Antibiotics in Respiratory Tract Infections in Hospital Pediatric Emergency Departments

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Their inappropriate use can affect the quality of care and healthcare expenditure, and can also facilitate onset of side effects and resistances.<a class="elsevierStyleCrossRefs" href="#bib0005">1–6</a>Since abuse of these drugs is a common problem in routine pediatric clinical practice,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> their use should be permanently monitored. A high prevalence of antibiotic use has been detected at international level, especially in preschool patients, with a rate of 2.2 prescriptions per person per year, and estimated unjustified use in at least one-third of children with infectious disease.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> Respiratory infections, most of which are viral in origin, are among the most prevalent affecting the pediatric population, and as such constitute a major target for potentially erroneous prescription of antibiotics.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> In Spain, a study conducted in 11 pediatric emergency departments found between 14% and 80% inappropriate antibiotic use in bronchial infections.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>The increase in antibiotic resistance is a major public health problem that has prompted the implementation of programs to improve prescription quality and to educate both healthcare personnel and the general public in their use, together with the introduction of both in-hospital and out-of-hospital treatment protocols or guidelines.<a class="elsevierStyleCrossRefs" href="#bib0050">10–13</a>The rational use of antibiotics is also one of the parameters assessed to determine the quality of medical care. For example, one of the indicators recommended for evaluation by the Spanish Society of Pediatric Emergencies (SEUP) is “antibiotic treatment in febrile syndrome of viral origin”, as a parameter adapted to pediatrics.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Thus, incorrect use of antibiotics would indicate poorer quality of care. However, their use in children is not only determined by pediatric prescription; among many other determining factors are the different levels of access to and use of healthcare services by the population, the use of medicines on the parents’ own initiative, and the extent to which they expect pediatricians to prescribe antibiotics. These factors are all very strongly associated with social and cultural levels.<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a>Despite the relevance of this topic, trends in the use of hospital pediatric emergency departments, the impact of visits for respiratory infections, and the quality of antibiotic prescription during these visits are largely unknown. These data must be obtained to be able to optimize the use of resources, and to monitor health care processes.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>The working hypothesis is that clinical practice guidelines on the use of antibiotics in pediatric respiratory infections are adequately followed in emergency departments. The objectives of this study were to determine the percentage of consultations for respiratory infections, the most common diagnoses, level of compliance with international recommendations on antibiotic prescription in our hospital pediatric emergency department, whether or not antibiotic therapy is correctly prescribed, and if so, the choice of antibiotic, and the existence of other factors that could be related to the type of visit and use of antibiotics.MethodsAll discharge reports issued from the pediatric emergency section of a secondary university general hospital between July 2005 and October 2007 were retrospectively reviewed. Informed consent was obtained from the parents or legal guardians in all cases, and the study protocol was approved by the local ethics committee. The following variables were evaluated: diagnoses (primary and secondary) according to the International Classification of Diseases (ICD-9), age, sex, and prescription of antibiotic at that visit (whether prescribed or not, and if so, the type of antibiotic selected). The data obtained were tabulated and a descriptive study was performed. The percentage of visits for infections out of all visits in the study period was analyzed, including visits for 2 respiratory disease sub-groups: upper respiratory tract infections (URTIs) and lower respiratory tract infections (LRTIs). The first sub-group included the common cold, acute otitis media (AOM), sinusitis and tonsillopharyngitis, and the second included laryngitis, bronchitis, bronchiolitis and pneumonia. The age variable associated with the type of visit was then analyzed. To perform the comparative analysis, the population using the hospital and the number visits during the study period based on all reports issued (both infectious and non-infectious cause) were analyzed.Finally, the use of antibiotics in these patients and their appropriateness according to the diagnosis was studied. The guidelines established in the protocols used in the department, which coincide with the recommendations of international guidelines, were considered correct. The prescription (or absence of prescription) as well as the appropriateness of the choice of specific antibiotic prescribed was analyzed.A descriptive statistical analysis of the sociodemographic data obtained was carried out. The chi-squared test was used to compare the quantitative data of absolute frequencies and percentages. The differences associated with P values <.05 were considered statistically significant. All statistical analyses were performed using statistical package SPSS (version 14.0, SPSS Inc, Chicago, IL, United States).ResultsA total of 23114 (13337 boys and 9777 girls; 42.3%) reports with a mean age of 2.5 years were analyzed; 15094 (65%) corresponded to infection.Among the reports with a diagnosis of infection, the group with highest attendance was infants under 2 (44.1%), in most cases for colds.URTIs constituted 47% of the visits due to infection; cold was the most frequent diagnosis (59.1%). AOM and tonsillopharyngitis together accounted for the remaining 40.9%. There were no cases of sinusitis. Antibiotics were used in 5.7% of the cases of colds. Amoxicillin was most commonly used, followed by amoxicillin-clavulanic acid. The use of antibiotics was proportionally greater among 5 and 6-year-old (33.2% of the patients who visited for a cold received antibiotics).Tonsillopharyngitis accounted for 19.8% of the visits for URTIs and for 9.3% of the reports of infectious cause. The highest visitation rate due to this cause was infants under 2, and there was a slight increase in cases among 6 and 8-year-old. In total, 36.7% of the cases were treated with antibiotics, mostly amoxicillin. Antibiotics were prescribed more often in patients over 3-years-old, peaking in the 11 to 12-year-old age group.AOM accounted for 21.1% of the visits due to URTI, mostly involving children aged 3–6 years. Diagnosis in infants under 2-years old was rare. Antibiotics were prescribed in 95.6% of cases. Amoxicillin was most widely used (72%), followed by amoxicillin-clavulanic acid (23%), cephalosporins (4%) and azithromycin (1%).AOM was diagnosed concurrently in 1411 cases in which the primary diagnosis was infection not suitable for antibiotic treatment, but this secondary diagnosis ultimately justified the use of these drugs.LRTI reports accounted for 13.6% of the total number of infections; among these, acute bronchitis was the most common diagnosis (49.9%). Most visits were concentrated in the under 4 age group. The use of antibiotics in bronchitis rose to 11.3%, with amoxicillin prescribed most often. Bronchiolitis accounted for 16.8% of all LRTIs; 3.2% were treated with antibiotics, with amoxicillin again being the most commonly used. Laryngitis accounted for 23.50% of all LRTI, 2.5% of which were treated with antibiotics. Pneumonia only accounted for 14.6% of total cases; most were considered of viral etiology and did not receive antibiotic treatment. Most of the remaining cases (42.3%) were treated with beta-lactam antibiotics. In school-age patients, azithromycin was the most widely used antibiotic, consistent with the higher incidence of so-called atypical pneumonias (caused by Mycoplasma pneumoniae and Chlamydia, among others). In total, macrolides were prescribed in 33% of the pneumonias treated with antibiotics (41 cases with azithromycin and one case with clarithromycin).With respect to the number of return visits for infection in general, considering this to be a further visit by the patient for the same reason within one week, this occurred in 1422 patients (9.4% of all visits for infection).DiscussionInfections accounted for 65.3% of all discharge reports. Most were URTIs (47%) and the common cold was the most commonly diagnosed illness. These figures are similar to those reported in the literature, according to which more than 50% of the visits to pediatric emergency departments are for nasopharyngitis symptoms (common cold).<a class="elsevierStyleCrossRefs" href="#bib0035">7,17</a> Respiratory disease continues to be the most common reason for prescribing antibiotics in children.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Infants under 2 years were the age group with the most visits and were most frequently discharged with the diagnosis of a cold, a finding that is also in line with the literature.<a class="elsevierStyleCrossRefs" href="#bib0035">7,19–21</a>One children's hospital in our area detected inappropriate prescribing in 22.3% of the visits for three common respiratory diseases (AOM, tonsillopharyngitis and community-acquired pneumonia).<a class="elsevierStyleCrossRef" href="#bib0095">19</a> This study was limited by the small sample size, the biodemographic characteristics derived from its location on the outskirts of a city, and its status as a tertiary referral hospital.In the pediatric emergency department of another tertiary referral hospital, the prescription rate after two educational talks delivered to physicians on the rational use of antibiotics was analyzed<a class="elsevierStyleCrossRef" href="#bib0100">20</a>; there was no significant reduction (13% and 12.7% before and after the intervention), although correct dosing improved.In our sample, antibiotics were predominantly used in cases of AOM, following strict diagnostic criteria,<a class="elsevierStyleCrossRefs" href="#bib0110">22–24</a> and this diagnosis was hardly made at all in infants under 2 years of age. Cases corresponding to non-serious, uncomplicated infections that did not require antibiotic treatment were acute catarrhal otitis media, and were included in the common cold group. Antibiotic prescription was very high in schoolchildren, which is in line with the literature.<a class="elsevierStyleCrossRefs" href="#bib0095">19,25,26</a> The prescription of amoxicillin for AOM and the lesser use of macrolides and cephalosporins were in line with published international recommendations.<a class="elsevierStyleCrossRefs" href="#bib0050">10,22,23</a>Antibiotics were used in pneumonia in less than 50% of the cases, which is in line with general recommendations and is probably based on the use of diagnostic tools used in the emergency department (laboratory and radiology). Beta-lactamic antibiotics were prescribed in more than 70% of the cases, also in line with current guidelines.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> The use of macrolides in schoolchildren is related to diagnosis of pneumonitis due to Mycoplasma pneumonia, which also appears to be consistent with recommendations.<a class="elsevierStyleCrossRef" href="#bib0135">27</a>In the case of tonsillopharyngitis, antibiotics were not prescribed in infants under 2 years old, an age group in which bacterial etiology is very rare.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>In infections with diagnoses of common cold, bronchitis and bronchiolitis, there was a low rate of antibiotic prescription (5.7%, 11.3% and 3.2%, respectively) compared with the literature,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> although the tendency should be towards not using them at all. Most of these infections were associated with AOM as a second diagnosis which required antibiotic treatment, justifying their prescription.Non-use of antibiotics in cases of the common cold is considered an indicator of high quality of care. The percentage found in our study was low (5.4%), lower than that described in other published series, in which it reached up to 50% of cases.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>The special characteristics of a population can influence both the types of infections seen and the way in which healthcare resources are used, as has been described in our setting and in other multi-ethnic populations.<a class="elsevierStyleCrossRefs" href="#bib0145">29–34</a> Furthermore, other factors such as self-medication and compliance are essential for analysis of the real situation of antibiotic use, and are related with the social and cultural level of patients’ families.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> In Spain, 20% of the parents state that they always use antibiotics for influenza or the common cold, and only one-third are aware of their specific anti-bacterial action. Moreover, they tend to have a poor opinion of the medical care received when antibiotics are not prescribed at the first visit but are given at a subsequent visit.<a class="elsevierStyleCrossRef" href="#bib0175">35</a>The large sample size is the greatest strength of our study. Limitations are the absence of specific coding on the etiology and topographic diagnosis of respiratory infections, as well as the lack of data on dosage, route of administration and duration of treatment. As these are patients who only visit the emergency department occasionally, it was not possible to perform follow-up that would have allowed therapeutic compliance to be evaluated. Nevertheless, 9.4% of repeat visits to the emergency department were due to infectious conditions in general. This suggests that these patients require follow-up in the primary care setting to ensure therapeutic compliance where needed, as well as the medical checkups necessary in patients considered to require only symptomatic treatment at their initial assessment.ConclusionsIn summary, this study offers a good profile of the number of patients visiting for infections in a hospital pediatric emergency department, and provides data for monitoring quality indicators.The common cold is still the main reason for visiting our pediatric emergency department, and URTIs as a whole account for 40% of all visits, representing overuse of the hospital emergency department for cases of minor complaints that could be seen in primary care. In general, there is good compliance with published recommendations in the use of antibiotics, both in terms of appropriateness of prescription, and the antibiotic selected empirically (although the prescription of antibiotics in cases of AOM needs to be adjusted according to the child's age). Prescription compliance and clinical course should be monitored to complete the study on the use of antibiotics. The existence of clinical protocols for antibiotic use in hospital pediatric emergency departments and the implementation of mechanisms and care quality indicators are essential to improve antibiotic prescription and related healthcare costs.Conflict of InterestThe authors declare that they have no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres364411" "titulo" => array:5 [ 0 => "Abstract" 1 => "Background" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec344016" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres364412" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec344015" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-05-20" "fechaAceptado" => "2014-01-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec344016" "palabras" => array:6 [ 0 => "Antibiotics" 1 => "Emergency room" 2 => "Pediatrics" 3 => "Prescription" 4 => "Upper respiratory tract infections" 5 => "Lower respiratory tract infections" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec344015" "palabras" => array:6 [ 0 => "Antibióticos" 1 => "Servicios médicos de urgencias" 2 => "Pediatría" 3 => "Prescripción" 4 => "Infecciones respiratorias de vías altas" 5 => "Infecciones respiratorias de vías bajas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "BackgroundRespiratory tract infections are one of the most frequent problems in pediatric clinics and generate an elevated prescription of antibiotics. The aim of this study was to find out the standard of care practice about antibiotic use in these infections in a pediatric emergency department and to evaluate compliance with clinical guidelines. MethodsA pediatric emergency department database was reviewed from July 2005 to October 2007 under the category “respiratory infection”, including variables such as age, antibiotic prescription and compliance with current clinical recommendations. ResultsOut of the 23114 reviewed reports, 32.7% (7567) were upper respiratory tract infections (URTI) (cold, acute otitis media [AOM], sinusitis and tonsillopharyngitis) or lower respiratory tract infections (LRTI) (laryngitis, bronchitis, bronchiolitis and pneumonia). Children under the age of 2 were the most represented age group.Amongst URTI, rhinopharyngitis was the most frequent infection, while bronchitis was the most frequent among LRTI. Antibiotic therapy (mainly amoxicillin) was prescribed in 30.8% of URTI (5.7% rhinopharyngitis, 96.5% AOM, and 36.7% tonsillopharyngitis) and in 12.4% of LRTI. ConclusionsThe percentage of respiratory tract infections was similar to previous studies and the antibiotic prescriptions followed current guidelines, except for cases diagnosed with AOM. Prescription compliance and clinical course of the cases should be monitored." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "IntroducciónLas infecciones respiratorias son un motivo frecuente de consulta en pediatría y originan un gran número de prescripciones de antibióticos. El objetivo de este trabajo es conocer la práctica clínica habitual en relación con el uso de antibióticos en estas patologías en un servicio de urgencias pediátricas hospitalario, así como su adecuación a las guías clínicas. MétodosRevisión de la base de datos clínicos de las visitas en el servicio de urgencias pediátricas de un hospital de segundo nivel en el período comprendido entre julio de 2005 y octubre de 2007 y análisis del porcentaje de consultas debidas a infecciones respiratorias, analizando las variables: edad, prescripción de antibióticos durante la visita y adecuación de la misma a las recomendaciones internacionales actuales. ResultadosDe los 23.114 informes estudiados, el 32,7% (7.567) correspondieron a infecciones respiratorias altas (IRVA) (catarro de vías altas, otitis media aguda [OMA], sinusitis y faringoamigdalitis) o bajas (IRVB) (laringitis, bronquitis, bronquiolitis y neumonía) como diagnóstico principal. El grupo de edad más representado fueron los menores de 2años.Entre las IRVA, la rinofaringitis fue la más frecuente, y entre las IRVB destacó la bronquitis. Se prescribieron antibióticos, principalmente amoxicilina, en el 30,8% de los casos de IRVA (en el 5,7% de las rinofaringitis, el 96,5% de las otitis medias agudas y el 36,7% de las faringoamigdalitis) y en el 12,4% de las IRVB. ConclusionesEl porcentaje de visitas por cuadros respiratorios infecciosos coincidió con el descrito previamente en estudios similares y la prescripción de antibióticos se ajustó a las recomendaciones actuales, excepto en el caso de la OMA. Es necesario el seguimiento del cumplimiento de la prescripción y de la evolución clínica de los casos." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Guzmán Molina C, Velasco Rodríguez-Belvís M, Coroleu Bonet A, Vall Combelles O, García-Algar Ó. Antibióticos en las infecciones respiratorias en urgencias pediátricas hospitalarias. 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Antibiotics in Respiratory Tract Infections in Hospital Pediatric Emergency Departments

Antibióticos en las infecciones respiratorias en urgencias pediátricas hospitalarias

Claudia Guzmán Molinaa,b, Marta Velasco Rodríguez-Belvísc, Albert Coroleu Bonetd,e, Oriol Vall Combellesb,c,d,e, Óscar García-Algarb,c,d,e,

Corresponding author

90458@parcdesalutmar.cat

Corresponding author.

a Pediatría, CAP Ciutat Vella, Institut Català de la Salut, Barcelona, Spain

b Departamentos de Pediatría, Obstetricia y Ginecología, y Medicina Preventiva, Universitat Autònoma de Barcelona, Barcelona, Spain

c Servicio de Pediatría, Hospital Infantil Universitario Niño Jesús, Madrid, Spain

d Unitat de Recerca Infancia i Entorn (URIE), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain

e Red SAMID, Instituto de Salud Carlos III, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The rational use of medicines is a fundamental pillar of medical practice that is particularly relevant in the case of antibiotics&#46; Their inappropriate use can affect the quality of care and healthcare expenditure&#44; and can also facilitate onset of side effects and resistances&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Since abuse of these drugs is a common problem in routine pediatric clinical practice&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> their use should be permanently monitored&#46; A high prevalence of antibiotic use has been detected at international level&#44; especially in preschool patients&#44; with a rate of 2&#46;2 prescriptions per person per year&#44; and estimated unjustified use in at least one-third of children with infectious disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Respiratory infections&#44; most of which are viral in origin&#44; are among the most prevalent affecting the pediatric population&#44; and as such constitute a major target for potentially erroneous prescription of antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In Spain&#44; a study conducted in 11 pediatric emergency departments found between 14&#37; and 80&#37; inappropriate antibiotic use in bronchial infections&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The increase in antibiotic resistance is a major public health problem that has prompted the implementation of programs to improve prescription quality and to educate both healthcare personnel and the general public in their use&#44; together with the introduction of both in-hospital and out-of-hospital treatment protocols or guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The rational use of antibiotics is also one of the parameters assessed to determine the quality of medical care&#46; For example&#44; one of the indicators recommended for evaluation by the Spanish Society of Pediatric Emergencies &#40;SEUP&#41; is &#8220;antibiotic treatment in febrile syndrome of viral origin&#8221;&#44; as a parameter adapted to pediatrics&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Thus&#44; incorrect use of antibiotics would indicate poorer quality of care&#46; However&#44; their use in children is not only determined by pediatric prescription&#59; among many other determining factors are the different levels of access to and use of healthcare services by the population&#44; the use of medicines on the parents&#8217; own initiative&#44; and the extent to which they expect pediatricians to prescribe antibiotics&#46; These factors are all very strongly associated with social and cultural levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite the relevance of this topic&#44; trends in the use of hospital pediatric emergency departments&#44; the impact of visits for respiratory infections&#44; and the quality of antibiotic prescription during these visits are largely unknown&#46; These data must be obtained to be able to optimize the use of resources&#44; and to monitor health care processes&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The working hypothesis is that clinical practice guidelines on the use of antibiotics in pediatric respiratory infections are adequately followed in emergency departments&#46; The objectives of this study were to determine the percentage of consultations for respiratory infections&#44; the most common diagnoses&#44; level of compliance with international recommendations on antibiotic prescription in our hospital pediatric emergency department&#44; whether or not antibiotic therapy is correctly prescribed&#44; and if so&#44; the choice of antibiotic&#44; and the existence of other factors that could be related to the type of visit and use of antibiotics&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">All discharge reports issued from the pediatric emergency section of a secondary university general hospital between July 2005 and October 2007 were retrospectively reviewed&#46; Informed consent was obtained from the parents or legal guardians in all cases&#44; and the study protocol was approved by the local ethics committee&#46; The following variables were evaluated&#58; diagnoses &#40;primary and secondary&#41; according to the International Classification of Diseases &#40;ICD-9&#41;&#44; age&#44; sex&#44; and prescription of antibiotic at that visit &#40;whether prescribed or not&#44; and if so&#44; the type of antibiotic selected&#41;&#46; The data obtained were tabulated and a descriptive study was performed&#46; The percentage of visits for infections out of all visits in the study period was analyzed&#44; including visits for 2 respiratory disease sub-groups&#58; upper respiratory tract infections &#40;URTIs&#41; and lower respiratory tract infections &#40;LRTIs&#41;&#46; The first sub-group included the common cold&#44; acute otitis media &#40;AOM&#41;&#44; sinusitis and tonsillopharyngitis&#44; and the second included laryngitis&#44; bronchitis&#44; bronchiolitis and pneumonia&#46; The age variable associated with the type of visit was then analyzed&#46; To perform the comparative analysis&#44; the population using the hospital and the number visits during the study period based on all reports issued &#40;both infectious and non-infectious cause&#41; were analyzed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Finally&#44; the use of antibiotics in these patients and their appropriateness according to the diagnosis was studied&#46; The guidelines established in the protocols used in the department&#44; which coincide with the recommendations of international guidelines&#44; were considered correct&#46; The prescription &#40;or absence of prescription&#41; as well as the appropriateness of the choice of specific antibiotic prescribed was analyzed&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A descriptive statistical analysis of the sociodemographic data obtained was carried out&#46; The chi-squared test was used to compare the quantitative data of absolute frequencies and percentages&#46; The differences associated with <span class="elsevierStyleItalic">P</span> values &#60;&#46;05 were considered statistically significant&#46; All statistical analyses were performed using statistical package SPSS &#40;version 14&#46;0&#44; SPSS Inc&#44; Chicago&#44; IL&#44; United States&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 23<span class="elsevierStyleHsp" style=""></span>114 &#40;13<span class="elsevierStyleHsp" style=""></span>337 boys and 9777 girls&#59; 42&#46;3&#37;&#41; reports with a mean age of 2&#46;5 years were analyzed&#59; 15<span class="elsevierStyleHsp" style=""></span>094 &#40;65&#37;&#41; corresponded to infection&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Among the reports with a diagnosis of infection&#44; the group with highest attendance was infants under 2 &#40;44&#46;1&#37;&#41;&#44; in most cases for colds&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">URTIs constituted 47&#37; of the visits due to infection&#59; cold was the most frequent diagnosis &#40;59&#46;1&#37;&#41;&#46; AOM and tonsillopharyngitis together accounted for the remaining 40&#46;9&#37;&#46; There were no cases of sinusitis&#46; Antibiotics were used in 5&#46;7&#37; of the cases of colds&#46; Amoxicillin was most commonly used&#44; followed by amoxicillin-clavulanic acid&#46; The use of antibiotics was proportionally greater among 5 and 6-year-old &#40;33&#46;2&#37; of the patients who visited for a cold received antibiotics&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Tonsillopharyngitis accounted for 19&#46;8&#37; of the visits for URTIs and for 9&#46;3&#37; of the reports of infectious cause&#46; The highest visitation rate due to this cause was infants under 2&#44; and there was a slight increase in cases among 6 and 8-year-old&#46; In total&#44; 36&#46;7&#37; of the cases were treated with antibiotics&#44; mostly amoxicillin&#46; Antibiotics were prescribed more often in patients over 3-years-old&#44; peaking in the 11 to 12-year-old age group&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">AOM accounted for 21&#46;1&#37; of the visits due to URTI&#44; mostly involving children aged 3&#8211;6 years&#46; Diagnosis in infants under 2-years old was rare&#46; Antibiotics were prescribed in 95&#46;6&#37; of cases&#46; Amoxicillin was most widely used &#40;72&#37;&#41;&#44; followed by amoxicillin-clavulanic acid &#40;23&#37;&#41;&#44; cephalosporins &#40;4&#37;&#41; and azithromycin &#40;1&#37;&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">AOM was diagnosed concurrently in 1411 cases in which the primary diagnosis was infection not suitable for antibiotic treatment&#44; but this secondary diagnosis ultimately justified the use of these drugs&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">LRTI reports accounted for 13&#46;6&#37; of the total number of infections&#59; among these&#44; acute bronchitis was the most common diagnosis &#40;49&#46;9&#37;&#41;&#46; Most visits were concentrated in the under 4 age group&#46; The use of antibiotics in bronchitis rose to 11&#46;3&#37;&#44; with amoxicillin prescribed most often&#46; Bronchiolitis accounted for 16&#46;8&#37; of all LRTIs&#59; 3&#46;2&#37; were treated with antibiotics&#44; with amoxicillin again being the most commonly used&#46; Laryngitis accounted for 23&#46;50&#37; of all LRTI&#44; 2&#46;5&#37; of which were treated with antibiotics&#46; Pneumonia only accounted for 14&#46;6&#37; of total cases&#59; most were considered of viral etiology and did not receive antibiotic treatment&#46; Most of the remaining cases &#40;42&#46;3&#37;&#41; were treated with beta-lactam antibiotics&#46; In school-age patients&#44; azithromycin was the most widely used antibiotic&#44; consistent with the higher incidence of so-called atypical pneumonias &#40;caused by <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> and <span class="elsevierStyleItalic">Chlamydia</span>&#44; among others&#41;&#46; In total&#44; macrolides were prescribed in 33&#37; of the pneumonias treated with antibiotics &#40;41 cases with azithromycin and one case with clarithromycin&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">With respect to the number of return visits for infection in general&#44; considering this to be a further visit by the patient for the same reason within one week&#44; this occurred in 1422 patients &#40;9&#46;4&#37; of all visits for infection&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Infections accounted for 65&#46;3&#37; of all discharge reports&#46; Most were URTIs &#40;47&#37;&#41; and the common cold was the most commonly diagnosed illness&#46; These figures are similar to those reported in the literature&#44; according to which more than 50&#37; of the visits to pediatric emergency departments are for nasopharyngitis symptoms &#40;common cold&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;17</span></a> Respiratory disease continues to be the most common reason for prescribing antibiotics in children&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Infants under 2 years were the age group with the most visits and were most frequently discharged with the diagnosis of a cold&#44; a finding that is also in line with the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;19&#8211;21</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">One children&#39;s hospital in our area detected inappropriate prescribing in 22&#46;3&#37; of the visits for three common respiratory diseases &#40;AOM&#44; tonsillopharyngitis and community-acquired pneumonia&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> This study was limited by the small sample size&#44; the biodemographic characteristics derived from its location on the outskirts of a city&#44; and its status as a tertiary referral hospital&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In the pediatric emergency department of another tertiary referral hospital&#44; the prescription rate after two educational talks delivered to physicians on the rational use of antibiotics was analyzed<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#59; there was no significant reduction &#40;13&#37; and 12&#46;7&#37; before and after the intervention&#41;&#44; although correct dosing improved&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In our sample&#44; antibiotics were predominantly used in cases of AOM&#44; following strict diagnostic criteria&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;24</span></a> and this diagnosis was hardly made at all in infants under 2 years of age&#46; Cases corresponding to non-serious&#44; uncomplicated infections that did not require antibiotic treatment were acute catarrhal otitis media&#44; and were included in the common cold group&#46; Antibiotic prescription was very high in schoolchildren&#44; which is in line with the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;25&#44;26</span></a> The prescription of amoxicillin for AOM and the lesser use of macrolides and cephalosporins were in line with published international recommendations&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;22&#44;23</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Antibiotics were used in pneumonia in less than 50&#37; of the cases&#44; which is in line with general recommendations and is probably based on the use of diagnostic tools used in the emergency department &#40;laboratory and radiology&#41;&#46; Beta-lactamic antibiotics were prescribed in more than 70&#37; of the cases&#44; also in line with current guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The use of macrolides in schoolchildren is related to diagnosis of pneumonitis due to <span class="elsevierStyleItalic">Mycoplasma pneumonia</span>&#44; which also appears to be consistent with recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In the case of tonsillopharyngitis&#44; antibiotics were not prescribed in infants under 2 years old&#44; an age group in which bacterial etiology is very rare&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In infections with diagnoses of common cold&#44; bronchitis and bronchiolitis&#44; there was a low rate of antibiotic prescription &#40;5&#46;7&#37;&#44; 11&#46;3&#37; and 3&#46;2&#37;&#44; respectively&#41; compared with the literature&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> although the tendency should be towards not using them at all&#46; Most of these infections were associated with AOM as a second diagnosis which required antibiotic treatment&#44; justifying their prescription&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Non-use of antibiotics in cases of the common cold is considered an indicator of high quality of care&#46; The percentage found in our study was low &#40;5&#46;4&#37;&#41;&#44; lower than that described in other published series&#44; in which it reached up to 50&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The special characteristics of a population can influence both the types of infections seen and the way in which healthcare resources are used&#44; as has been described in our setting and in other multi-ethnic populations&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#8211;34</span></a> Furthermore&#44; other factors such as self-medication and compliance are essential for analysis of the real situation of antibiotic use&#44; and are related with the social and cultural level of patients&#8217; families&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In Spain&#44; 20&#37; of the parents state that they always use antibiotics for influenza or the common cold&#44; and only one-third are aware of their specific anti-bacterial action&#46; Moreover&#44; they tend to have a poor opinion of the medical care received when antibiotics are not prescribed at the first visit but are given at a subsequent visit&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The large sample size is the greatest strength of our study&#46; Limitations are the absence of specific coding on the etiology and topographic diagnosis of respiratory infections&#44; as well as the lack of data on dosage&#44; route of administration and duration of treatment&#46; As these are patients who only visit the emergency department occasionally&#44; it was not possible to perform follow-up that would have allowed therapeutic compliance to be evaluated&#46; Nevertheless&#44; 9&#46;4&#37; of repeat visits to the emergency department were due to infectious conditions in general&#46; This suggests that these patients require follow-up in the primary care setting to ensure therapeutic compliance where needed&#44; as well as the medical checkups necessary in patients considered to require only symptomatic treatment at their initial assessment&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">In summary&#44; this study offers a good profile of the number of patients visiting for infections in a hospital pediatric emergency department&#44; and provides data for monitoring quality indicators&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The common cold is still the main reason for visiting our pediatric emergency department&#44; and URTIs as a whole account for 40&#37; of all visits&#44; representing overuse of the hospital emergency department for cases of minor complaints that could be seen in primary care&#46; In general&#44; there is good compliance with published recommendations in the use of antibiotics&#44; both in terms of appropriateness of prescription&#44; and the antibiotic selected empirically &#40;although the prescription of antibiotics in cases of AOM needs to be adjusted according to the child&#39;s age&#41;&#46; Prescription compliance and clinical course should be monitored to complete the study on the use of antibiotics&#46; The existence of clinical protocols for antibiotic use in hospital pediatric emergency departments and the implementation of mechanisms and care quality indicators are essential to improve antibiotic prescription and related healthcare costs&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of Interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests&#46;</p></span></span>"
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    "fechaRecibido" => "2013-05-20"
    "fechaAceptado" => "2014-01-07"
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            0 => "Antibiotics"
            1 => "Emergency room"
            2 => "Pediatrics"
            3 => "Prescription"
            4 => "Upper respiratory tract infections"
            5 => "Lower respiratory tract infections"
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            0 => "Antibi&#243;ticos"
            1 => "Servicios m&#233;dicos de urgencias"
            2 => "Pediatr&#237;a"
            3 => "Prescripci&#243;n"
            4 => "Infecciones respiratorias de v&#237;as altas"
            5 => "Infecciones respiratorias de v&#237;as bajas"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Respiratory tract infections are one of the most frequent problems in pediatric clinics and generate an elevated prescription of antibiotics&#46; The aim of this study was to find out the standard of care practice about antibiotic use in these infections in a pediatric emergency department and to evaluate compliance with clinical guidelines&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A pediatric emergency department database was reviewed from July 2005 to October 2007 under the category &#8220;respiratory infection&#8221;&#44; including variables such as age&#44; antibiotic prescription and compliance with current clinical recommendations&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Out of the 23<span class="elsevierStyleHsp" style=""></span>114 reviewed reports&#44; 32&#46;7&#37; &#40;7567&#41; were upper respiratory tract infections &#40;URTI&#41; &#40;cold&#44; acute otitis media &#91;AOM&#93;&#44; sinusitis and tonsillopharyngitis&#41; or lower respiratory tract infections &#40;LRTI&#41; &#40;laryngitis&#44; bronchitis&#44; bronchiolitis and pneumonia&#41;&#46; Children under the age of 2 were the most represented age group&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Amongst URTI&#44; rhinopharyngitis was the most frequent infection&#44; while bronchitis was the most frequent among LRTI&#46; Antibiotic therapy &#40;mainly amoxicillin&#41; was prescribed in 30&#46;8&#37; of URTI &#40;5&#46;7&#37; rhinopharyngitis&#44; 96&#46;5&#37; AOM&#44; and 36&#46;7&#37; tonsillopharyngitis&#41; and in 12&#46;4&#37; of LRTI&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The percentage of respiratory tract infections was similar to previous studies and the antibiotic prescriptions followed current guidelines&#44; except for cases diagnosed with AOM&#46; Prescription compliance and clinical course of the cases should be monitored&#46;</p>"
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        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Las infecciones respiratorias son un motivo frecuente de consulta en pediatr&#237;a y originan un gran n&#250;mero de prescripciones de antibi&#243;ticos&#46; El objetivo de este trabajo es conocer la pr&#225;ctica cl&#237;nica habitual en relaci&#243;n con el uso de antibi&#243;ticos en estas patolog&#237;as en un servicio de urgencias pedi&#225;tricas hospitalario&#44; as&#237; como su adecuaci&#243;n a las gu&#237;as cl&#237;nicas&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n de la base de datos cl&#237;nicos de las visitas en el servicio de urgencias pedi&#225;tricas de un hospital de segundo nivel en el per&#237;odo comprendido entre julio de 2005 y octubre de 2007 y an&#225;lisis del porcentaje de consultas debidas a infecciones respiratorias&#44; analizando las variables&#58; edad&#44; prescripci&#243;n de antibi&#243;ticos durante la visita y adecuaci&#243;n de la misma a las recomendaciones internacionales actuales&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">De los 23&#46;114 informes estudiados&#44; el 32&#44;7&#37; &#40;7&#46;567&#41; correspondieron a infecciones respiratorias altas &#40;IRVA&#41; &#40;catarro de v&#237;as altas&#44; otitis media aguda &#91;OMA&#93;&#44; sinusitis y faringoamigdalitis&#41; o bajas &#40;IRVB&#41; &#40;laringitis&#44; bronquitis&#44; bronquiolitis y neumon&#237;a&#41; como diagn&#243;stico principal&#46; El grupo de edad m&#225;s representado fueron los menores de 2<span class="elsevierStyleHsp" style=""></span>a&#241;os&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Entre las IRVA&#44; la rinofaringitis fue la m&#225;s frecuente&#44; y entre las IRVB destac&#243; la bronquitis&#46; Se prescribieron antibi&#243;ticos&#44; principalmente amoxicilina&#44; en el 30&#44;8&#37; de los casos de IRVA &#40;en el 5&#44;7&#37; de las rinofaringitis&#44; el 96&#44;5&#37; de las otitis medias agudas y el 36&#44;7&#37; de las faringoamigdalitis&#41; y en el 12&#44;4&#37; de las IRVB&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El porcentaje de visitas por cuadros respiratorios infecciosos coincidi&#243; con el descrito previamente en estudios similares y la prescripci&#243;n de antibi&#243;ticos se ajust&#243; a las recomendaciones actuales&#44; excepto en el caso de la OMA&#46; Es necesario el seguimiento del cumplimiento de la prescripci&#243;n y de la evoluci&#243;n cl&#237;nica de los casos&#46;</p>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guzm&#225;n Molina C&#44; Velasco Rodr&#237;guez-Belv&#237;s M&#44; Coroleu Bonet A&#44; Vall Combelles O&#44; Garc&#237;a-Algar &#211;&#46; Antibi&#243;ticos en las infecciones respiratorias en urgencias pedi&#225;tricas hospitalarias&#46; Arch Bronconeumol&#46; 2014&#59;50&#58;375&#8211;378&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
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Article information

ISSN: 15792129
Original language: English

DOI:10.1016/j.arbr.2014.06.013

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Year/Month	Html	Pdf	Total

2024 November	1	1	2
2024 October	68	30	98
2024 September	67	21	88
2024 August	78	27	105
2024 July	58	18	76
2024 June	58	26	84
2024 May	50	31	81
2024 April	39	35	74
2024 March	40	18	58
2024 February	18	14	32
2023 March	21	4	25
2023 February	69	26	95
2023 January	48	33	81
2022 December	68	35	103
2022 November	113	34	147
2022 October	87	66	153
2022 September	66	25	91
2022 August	62	38	100
2022 July	63	31	94
2022 June	61	32	93
2022 May	56	43	99
2022 April	56	21	77
2022 March	75	41	116
2022 February	66	30	96
2022 January	89	32	121
2021 December	41	26	67
2021 November	45	43	88
2021 October	64	42	106
2021 September	49	59	108
2021 August	58	30	88
2021 July	36	28	64
2021 June	34	38	72
2021 May	48	35	83
2021 April	224	94	318
2021 March	96	39	135
2021 February	77	22	99
2021 January	75	25	100
2020 December	60	23	83
2020 November	55	17	72
2020 October	40	17	57
2020 September	55	19	74
2020 August	52	19	71
2020 July	52	32	84
2020 June	64	11	75
2020 May	61	12	73
2020 April	45	24	69
2020 March	64	12	76
2020 February	63	22	85
2020 January	65	24	89
2019 December	100	19	119
2019 November	73	19	92
2019 October	108	7	115
2019 September	112	21	133
2019 August	119	25	144
2019 July	74	29	103
2019 June	74	30	104
2019 May	116	26	142
2019 April	105	38	143
2019 March	87	27	114
2019 February	61	23	84
2019 January	39	20	59
2018 December	31	17	48
2018 November	49	26	75
2018 October	71	18	89
2018 September	33	8	41
2018 July	2	0	2
2018 May	5	1	6
2018 April	39	4	43
2018 March	19	4	23
2018 February	27	6	33
2018 January	24	7	31
2017 December	38	5	43
2017 November	31	6	37
2017 October	32	10	42
2017 September	51	7	58
2017 August	61	10	71
2017 July	38	4	42
2017 June	66	11	77
2017 May	68	7	75
2017 April	50	6	56
2017 March	48	6	54
2017 February	39	1	40
2017 January	19	4	23
2016 December	62	8	70
2016 November	36	7	43
2016 October	35	17	52
2016 September	50	11	61
2016 August	59	14	73
2016 July	31	20	51
2016 March	4	0	4
2016 February	1	0	1
2016 January	1	0	1
2015 December	2	0	2
2015 October	58	3	61
2015 September	48	12	60
2015 August	48	21	69
2015 July	46	13	59
2015 June	41	14	55
2015 May	62	21	83
2015 April	46	22	68
2015 March	45	14	59
2015 February	48	13	61
2015 January	51	16	67
2014 December	27	14	41
2014 October	0	2	2
2014 September	1	0	1

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