Increased use of Paxlovid could cut hospitalizations, deaths and costs

Increased use of Paxlovid, the antiviral drug used to treat COVID-19, could prevent hundreds of thousands of hospitalizations and save tens of billions of dollars a year, according to a new epidemiological model published by researchers at The University of Texas at Austin. In fact, epidemiologists found that treating even 20% of symptomatic cases would save lives and improve public health.

A 2023 National Institutes of Health study found that only about 15% of high-risk patients take Paxlovid when infected with COVID-19. Using a multiscale mathematical model based on conditions seen over 300 days beginning in January 2022, the researchers found that using Paxlovid on 20% of symptomatic COVID-19 patients during the omicron wave would have resulted in up to 850,000 fewer hospitalizations and saved up to $170 billion. Even with lower transmission levels of the virus, the researchers estimate that an expanded use of Paxlovid could save approximately 30,000 lives during an outbreak.

The findings appear in the February issue of Emerging Infectious Diseases.

“This model shows us there are real benefits to using Paxlovid, not just for the patients receiving treatment, but for the people around them,” said Lauren Ancel Meyers, UT professor of integrative biology and statistics and data sciences, director of the Center for Pandemic Decision Science and corresponding author of the paper. “Not only does this drug help keep high-risk patients out of the hospital, but it can substantially decrease the chance that a treated patient will infect other people.”

The team of researchers assumed patients would take Paxlovid within five days of symptom onset, which is recommended, and estimated different outcomes based on different potential levels of viral transmission, which can vary in communities and with the variant of the virus. If each symptomatic person was assumed to go on to infect about one other person, giving Paxlovid to even 1 out of every 5 of all symptomatic patients could result in 280,000 fewer hospitalizations and save nearly $57 billion. If the virus were to lead the average symptomatic patients to go on to infect closer to three people, as some research has found with the omicron variant, using Paxlovid in 20% of patients would be predicted to result in 850,000 fewer hospitalizations and save more than $170 billion.

“We conducted this analysis to help doctors and policymakers make good decisions about using Paxlovid to combat future waves of COVID,” Meyers said. “A lot of our work is aimed at improving global preparedness for future pandemics. These kinds of models can help to ensure that the U.S. has enough antivirals stockpiled and to design playbooks for using vaccine, drugs and other measures in the heat of threat to slow viral spread and save as many lives as possible.”

Reference:

Bai Y, Du Z, Wang L, Lau E, Fung I, Holme P, et al. Public Health Impact of Paxlovid as Treatment for COVID-19, United States. Emerg Infect Dis. 2024;30(2):262-269. https://doi.org/10.3201/eid3002.230835.

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Do’s and don’ts with direct oral anticoagulants

Direct oral anticoagulants (DOACs) are a common treatment for patients with a wide variety of cardiovascular conditions. DOACs are the preferred treatment over vitamin K antagonists (VKAs) for many patients with atrial fibrillation or venous thromboembolism, since the latter would have a higher risk of intracranial bleeding and more complex dosing routine. However, new research suggests that DOACs should not be the first line of treatment for every patient who need to treat or prevent blood clots. A systematic overview from researchers at Brigham and Women’s Hospital, a founding member of Mass General Brigham, discusses the efficacy of DOACs compared to other treatment methods.

This review utilized data from randomized controlled trials to compare DOACs with other treatment methods for various cardiovascular conditions. Although there is merit to using DOACs in many common conditions, the manuscript provides a robust summary of clinical trials indicating that DOACs fare worse in patients with mechanical heart valves, thrombotic antiphospholipid syndrome, atrial fibrillation associated with rheumatic heart disease, and patients with embolic stroke of unclear source. The authors also highlight clinical scenarios in which there is uncertainty, with a look toward future for better evidence generation.

“The results we reviewed here have significant implications for optimizing anticoagulation therapy and improving patient outcomes in clinical practice,” said Behnood Bikdeli, MD, MS, of the Brigham’s Heart and Vascular Center. “There is a critical need for further research regarding why DOACs are less efficacious or safe than the standard of care in certain scenarios.”

Reference:

Antoine Bejjani, Candrika D. Khairani, Ali Assi, Gregory Piazza, Parham Sadeghipour, Azita H. Talasaz, John Fanikos, Jean M. Connors, Deborah M. Siegal, Geoffrey D. Barnes, Karlyn A. Martin, Dominick J. Angiolillo, Dawn Kleindorfer, Manuel Monreal, David Jimenez, Saskia Middeldorp, Mitchell S.V. Elkind, Christian T. Ruff, Samuel Z. Goldhaber, Harlan M. Krumholz, Roxana Mehran, Mary Cushman, John W. Eikelboom, Gregory Y.H. Lip, Jeffrey I. Weitz, Renato D. Lopes, Behnood Bikdeli, When Direct Oral Anticoagulants Should Not Be Standard Treatment: JACC State-of-the-Art Review, Journal of the American College of Cardiology, https://doi.org/10.1016/j.jacc.2023.10.038.

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Latest research redefines neurodevelopmental risks, outcomes for congenital heart disease

More than a decade of new knowledge about neurodevelopmental risk in people with congenital heart disease has changed the thinking about who is most at risk and the factors that impact neurological development, learning, emotions and behaviors, according to a new American Heart Association scientific statement published today in the Association’s flagship, peer-reviewed journal Circulation.

Congenital heart disease, defined as structural abnormalities in the heart or nearby blood vessels that arise before birth, is the most common birth defect. While advances in treatment have helped more than 90% of people with congenital heart disease in developed countries live to adulthood, the risk of neurodevelopmental issues when individuals have a more severe form of congenital heart disease has not meaningfully improved.

The new scientific statement, “Neurodevelopmental Outcomes for Individuals With Congenital Heart Disease: Updates in Neuroprotection, Risk-Stratification, Evaluation, and Management,” describes the significant advancement in understanding the impact of congenital heart disease on an individual’s development, learning, emotions and behaviors throughout childhood and adulthood.

“Neurodevelopmental difficulties are among the most common and enduring complications faced by people with congenital heart disease. These difficulties can affect a person’s ability to function well at school, at work or with peers, and can affect health-related quality of life throughout childhood and into adulthood,” said Vice Chair of the writing statement group Erica Sood, Ph.D., a senior research scientist and pediatric psychologist at Nemours Children’s Health, Delaware Valley. “It is important for health care professionals and individuals with congenital heart disease and their families to understand how common neurodevelopmental difficulties are. It is also important to understand what places a person with congenital heart disease at high-risk for these difficulties, as well as how these difficulties can be prevented or managed.”

The statement includes updated guidance for health care professionals on how to identify which patients are at high-risk for neurodevelopmental difficulties and what type of evaluations may be helpful to better understand these difficulties. Optimizing neurodevelopmental outcomes through clinical care and research has become increasingly critical since more patients are surviving into adulthood.

The key findings of the statement include:

  • The algorithm for risk stratification of people with congenital heart disease into high or low risk for developmental delays or disorders has been revised to reflect the latest research.
  • The statement suggests health care professionals sequentially review three risk categories: Risk Category 1 includes patients with a history of cardiac surgery with cardiopulmonary bypass during infancy. Risk Category 2 is people with a history of chronic cyanosis, those with blue or purple discoloration due to low blood-oxygen levels, who did not undergo cardiac surgery with cardiopulmonary bypass during infancy. Risk Category 3 has two criteria. The first criterion for Risk Category 3 is a history of an intervention or hospitalization secondary to congenital heart disease in infancy, childhood or adolescence. The second criterion is the presence of one or more factors known to increase neurodevelopmental risk.
  • The statement features an updated list of factors known to increase neurodevelopmental risk, including genetic, fetal and perinatal impact, surgical aspects of treatment and care, socioeconomic and family influences and factors related to growth and development. For example, genetic variants that may alter fetal development of the heart, brain and other organs cause up to nearly a third of congenital heart disease cases.
  • There is a new section on emerging risk factors, such as abnormal placental development, prolonged or repeated anesthetic exposure and exposure to neurotoxic chemicals.
  • In addition, there is a new section on neuroprotective strategies, including detection of congenital heart disease before birth, monitoring of brain blood flow and the delivery of oxygen, and functional support care, such as physical therapy, occupational therapy and speech-language pathology.
  • The statement provides updated information about referral to age-based evaluation of people with congenital heart disease at high risk for developmental delay or disorder. The statement refers to guidance from the Cardiac Neurodevelopmental Outcome Collaborative, which recommends that children with congenital heart disease at high risk for developmental delay or disorders have neurodevelopmental assessments throughout infancy, childhood and adolescence.
  • The statement also provides updated information about management of developmental delay or disorder in infants, children and adolescents, and a new section on management of neuropsychological deficits in adults.

“Reducing barriers that people with congenital heart disease and their families often face when trying to access neurodevelopmental supports and services, and ensuring sufficient research funding are priority areas for future policies,” said Chair of the statement writing group Bradley S. Marino, M.D., M.P.P., M.S.C.E., M.B.A., FAHA, chief of cardiology and cardiovascular medicine at Cleveland Clinic Children’s. “More research will result in a better understanding of how to prevent and manage neurodevelopmental conditions related to congenital heart disease, which will ultimately improve neurodevelopmental outcomes and health-related quality of life for people with congenital heart disease across their life span.”

Reference:

Erica Sood, Jane W. Newburger, Julia S. Anixt, Adam R. Cassidy, Jamie L. Jackson, Richard A. Jonas, Amy J. Lisanti, Keila N. Lopez, Shabnam Peyvandi, Bradley S. Marino, Neurodevelopmental Outcomes for Individuals With Congenital Heart Disease: Updates in Neuroprotection, Risk-Stratification, Evaluation, and Management: A Scientific Statement From the American Heart Association, Circulation, https://doi.org/10.1161/CIR.0000000000001211.

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Feeling depressed after menopause? Hormone therapy may help

Hormone therapy (HT) is already recognized as the most effective treatment option for physiologic menopause symptoms such as hot flashes, but a new study is one of the first to suggest that it might also help manage depressive symptoms. It further documented a high rate of depression during menopause.

Results of the study have been published online in Menopause, the journal of The Menopause Society.

Depression and other mood-related symptoms can strike at any time during a woman’s life but have been shown to be especially likely during and immediately after the menopause transition. In a new study involving 170 women who were patients at a menopause clinic in Ontario, Canada, there was a high prevalenc-62%-of participants who scored as being “depressed.” Although these symptoms may not necessarily reach the severity of a major depressive disorder, they still could significantly affect quality of life and relationships.

To date, the effectiveness of HT to effectively manage hot flashes (technically known as vasomotor symptoms) has been well documented. However, its ability to address mood-related symptoms is less established. This new study from Canada sought to correct that problem.

Hormone influences on neurotransmitter-receptor pathways, which regulate mood during and after the menopause transition, are thought to play a role in depressive symptoms. In addition, the domino theory suggests that the toll of physiologic symptoms experienced during menopause, such as hot flashes and an array of genitourinary problems, could also contribute to adverse moods.

As part of their study, researchers attempted to determine whether the stage of menopause contributed to an increased risk of depression, but no association was found, although a lower education level (high school or less) and younger age did show a direct correlation. The addition of progestin to the HT regimen did not have a significant effect on overall effectiveness. Additionally, although women who went through natural menopause experienced significant improvements with regard to their depressive symptoms, women who experienced iatrogenic menopause (surgical or chemotherapy based) did not have similar improvements.

On the basis of these results, the researchers concluded that HT-whether used alone or in conjunction with antidepressants-can improve not only hot flashes but also depressive symptoms commonly associated with menopause.

Survey results are published in the article “Does menopause hormone therapy improve symptoms of depression? Findings from a specialized menopause clinic.”

“This study showed a beneficial effect of hormone therapy on mood symptoms during menopause when used alone and a synergistic effect when used in combination with antidepressants. It also highlights the high prevalence of mood symptoms during this transition and the need to address women’s symptoms holistically rather than having a singular focus on hot flash management,” says Dr. Stephanie Faubion, medical director for The Menopause Society.

Reference:

Gnanasegar R, Wolfman W, Galan LH, Cullimore A, Shea AK. Does menopause hormone therapy improve symptoms of depression? Findings from a specialized menopause clinic. Menopause. 2024 Feb 20. doi: 10.1097/GME.0000000000002325.  

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Hepatitis E Vaccine Provides Long-term Protection

Hepatitis E virus (HEV) is a common cause of acute hepatitis, yet its prevention often receives less attention compared to other hepatitis viruses. Understanding the long-term effectiveness of hepatitis E vaccines is crucial for disease control and prevention efforts.

A recent study conducted in Dongtai County, China, extended a phase-3 clinical trial to evaluate the durability of protection provided by a hepatitis E vaccine over a 10-year period. The initial trial enrolled over 112,000 healthy adults and randomly assigned them to receive either the hepatitis E vaccine or a placebo. This study was published in the journal The Lancet by Shoujie H. and colleagues.

Participants received three doses of the vaccine or placebo intramuscularly at months 0, 1, and 6. A comprehensive surveillance system was established to monitor hepatitis E cases in the study region over the following 10 years. The primary outcome was the efficacy of the vaccine in preventing confirmed cases of hepatitis E occurring at least 30 days after the third dose.

The key findings of the study were:

  • Over the 10-year study period, 90 cases of hepatitis E were identified, with significantly fewer cases in the vaccine group compared to the placebo group.

  • The vaccine demonstrated an efficacy of 83.1% in the modified intention-to-treat analysis and 86.6% in the per-protocol analysis.

  • Moreover, antibody persistence was assessed in subsets of participants, showing that a significant proportion maintained detectable antibody levels even after several years.

The study findings indicate that immunization with the hepatitis E vaccine provides long-lasting protection against hepatitis E, with vaccine-induced antibodies persisting for at least 8.5 years. This underscores the importance of vaccination programs in preventing hepatitis E infections and highlights the effectiveness of the vaccine in reducing disease burden over the long term.

Reference:

Huang, S., Zhang, X., Su, Y., Zhuang, C., Tang, Z., Huang, X., Chen, Q., Zhu, K., Hu, X., Ying, D., Liu, X., Jiang, H., Zang, X., Wang, Z., Yang, C., Liu, D., Wang, Y., Tang, Q., Shen, W., … Xia, N. Long-term efficacy of a recombinant hepatitis E vaccine in adults: 10-year results from a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet,2024. https://doi.org/10.1016/s0140-6736(23)02234-1

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Vision impairment in older adults tied to symptoms of depression, anxiety and social isolation: JAMA

USA: A cross-sectional study comprising 2822 US adults revealed that worse examination-based and self-reported vision impairment is associated with anxiety and depressive symptoms, and worse examination-based vision impairment is linked with severe social isolation.

These findings, published in JAMA Ophthalmology, provide evidence to support prioritizing research aimed at enhancing the health and inclusion of people with vision impairment.

Vision impairment and psychosocial function, including symptoms of anxiety, depression and social isolation, are a major cause of morbidity in the US. However, there is a lack of nationally representative studies evaluating associations between subjective and objective vision impairment with psychosocial function following the COVID-19 pandemic.

To address this knowledge gap, Louay Almidani, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues provided updated national estimates on the associations of vision impairment with depressive and anxiety symptoms and social isolation in US adults 65 years and older.

The study was a cross-sectional analysis of the National Health and Aging Trends Study rounds 9 (2019) and 11 (2021), a nationally representative sample of Medicare beneficiaries aged 65 years and above. Binocular distance visual acuity, contrast sensitivity, and near visual acuity were tested.

Objectively measured vision impairment was defined as vision impairment in either distance visual acuity (worse than 20/40), near visual acuity (worse than 20/40), or contrast sensitivity (worse than 1.55 logCS). Self-reported vision impairment was defined based on participants’ reports on their vision status.

Depression and anxiety symptoms were assessed via the Patient Health Questionnaire. Social isolation was defined based on communication frequency, living arrangement, and activity participation responses.

The researchers reported the following findings:

  • Among 2822 community-dwelling adults sampled from a population of 26 182 090, the mean age was 78.5 years; 54.7% were female; 32.3% had objectively measured vision impairment, and 6.4% had self-reported vision impairment.
  • In adjusted models, all outcomes were significantly associated with objectively measured vision impairment, including depressive symptoms (odds ratio [OR], 1.81), anxiety symptoms (OR, 1.74), and severe social isolation (OR, 2.01).
  • Depressive symptoms (OR, 2.37) and anxiety symptoms (OR, 2.10) but not severe social isolation symptoms (OR, 2.07) were significantly associated with self-reported vision impairment.

In the study, vision impairment was associated with several psychosocial outcomes, including symptoms of depression, anxiety and social isolation.

Reference:

Almidani L, Miller R, Varadaraj V, Mihailovic A, Swenor BK, Ramulu PY. Vision Impairment and Psychosocial Function in US Adults. JAMA Ophthalmol. Published online February 22, 2024. doi:10.1001/jamaophthalmol.2023.6943

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Study Unveils Complexities of BP Management with Bruton’s Tyrosine Kinase Inhibitors in Lymphoid Malignancies

In a groundbreaking study, researchers
have delved into the optimal approaches for managing hypertension (HTN) in
patients undergoing Bruton’s tyrosine kinase inhibitor (BTKi) treatment, a
revolutionary therapy for lymphoid malignancies. They found that managing HTN in patients undergoing BTKi
treatment can be complex and may necessitate multiple anti-hypertensive
medications.


The
study results were published in the journal Blood Advances.  


While BTKis, such as ibrutinib, have
proven to be generally well-tolerated and less toxic than traditional
chemotherapy options, this research sheds light on the potential challenge of
new or worsening HTN associated with their use.

While Bruton’s tyrosine kinase
inhibitors (BTKis) are typically well-tolerated and exhibit lower toxicity
compared to chemotherapy options for lymphoid malignancies, notable concern
arises as BTKis, including ibrutinib, may trigger the onset or exacerbation of
hypertension (HTN).

The optimal management of HTN associated with BTKis remains
a relatively unexplored territory.

The study, which included 196 patients
with lymphoid malignancies on BTKis and concurrent anti-hypertensive
medications, aimed to identify effective strategies for blood pressure
management. Patients were categorized into two groups based on their HTN status:
those with pre-existing hypertension before starting BTKi treatment (prior-HTN)
and those who developed HTN after initiating BTKi therapy (de novo HTN).

The
analysis considered patients with a minimum of 3 months of follow-up data.

Using generalized estimating
equations, the researchers explored the associations between time-varying mean
arterial pressures (MAPs) and different anti-hypertensive drug categories.

Findings:

  • Among the significant findings, 118 patients had prior-HTN, while 78 developed
    de novo HTN.
  • Notably, patients with prior HTN
    experienced a statistically significant mean MAP reduction when taking a
    combination of beta blockers (BBs) with hydrochlorothiazide (HCTZ), showing a
    reduction of -5.05 mmHg (95% CI -10.0 to -0.0596; p = 0.047).

  • Similarly, patients with de novo HTN
    exhibited a significant MAP reduction when prescribed either an
    angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor
    blocker (ARB) with HCTZ, demonstrating a reduction of -5.47 mmHg (95% CI -10.9 to
    -0.001; p = 0.05).

  • These regimens were also associated
    with the highest percentages of normotensive MAPs.


  • The study’s findings suggest that
    managing HTN in patients undergoing BTKi treatment is intricate and may require
    a multifaceted approach involving multiple anti-hypertensive medications.
  • For
    patients with prior-HTN, combination regimens with BBs and HCTZ appeared to be
    beneficial, while those with de novo HTN showed improved outcomes with
    ACEi/ARBs combined with HCTZ.

The researchers underscore the importance of
further prospective studies to validate these encouraging results.

This breakthrough study not only
enhances our understanding of blood pressure management in the context of
cutting-edge lymphoid malignancy treatments but also underscores the critical
need for personalized approaches to ensure the well-being of patients
navigating these innovative therapeutic landscapes. 

Further reading: Hypertension Treatment in Patients Receiving Ibrutinib: A Multicenter Retrospective Study. Doi: https://doi.org/10.1182/bloodadvances.2023011569

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Silver diamine fluoride additional tool for addressing dentine hypersensitivity and improving QoL of patients, states study

Silver diamine fluoride additional tool for addressing dentine hypersensitivity and improving QoL of patients states a study published in the Journal of Dentistry.

A study was done to assess the clinical evidence for silver diamine fluoride (SDF) to reduce dentine hypersensitivity in adults. Two independent researchers searched the English literature in five databases (Scopus, PubMed, Web of Science, EMBASE and the Cochrane Library) up to 15th July 2023 for clinical trials investigating the desensitising effect of professionally applied SDF to manage dentine hypersensitivity in adults aged 18 or above at any follow-up period. The primary outcome was the change in dentine hypersensitivity between baseline and follow-up visits after SDF application regarding any validated pain outcome measures. The Cochrane guidelines were used for the risk of bias assessment.

Results: Three hundred and thirty-one studies were identified, and four of them were finally included. Three of the included studies were rated as having a ‘low risk’ of bias. The SDF solution reduced dentine hypersensitivity in adults. The percentage reduction in dentine hypersensitivity ranged from 23 % to 56 % after a single application of SDF solution. Moreover, the SDF solution was more effective than potassium nitrate, potassium oxalate and glutaraldehyde plus hydroxyethyl methacrylate in reducing dentine hypersensitivity. Meta-analysis indicated a more significant reduction in visual analogue scales (1–10) by 1.35 (95 % CI:0.9–1.8; p<0.00001) after receiving the SDF application than controls. The included clinical trials showed that SDF solution reduced dentine hypersensitivity in adults. However, clinical trials are few, and their protocol varied from one another. Further well-designed clinical trials should be conducted to provide more evidence on its use to manage dentine hypersensitivity. SDF is cleared as desensitizing agents by the US Food and Drug Administration to manage dentine hypersensitivity, which induces pain, limits food choice, and impacts the quality of life. Evidence from this systematic review informs clinicians and provides researchers insight for future research on SDF use for dentine hypersensitivity.

Reference:

Alice Kit Ying Chan, Yiu Cheung Tsang, Ollie Yiru Yu, Edward Chin Man Lo, Katherine Chiu Man Leung, Chun Hung Chu. Clinical evidence for silver diamine fluoride to reduce dentine hypersensitivity: A systematic review. Journal of Dentistry, Volume 142, 2024, 104868. ISSN 0300-5712, https://doi.org/10.1016/j.jdent.2024.104868. (https://www.sciencedirect.com/science/article/pii/S0300571224000381)

Keywords:

Silver diamine fluoride, additional tool, dentine hypersensitivity, QoL of patients, Journal of Dentistry, Silver diamine fluoride; Dentine hypersensitivity; Oral health; Caries; Older adult, Alice Kit Ying Chan, Yiu Cheung Tsang, Ollie Yiru Yu, Edward Chin Man Lo, Katherine Chiu Man Leung, Chun Hung Chu

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Increased retinal detachment risk observed among vitiligo patients: Study

Vitiligo is a condition characterized by the loss of skin pigment and has long been known to be associated majorly with various ocular abnormalities. A recent study from Taiwan explored a concerning association between vitiligo and retinal detachment (RD). The key findings of this studywere published in the journal of Clinical and Experimental Dermatology.

The study was conducted as a nationwide population-based cohort study in Taiwan that analyzed data from the Taiwan National Health Insurance Database from 2007 to 2018. This study identified a cohort of 21,132 vitiligo patients and matched them in a 1:4 ratio with non-vitiligo patients based on age, sex and propensity score of comorbidities.

The findings of the study were;

The vitiligo cohort expressed a significantly higher rate of retinal detachment when compared to the non-vitiligo cohort. After adjusting for various factors, including age, sex and comorbidities, the research found that vitiligo patients underwent a 1.44-fold increased risk of retinal detachment.

Also, the vitiligo patients who required treatments such as phototherapy, systemic corticosteroids or immunosuppressants showed an even greater risk, with a marked 1.57-fold increase in retinal detachment risk.

This study emphasized the importance of these findings which highlights the need for increased vigilance among healthcare professionals regarding the ocular health of vitiligo patients. It’s crucial that clinicians consider the potential risk of retinal detachment in these patients who undergo specific treatments.

With vitiligo affecting approximately 1% of the global population, the clear understanding of its potential systemic associations is critical for comprehensive patient care. Thereby, the comprehensive analysis of study that was over a 10-year follow-up period, further solidifies the observed association between vitiligo and retinal detachment.

Reference:

Chen, C.-L., Wu, C.-Y., Chen, Y.-L., Chen, C.-C., Chang, Y.-T., & Wu, C.-Y. (2024). Association between vitiligo and risk of retinal detachment: A population-based cohort study in Taiwan. In Clinical and Experimental Dermatology. Oxford University Press (OUP). https://doi.org/10.1093/ced/llae035

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Which Antibiotics Best Prevent Infections for Children With Vesicoureteral Reflux?

Children with vesicoureteral reflux often need to take continuous antibiotics to reduce the risk of urinary tract infections (UTIs). But which antibiotics do the best job at preventing these infections?

Researchers in the Division of Urology at Children’s Hospital Los Angeles recently conducted a study to shed more light on this issue. The results were presented in recently at the Societies for Pediatric Urology Congress in Houston.

“This is a complex question because we know that antibiotic resistance patterns are variable, based on region and many other factors,” says Scott Sparks, MD, a pediatric urologist at CHLA who led the study. “We wanted to see if we could identify any definitive trends about antibiotic effectiveness for our patients here in Los Angeles.”

Key findings

Vesicoureteral reflux is typically a congenital condition in which urine flows backward from the bladder to the ureters or kidneys. Reflux commonly resolves on its own as children grow. But until that happens, some patients may benefit from continuous low-dose antibiotic therapy to prevent UTIs.

The retrospective study examined how often these patients have breakthrough UTIs. The study included 402 children with reflux who were seen at CHLA from 2015 to 2021. All the patients were on continuous antibiotic therapy.

The study found that:

  • Patients taking cephalexin had the highest rates of breakthrough UTIs, at 2.52 per 100 person months.
  • Patients taking sulfamethoxazole/trimethoprim also had relatively high rates of infections, at 1.52 per 100 person months.
  • A large percentage of breakthrough UTIs were resistant to both cephalexin and sulfamethoxazole/trimethoprim.
  • Nitrofurantoin had the lowest rates of breakthrough UTIs.

Guiding discussions with families

Dr. Sparks cautions that these findings are specific to the Los Angeles area. Breakthrough rates are also just one factor in deciding on the best antibiotic for a particular patient.

For example, while nitrofurantoin had the lowest rates of infections, it can be difficult for parents to administer. The medicine does not come in a liquid, and because patients with reflux are typically very young, capsules must be opened up and sprinkled on food.

“I think the biggest take-home message is that, while there’s no perfect choice, it’s important for physicians to be aware of the antibiotic resistance patterns in their own community,” Dr. Sparks says.

“I haven’t significantly changed my prescribing patterns based on these findings,” he adds. “But it has helped me have better discussions with families. I can give them more specific data now about each medicine and what they can expect. Then together, we can make the best choice for each child.”

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