Editorials

Heart Disease Prevention Begins in Childhood

PATRICK E. MCBRIDE, M.D., M.P.H.
University of Wisconsin Medical School
Madison, Wisconsin

Coronary artery disease risk factors, including systolic and diastolic blood pressures, serum lipoprotein levels, cigarette smoking, and body mass index, are directly related to the initiation and progression of atherosclerosis in children.^1,2

See article in this issue.

Risk factors that we know are important in adults are common in children and adolescents.³ Since 1990, the prevalence of tobacco use, obesity and sedentary lifestyle has steadily increased among U.S. children and adolescents. The incidence of smoking in youth has increased each year since 1991 and, every day, more than 3,000 adolescents start smoking. More than 20 percent of U.S. adolescents are currently overweight, representing a relative increase in prevalence of more than 50 percent since 1980. In addition, the number of high school students participating in physical education has steadily decreased. These declines in the health status of adolescents in the United States have important implications for future rates of cardiovascular disease. Cardiovascular disease will soon be the leading cause of premature death and disability worldwide.³

Because of their knowledge of family health, family physicians are in a unique position to screen for children at risk. In this issue of American Family Physician, Reginald Washington, M.D., an expert in cardiovascular disease in children, presents a practical, practice-based approach to assessing and managing risk factors for cardiovascular disease.⁴ He presents methods of incorporating risk assessments into children's health maintenance schedules and provides practical advice on managing risk factors. These recommendations are consistent with national guidelines for reducing future premature cardiovascular disease.

Controversy remains, however, on screening for hyperlipidemia in children and the medical treatment of high blood cholesterol levels and blood pressure in this age group.^5,6 Can the treatment of risk factors wait until adulthood? The pathologic studies suggest that atherosclerosis is diffuse and advanced as early as adolescence.^1,2 Expert panels have concluded that adolescents who have blood pressure or low-density lipoprotein (LDL) cholesterol levels greater than the 90th percentile should receive medication if they are not responding to lifestyle changes, based on the risk associated with prolonged extreme elevations of blood pressure or LDL cholesterol levels.^5,7

Nevertheless, it is difficult to extrapolate health care recommendations for children from the results of clinical trials performed in adults. Long-term trials of risk factor modification in children to prevent future cardiovascular events are not available, nor are they likely to be, because of the large sample sizes, expense and length of time required for meaningful results.

Research studies other than trials that assess morbidity and mortality could answer important questions and guide clinical decisions. We need new methods of promoting behavior change or preventing the initiation of unhealthy behaviors. Innovative ways of demonstrating whether medical treatment of high blood pressure or cholesterol levels reduces the incidence of atherosclerosis and its progression--such as noninvasive methods of measuring atherosclerosis--could assess whether medical treatment is beneficial in high-risk children and adolescents.

Primary prevention of atherosclerosis is important because over 40 percent of cardiovascular events occur in persons under 65 years of age, and nearly 50 percent of these events are fatal.³ The issue remains at what age do we start medical treatment? It is reasonable to make every effort to ensure that our children avoid tobacco, be physically active and have a healthy diet. It is also reasonable to treat extreme risk that is highly likely to result in premature cardiovascular disease. The conservative recommendations of Washington⁴ and the National Institutes of Health⁵ serve as appropriate guidelines for health maintenance.

Dr. McBride is associate professor and director of preventive cardiology in the Departments of Medicine-Cardiology and Family Medicine, University of Wisconsin Medical School, Madison.

Address comments to Patrick McBride, M.D., M.P.H., University of Wisconsin Medical School, H6/349 Clinical Science Center, 600 Highland Ave., Madison, WI 53792.

REFERENCES

1. Berenson GS, Srinivasan SR, Bao W, for the Bogalusa Heart Study. Association between multiple cardiovascular disease risk factors and atherosclerosis in children and young adults. N Engl J Med 1998;338:1650-6.
2. McGill HC, McMahan CA, Malcolm GT, Oalmann MC, Strong JP. Effects of serum lipoproteins and smoking on atherosclerosis in young men and women. Arterioscler Thromb Vasc Biol 1997; 17:95-106.
3. Hennekens CH. Increasing burden of cardiovascular disease: Current knowledge and future directions for research on risk factors. Circulation 1998;97:1095-102.
4. Washington RL. Interventions to reduce cardiovascular risk factors in children and adolescents. Am Fam Physician 1999;59:2211-8.
5. National Cholesterol Education Program Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Highlights of the Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Am Fam Physician 1992;45:2127-36.
6. Schoen EJ. Childhood cholesterol screening: An alternative view. Am Fam Physician 1992;45:2179-82.
7. Goldstein JC, Brown MB. Familial hypercholesterolemia. In: Scriver CS, Beaudat AL, Sly WS, eds. Metabolic basis of inherited disease, New York: McGraw-Hill;1989:1215-51.

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Confronting Antimicrobial Resistance: A Shared Goal of Family Physicians and the CDC

DAVID M. BELL, M.D.
D. PETER DROTMAN, M.D., M.P.H.
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Atlanta, Georgia

Because the clinical care and public health systems in the United States must be able to respond rapidly to emerging and reemerging infectious disease threats, the Centers for Disease Control and Prevention (CDC) recently published a plan, Preventing Emerging Infectious Diseases: A Strategy for the 21st Century,¹ which was developed in consultation with many partners and with input from primary care clinicians. The plan addresses four major goals--surveillance and response, applied research, infrastructure and training, and prevention and control--and is designed to foster stronger and more flexible responses to emerging infectious diseases.

See "Special Medical Reports" in this issue.

Antimicrobial resistance is a major target area in the plan. Approximately 11 percent of invasive pneumococcal isolates in a multiregion surveillance project of the CDC are no longer susceptible to penicillin or third-generation cephalosporins²; resistance to new fluoroquinolones has already been reported (C. Whitney, unpublished data from CDC, 1998). In intensive care units, 28 percent of the bacteria that most frequently cause hospital-acquired infections are resistant to the preferred antibiotic³ (S. Fridkin, unpublished data from CDC, 1998). Reports of community-acquired, methicillin-resistant Staphylococcus aureus are increasing,⁴ and strains of S. aureus with decreased susceptibility to vancomycin have been identified in Japan, Michigan, New Jersey, New York and Europe.^5-7 Resistance has also emerged in pathogens that cause tuberculosis, gonorrhea, acquired immunodeficiency syndrome, salmonellosis, candidiasis, malaria and other common infections.⁸

The CDC and family physicians share common goals that can be of mutual benefit in preventing antimicrobial resistance. As a public health agency, the CDC conducts surveillance of resistance to assist in clinical decision making, new drug development, and targeting of prevention and control measures. The CDC supports applied research to identify the molecular basis of antimicrobial resistance and risk factors for its development and spread, to develop better and rapid diagnostic tests, and to assess the roles of new drugs and vaccines. Infrastructure and training goals include ensuring that clinical laboratories can detect and report resistant pathogens to clinicians and that public health agencies can respond appropriately.

The ultimate goal we share is the prevention and control of antimicrobial resistance. Although specific measures differ for different pathogens, a common theme is that antimicrobial drug use exerts selective pressure favoring resistance. Judicious prescribing of antimicrobials is therefore essential to maximize the life of existing drugs while new drugs are being developed. Infection control is also important in settings that may amplify infection transmission (e.g., health care and child care settings). Simple strategies such as washing one's hands between patients must be reinforced continuously.

Family physicians are on the front lines in the battle against antimicrobial resistance. In caring for patients with a wide range of ages and presenting conditions, they represent the first link in the chain of surveillance and play a critical role in developing and implementing realistic prevention and control recommendations, and educating patients. Public health agencies can assist clinicians by providing surveillance summaries, updated treatment information and educational materials, and by facilitating the development and evaluation of new drugs, vaccines and diagnostic tests.

In respiratory illness seasons, the most important contribution that physicians can make is to limit the prescribing of antimicrobial drugs. The CDC estimates that 50 million unnecessary prescriptions of antibiotics for upper respiratory infections are written annually in the United States, representing enormous selective pressure for resistant bacteria. Unnecessary antibiotic use increases an individual patient's risk of acquiring a drug-resistant infection, not just the community's risk.⁹

Patients often require an explanation that antimicrobials offer no benefit for their viral illness and may even be harmful. With input from family practitioners and other experts, the CDC has developed clinical aids to save physicians' time in the examining room, including "prescription pads" outlining treatment for viral illnesses and colorful, attractive, easy-to-read educational brochures for the waiting room. One such brochure in Spanish and English is free to family physicians and is available by faxing a request on letterhead to CDC's Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases (404-639-0817), or by accessing the CDC Web site (http://www.cdc.gov/ncidod/diseases/antimic-d.htm).

Actions to Protect Patients from Antimicrobial Resistant Infections Prescribe no antibiotics for simple coughs and colds. (Remember that purulent rhinitis is part of the natural history of a viral cold; acute bronchitis/cough illnesses lasting less than 10 days are usually viral.) Prescribe no antibiotics for viral sore throats; prescribe a penicillin for laboratory-diagnosed group A streptococcal pharyngitis. Limit antibiotic prescribing for uncomplicated cystitis to three days in otherwise healthy women. Limit prescribing of antibiotics over the telephone to exceptional cases. Prescribe amoxicillin as the drug of choice for acute otitis media, but no antibiotics for initial treatment of otitis media with effusion. (In most patients over two years of age, five to seven days of treatment for acute otitis media is enough, even if asymptomatic effusions have not yet resolved.) Obtain current information and order education materials for patients through the antibiotic resistance page on the Web site of the Centers for Disease Control and Prevention (http://www.cdc.gov/ncidod/diseases/antimic-d.htm). Information from United Kingdom Department of Health Standing Medical Advisory Committee, Sub-Group on Antimicrobial Resistance. The path of least resistance: summary and recommendations. London: Department of Health, 1998; Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Otitis media--principles of judicious use of antimicrobial agents. Pediatrics 1998;101(2 pt 2):165-71; Rosenstein N, Phillips WR, Gerber MA, Marcy SM, Schwartz B, Dowell SF. The common cold--principles of judicious use of antimicrobial agents. Pediatrics 1998;101(2 pt 2):181-4.

Physicians should also be familiar with the latest diagnostic and therapeutic recommendations (see table). For example, it is now known that purulent rhinitis is part of the natural history of a viral cold. An illness characterized by bronchitis or a cough that lasts fewer than 10 days is usually viral in origin. High-dose amoxicillin (80 to 90 mg per kg per day) is the drug of choice for acute otitis media.¹⁰ Antimicrobial therapy for acute otitis media in most patients over two years of age can be stopped after five to seven days, even if asymptomatic effusions have not yet resolved.^11-13 Educational materials for patients and clinicians can be obtained through the health information page on the CDC Web site (http://www.cdc.gov/ncidod/diseases/antimic-d.htm).

Recent increases in antimicrobial resistance are cause for alarm but not pessimism. Improving prescribing practices and decreasing the spread of antimicrobial resistance can be accomplished.^14,15 By forming effective partnerships involving clinicians, public health officials and patients, we can prolong the effectiveness of currently available drugs and reduce the threat of antimicrobial resistance for patients today and for patients of future generations.

Dr. Bell is assistant to the Director for Antimicrobial Resistance, National Center for Infectious Diseases, CDC. He is a member of the National Center for Infectious Diseases Plan Steering Committee. Dr. Drotman is senior medical officer in the Office of the Director, National Center for Infectious Diseases, CDC.

Address correspondence to David M. Bell, M.D., Centers for Disease Control and Prevention, 1600 Clifton Rd NE (C-12), Atlanta, GA 30333

REFERENCES

1. Rose VL. CDC releases updated plan for emerging infectious diseases (Special Medical Report). Am Fam Physician 1999;59:2361-6.
2. Cetron MS, Breiman RF, Jorgenson JH, et al. Multi-site population-based surveillance for drug resistant Streptococcus pneumoniae (DRSP). Abstract C-283. Abstracts of the 97th General Meeting of the American Society for Microbiology, May 4-8,1997. Washington DC: American Society for Microbiology:169.
3. National Nosocomial Infections Surveillance (NNIS) Report, data summary from October 1986-1996, issued May 1996. A report from the National Nosocomial Infections Surveillance (NNIS) System. Am J Infect Control 1996;24:380-8.
4. Herold BC, Immergluck LC, Maranan MC, Lauderdale DS, Gaskin RE, Boyle-Vavra S, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk JAMA 1998;279:593-8.
5. Hiramatsu K, Hanaki H, Ino T, Yabuta K, Oguri T, Tenover FC. Methicillin-resistant Staphylococcus aureus clinical strains with reduced vancomycin susceptibility. J Antimicrob Chemother 1997;40:135-6.
6. Update: Staphylococcus aureus with reduced susceptibility to vancomycin--United States, 1997; MMWR Morb Mortal Wkly Rep 1997;46:813-5 (published erratum appears in MMWR Morb Mortal Wkly Rep 1997;46:851).
7. Ploy MC, Grelaud C, Martin C, de Lumley L, Denis F. First clinical isolate of vancomycin-intermediate Staphylococcus aureus in a French hospital. Lancet 1998;351:1212.
8. Institute of Medicine. Antimicrobial resistance: issues and options. Washington DC: National Academy Press, 1998:1-115.
9. Dowell SF, Schwartz B. Resistant pneumococci: protecting patients through judicious use of antibiotics. Am Fam Physician 1997;55:1647-54,1657-8.
10. Dowell SF, Butler JC, Giebink GS, Jacobs MR, Jernigen D, Musher DM, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance--a report from the Drug-resistant Streptococcus pneumoniae Therapeutic Working group. Ped Infect Dis J 1999;18:1-9.
11. Dowell SF, Schwartz B, Phillips WR, Pediatric URI Consensus Team. Appropriate use of antibiotics for URIs in children: Part I. Otitis media and acute sinusitis. Am Fam Physician 1998;58:1113-8,1123.
12. Dowell SF, Schwartz B, Phillips WR. Appropriate use of antimicrobial agents for URIs in children: Part II. Cough, pharyngitis, and the common cold. Am Fam Physician 1998;58:1335-42,1345.
13. Gonzales R, Sande M. What will it take to stop physicians from prescribing antibiotics in acute bronchitis? Lancet 1995;345:665-6.
14. Stephenson J. Icelandic researchers are showing the way to bring down rates of antibiotic-resistant bacteria. JAMA 1996;275:175.
15. Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med 1996;124:884-90.

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