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Letters from readers
|Jump to:||Choose article section... Correction Alternatives to penicillin for sinusitis Obtaining a throat culture in difficult patients|
The correct Web site address for Pediatrics on Hand (Resources, January 2003) is www.pediatricsonhand.com (not .org). The site is maintained independently by David Stockwell, MD, not by the Children's National Medical Center.
In "Why won't this child's nose stop running?" (December 2002), the authors suggest that azithromycin or clarithromycin is a good choice to treat sinusitis in penicillin-allergic patients. In many areas of the country, including where I practice (the Southeast), the SENTRY antimicrobial surveillance program is reporting a high and increasing rate of macrolide resistance in streptococcal pneumonia. This fits clinically with what we have been seeing in terms of more treatment failure with acute otitis media and sinusitis when macrolides are used.
Author reply:Thanks to Dr. Allen for raising the question of antibiotic choices. Certainly, cephalosporins have only a 3% to 5% cross-reactivity with penicillin allergy and remain excellent choices, as well as macrolides. In Connecticut (where I practice), Streptococcus pneumoniae resistance to macrolide therapy is approximately 15% to 20%. However, over 90% of S pneumoniae isolates are sensitive to clindamycin, indicating that the resistance pattern is primarily due to the efflux pump mechanism. This mechanism of resistance is usually overcome by adequate dosing when using macrolides. Of course, the rate of resistance pattern differs from region to region, and clinicians must tailor their practice with that in mind.
Dr. Barton Schmitt's approach to the uncooperative child needing a throat culture (Clinical Tip, "Throat cultures: The road less taken," January 2003) is terrific. My approach has been to suggest that the parent and child wait in an examining room and let me know when the child is ready to have the throat culture done. I then leave the two in the room alone for them to work it out. I am usually called for in less than 15 minutes. I am successful in obtaining a culture about 80% of the time with a difficult child.