin, and thimerosal have been recorded. Thus, a history of allergy to gelatin should be obtained from any individual before giving them a gelatin-containing vaccine. Additionally, vaccines with high amounts of egg protein, including influenza vaccines, should be given to egg-allergic patients only after evaluation by an allergist. Most of these patients can still receive a flu vaccine.

Report all adverse events following immunization to the Vaccine Adverse Event Reporting System established by the CDC and FDA even if there is uncertainty regarding the cause.

• Measuring levels of IgG antibody to the immunizing agent in a vaccine suspected of causing a serious adverse reaction to determine if protective levels are already presentcan help determine whether further doses are needed. Even if the recommended number of doses has been achieved, the cause of the reaction should still be investigated.
• All suspected anaphylactic reactions should be investigated by an allergist to find the specific allergen that caused it and to find out whether it was IgE mediated. This should include skin testing by prick test and then intradermal test. If the intradermal skin test is negative, the chance a patient has IgE antibody to any of the vaccine components is negligible and the vaccine can be administered as normal.
• If additional doses of vaccine are called for in individuals confirmed by testing to have an allergy to the vaccine, consideration can be given to administering the vaccine in graded doses under close observation with emergency medical treatment available.
• Pregnant women should not be vaccinated with live vaccines, but they should be given inactivated influenza vaccine, as well as the tetanus and hepatitis B vaccines if otherwise indicated.
• Live vaccines should not be given to individuals who are immunocompromised because of the risk of generalized infection with the immunizing agent.

Seasonal Influenza Information Guide

Indications

Annual vaccination against seasonal influenza is recommended for

·         All persons who want to reduce their risk of becoming ill with influenza or of spreading it to others

·         All children and teens ages 6 months through 18 years

·         All persons age 50 years and older

·         All children and teens receiving long-term aspirin therapy

·         All women who will be pregnant during the influenza season

·         Adults and children with any of the following conditions:

o    a chronic disorder of the pulmonary (including asthma) or cardiovascular (except hypertension) system

o    a chronic disease of the blood. liver. or kidneys; immunosuppression (e.g., including that caused by medications. HIY); or metabolic disorder (e.g., diabetes)

o    a neurologic or n uromuscular disorder (e.g., cognitive dysfunction)

·         All residents of nursing homes or other chronic-care facilities

·         All healthcare personnel

·         All household contacts (including children) and caregivers of (1) children ages 0-59 months (especially younger than 6 months; (2) adults age 50 years and older; and (3) persons with high risk medial conditions

·         Persons planning to travel to an area of the world with influenza activity (e.g., to the tropics at any time of the year)

Contraindications and Precautions

·         Do not give influenza vaccine to a person who has had an anaphylactic reaction to a prior dose of the vaccine or any of its components (e.g., eggs). Minor illnesses with or without fever do not contraindicate use of influenza vaccine.

·         Do not give nasal spray LAIV to persons who are younger than age 2 years; age 2 through 4 years with possible reactive airways disease (e.g., history of recurrent wheezing or a recent wheezing episode*); age 50 years or older; pregnant; have a chronic disease that is an indication for routine influenza vaccination; or are a child or teen receiving long-term aspirin therapy. Injectable TIV is preferred for persons who have close contact with severely immunosuppressed persons during periods when the immunocompromised person requires protective isolation.

·         Guillain-Barré syndrome within 6 weeks following a previous dose of influenza vaccine is a precaution for vaccination with TIV or LAIV.

*Ask parents of children 2-4 years: “In the past 12 months, has a healthcare provider ever told you that your child had wheezing or asthma?” If yes, do not give LAIV; instead give TIV.

Vaccine Dosing and Administration

·         TIV: Give 0.25 mL if age 6-35 monyhs; give 0.5 mL if age 3 years or older. Give 1M with a 22-25g, 1-1½” needle. Choose vaccine according to patient’s age (i.e., FluZone: 6 months and older; Fluvirin: 4 years and older; Afluria, Fluarix, and FluLaval: 18 years and older).

·         LAIV (FluMist): Give 0.2 mL (0.1 mL sprayed into each nostril) to healthy non-pregnant persons ages 2 through 49 years.

·         Give 2 doses to all children younger than age 9 years who are receiving influenza vaccine for the first time or who failed to receive the 2^nd dose in the preceding year. Separate the 2 doses by at least 4 weeks.

Side Effects

·         The most common side effects from TIV are soreness and redness at the injection site, lasting 1-2 days

·         The most common side effect from LAIV are runny nose and nasal congestion.

Talking Points with Patients

·         Influenza is a serious respiratory disease caused by a virus. It is not the same as the common cold or an intestinal illness.

·         An average of 36,000 deaths and more than 200,000 hospitalizations related to seasonal influenza occur in the U.S. each year.

·         Vaccination is usually 70-90% effective in preventing influenza in healthy adults and children. Its effectiveness may be lower if the circulating influenza viruses are not matched by the vaccine strains, but vaccinated persons will likely have milder illness.

·         Unvaccinated healthy people who get influenza can spread their infection to others who are most vulnerable to its complications.

Timing: Vaccination should begin as soon as vaccine becomes available and should continue until supply is depleted.

Current information on H1NI influenza can be found at www.cdc.gov/h1n1flu