Do Antibacterial Products Really Work?

Patient Presentation
A resident physician was discussing a premature female infant’s health supervision visit with his attending physician.
The resident felt that he had adequately answered all of the mother’s questions except for one that was “do those antibacterial cleaning wipes actually work?”The attending physician said that although he didn’t have any research studies to point the resident to, he thought that they did not work because of all the variabilities of which product, surface type, drying times, etc.. They then went on to discuss whether or not alcohol-based handrubbing products worked.
The attending physician said that again he couldn’t point to the literature, but knew that there were several studies that supported the use of alcohol-based handrubbing products.
The attending physician also pointed out that the hospital was now providing and promoting the handrubbing products. He said, “Someone who looks at this all the time, must think that they work or they wouldn’t have us use them.”Later in the week, the resident did a PUBMED search and found a research article which compared various antibacterial cleaning wipes for food surface decontamination.
The resident and the attending discussed the article at their next continuity clinic and both agreed that they could improve upon their own cleaning procedures at home and would be better able to talk to parents about the issue.

Discussion
Hand hygiene, and food and other surface decontamination procedures are some of the most important ways to decrease infection transmission.
Over the past several years, new consumer and professional products have been developed to help improve these procedures.

Bacteria survival and transfer between surfaces including hands is influenced by temperature, nature of the surface, moisture level, bacteria type, inoculum, and time since bacterial inoculation.

Learning Point
According to the Hand Hygiene Resource Center, “Two million people each year become ill as a result of a hospital-acquired infection. Proper hand hygiene is critical to the prevention of these infections – which contribute to the death of nearly 90,000 hospital patients per year and $4.5 billion in medical expenses.”The Centers for Disease Control recommended alcohol-based handrubbing products in healthcare settings in 2002.
These recommendations include using these products when hands are not visibly soiled and:

  • Before and after having direct contact with patients
  • Before putting on and after taking off sterile and non-sterile gloves
  • If during patient care, one moves from a contaminated-body site to a clean-body site
  • After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings
  • After contact with inanimate objects, including medical equipment, in the immediate area of the patient

These recommendations include using plain soap and water or an antibacterial soap and water when:

  • Hands are visibly soiled
  • Before eating
  • After using the restroom
  • Exposure to Bacillus anthracis is suspected or proven

One study of the effectiveness of antibacterial products on decontaminating food surfaces inoculated food preparation surfaces with Escherichia coli and Staphylococcus aureus. Four different antibacterial products were evaluated none of which was household bleach. The study found that survival of the bacteria depended on:

  • Surface type – with glass > plastic >> wood surfaces, with glass having the highest bacterial survival and wood having the least survival.

  • Antibacterial product – wipes > sprays, with wipes having highest bacterial survival

The products ability to decontaminate the surfaces was wood > glass >> plastic with wood having the best decontamination rate and plastic the least
This was presumably because of the uneven surface of the plastic. Wood apparently has some intrinsic antibacterial properties and also the porous nature allows the bacteria to penetrate the wood and not be recoverable on the surface thereby decreasing contamination.
The study also found that the one antibacterial product that did not perform as well as the other products had confusing consumer instructions and the authors felt that this could contribute to an even higher rate of continued contamination when using these products.

Childcare centers and other settings often use bleach as a disinfectant because it is inexpensive and easy to use. The recommendation is to mix 1/4 cup (2 ounces) household bleach in 1 gallon (128 ounces) of water and dispense by a spray bottle. For smaller amounts 1 tablespoon (15 ml) in 1 quart (32 ounces) of water can be used. The solution must be mixed fresh everyday because the chlorine evaporates.
The bleach solution should contact the surface for 2 minutes or longer to provide disinfection.

Questions for Further Discussion
1. Does using alcohol-based handrubbing product increase or decrease the skin condition (i.e. irritation) of health care providers?
2. How can household sponges be appropriately cleaned?
3. How long should hands be washed or rubbed for?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Germs and Hygiene
and Food Contamination and Poisoning

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Wilson E. Child Care Home: Disease Prevention. National Network for Child Care. Available from the Internet at http://www.nncc.org/Health/cch.disease.html (rev. 1996, cited 5/14/2007).

Boyce JM, Pettet D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR. October 25, 2002 / 51(RR16);1-44. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm (cited 5/14/2007).

Hand Hygiene Resource Center. Available from the Internet at http://www.handhygiene.org/ (rev. 2/2/2007, cited 5/14/2007).

Girou E,
Loyeau S,
Legrand P,
Oppein F,
Brun-Buisson C.
Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial.
BMJ. 2002:17; 325(7360):362.

Larson EL,
Cimiotti J,
Haas J,
Parides M,
Nesin M,
Della-Latta P,
Saiman L.
Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units.
Arch Pediatr Adolesc Med. 2005;159(4):377-83.

Devere E,
Purchase D.
Effectiveness of domestic antibacterial products in decontaminating food contact surfaces.
Food Microbiol. 2007;24(4):425-30.

ACGME Competencies Highlighted by Case

  • Patient Care

    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    June 25, 2007

  • Does She Still Need Antibiotics for Her Heart?

    Patient Presentation
    A 9-year-old female came to clinic for her health maintenance examination. She was doing well.
    She had a history of atrial septal defect that she had repaired by a prosthetic device placed by an interventional cardiology procedure 2 years ago.
    She had taken prophylactic antibiotics in the past for dental procedures, but her mother heard on the news that there were new guidelines and wanted to know if her daughter needed to continue to take the antibiotics.
    The past medical history was otherwise normal.
    The pertinent physical exam showed a thin female with growth percentiles in the 10-25%. Her cardiac examination showed a regular rate and rhythm without murmurs. Her upper extremity pulses were equal to her lower extremity pulses.
    The diagnosis of a healthy female with stable, repaired, atrial septal defect was made. The physician was not aware of the new recommendations. He went to the American Dental Association’s website which gave him an overview of the recommendations and then he also accessed the new guidelines from the American Heart Association.
    Since she was more than 2 years out from her procedure, she was not deemed to be at highest risk and therefore prophylactic antibiotics were not recommended for dental procedures or other procedures.

    Discussion
    The American Heart Association updated their prophylactic antibiotics guidelines for infective endocarditis (IE) prevention in May 2007. The guidelines are aimed at patients with the greatest risks, and eliminate patients with fewer risks who previously had prophylactic antibiotics recommended.
    The Committee recommended changes after a literature evaluation. The changes were recommended based upon the risk/benefit balance of potential adverse side effects to the antibiotics verses risk of developing IE.
    The main reasons for the new recommendations are that : 1. IE is more likely to be caused by activities of daily living (such as toothbrushing) than by various medical procedures (e.g. dental, gastrointestinal or genitourinary), 2. prophylaxis if given may prevent a very small number of IE cases and the risks of prophylactic antibiotic therapy outweigh the benefits,
    and, 3. “maintenance of oral health and hygiene may decrease the incidence of bacteremia and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.”

    Infective endocarditis is a serious, potentially life-threatening but uncommon condition.
    It is thought to be caused by a series of events where there is endothelial damage on the cardiac valve or elsewhere, production of nonbacterial thrombosis at the site of the endothelial damage, bacteria from a bacteremia in the bloodstream that then adheres to the thrombosis and finally proliferation of the bacteria within the thrombosis forming a vegetation.

    Learning Point
    The cardiac conditions associated with the highest risk of adverse outcome from IE for which antibiotic prophylaxis for dental procedures is recommended are:

    • Previous IE
    • Prosthetic cardiac valve
    • Congenital heart disease (CHD)
      • Unrepaired cyanotic CHD including palliative shunts and conduits
      • Completely repaired CHD defect with prosthetic material or device, whether placed by catheter intervention or surgery, during the first 6 months after the procedure. (Endothelialization of the prosthetic material occurs during the first 6 months after the procedure so that prophylaxis is needed during this time period only.)
      • Repaired CHD that has residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
    • Cardiac transplantation recipients who develop cardiac valvulopathy

    Note: except for the CHD conditions noted above, antibiotic prophylaxis is NOT RECOMMENDED for any other CHD conditions.

    Dental procedures for which antibiotic prophylaxis is recommended are:

    • All dental procedures that involve manipulation of the gingival tissue or the periapical region of the teeth or perforation of the oral mucosa in patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE listed above.

    Dental procedures for which antibiotic prophylaxis is not recommended are:

    • Anesthesia (routine) through non-infected tissue
    • Dental radiographs, taking of
    • Appliances, placement of removable prosthodontic or orthodontic
    • Appliances, adjustment of orthodontic
    • Brackets, placement of orthodontic
    • Deciduous teeth shedding
    • Bleeding from trauma to the lips or oral mucosa

    Recommendations for respiratory tract, skin, musculoskeletal procedures

    • Prophylactic antibiotics are recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE listed above.

    Recommendations for gastrointestinal or genitourinary procedures

    • Prophylactic antibiotics solely to prevent IE is not recommended during gastrointestinal or genitourinary procedures.
    • For patient with patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE previously listed above who are being treated with antibiotics for other reasons, may have antibiotics that prevent IE considered in the overall antibiotic treatment plan.

    Questions for Further Discussion
    1. What U.S. government agency produces the National Guideline Clearinghouse website that lists current guidelines from multiple institutions and organizations?
    2. What are the five T’s of congenital heart disease?
    3. What medications are recommended for treatment of IE?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Endocarditis
    and Congenital Heart Defects.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    American Dental Association. Infective Endocarditis. Available from the Internet at http://www.ada.org/prof/resources/topics/infective_endocarditis.asp (rev. 4/19/07, cited 5/2/07).

    American Heart Association Rheumatic Fever,
    Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular
    Disease in the Young, and the Council on Clinical Cardiology, Council on
    Cardiovascular Surgery and Anesthesia, and the Quality of Care and
    Outcomes Research Interdisciplinary Working Group. Prevention of Infective Endocarditis
    Guidelines. Circulation. 2007;115: Available from the Internet at http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095 (cited 5/3/07).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    June 18, 2007

  • "I Don't Want a New Vaccine for My Child"

    Patient Presentation
    A 1-year-old female came to clinic for her health supervision visit. She was developmentally appropriate, growing well, and had no previous problems with her vaccinations. Her mother had no concerns.
    The pertinent physical exam showed a happy, newly-walking female with growth percentiles in the 10-50% range. Her examination was unremarkable.
    The diagnosis of a healthy one year old was made. When the physician was discussing the vaccinations the mother stated that she didn’t want the new combination vaccine with the measles-mumps-rubella and varicella.
    She just wanted the measles-mumps-rubella only because the chickenpox vaccine “hasn’t been around for 50 years.”
    The physician discussed the potential risks and benefits of the both vaccines and also showed the mother a card with the dates of the vaccines and when they were licensed.
    The mother was very surprised to learn that most of the vaccines in the recommended schedule had not been available for more than 50 years.
    After more discussion, she agreed to having her daughter receive both vaccines but as separate injections.

    Discussion
    Parents have many questions about their children and the recommended vaccines they receive. Some parent just want more information and some parents are fearful because of inadequate or mis-information.
    Parents may believe that a vaccine that is added to the recommended schedule has not been available for a long time. This is not true as some vaccines have been used in other countries sometimes for years before they are approved for use in the U.S (i.e. varicella vaccine).
    Some vaccines have been available in the U.S. for limited, at-risk populations but are now being recommended for larger populations (i.e. Hepatitis A).
    Some parents believe that a vaccine is “bad” because it was used in the U.S. and currently is not approved or not manufactured. This again is not true. For example, Lyme vaccine was discontinued by the manufacturer because of inadequate sales.
    Rotashield® was approved but was voluntarily withdrawn in the U.S. market because of the risk/benefit balance tilted more toward the risks (i.e. risk of intussusception potentially from the vaccine versus dehydration, hospitalization, etc. potentially from the disease).
    In other countries the risk/benefit balance is different and Rotashield® continues to be used successfully in those countries.

    Learning Point
    Although some types of vaccination have been available for more than 200 years, vaccination in its truest sense began with Edward Jenner’s smallpox vaccination in 1798. He is often considered the father of vaccination.
    For the next 150 years, a few more vaccines were developed but it has only been in the past 40-50 years there has been a dramatic increase in the number of vaccines developed.
    The current recommended vaccine schedule for children only has 5 vaccines that are more than 50 years old. Those vaccines are Diphtheria, Influenza, Pertussis, Polio, and Tetanus.
    The table below gives an abbreviated history of vaccine licensure.

    • Diphtheria
      • 1923 – Diphtheria toxoid vaccine first licensed
    • Diphtheria-Tetanus-Pertussis-Haemophilus influenza type b-Polio-Hepatitis B Combinations
      • 1947 – Diphtheria-Tetanus toxoids vaccine first licensed (DT) in U.S.
      • 1949 – Diphtheria-Tetanus toxoids and Pertussis (DTP) vaccine first licensed
      • 1953 – Tetanus and Diphtheria toxoids (adult formulation, dT) vaccine first licensed in U.S.
      • 1991/1992 – Diphtheria-Tetanus toxoids and accellular Pertussis (DTaP) vaccines licensed for 4th and 5th doses in series
      • 1993 – Whole cell DTP and Haemophilus influenza type b vaccine (Tetramume) licensed
      • 1996 – Diphtheria-Tetanus toxoids and acellular Pertussis and Haemophilus influenza type b vaccine (Tripedia) licensed
      • 1996 – Diphtheria-Tetanus toxoids and acellular Pertussis (DTaP) vaccines licensed for entire series
      • 2002 – Diphtheria, Tetanus, acellular Pertussis, inactivated Polio, and Hepatitis B vaccine licensed
      • 2004 – Diphtheria-Tetanus toxoids vaccine, preservative free for adult use licensed
      • 2005 – Diphtheria-Tetanus toxoids and acellular Pertussis (Tdap) vaccine for adult use licensed
    • Haemophilus influenza type b
      • 1985 – Haemophilus influenza type b polysaccharide vaccines first licensed
      • 1987 – Protein-conjungated Haemophilus influenza type b licensed
      • 1988 – Conjugated Haemophilus influenza type b vaccine licensed
    • Haemophilus influenza type b and Hepatitis B Combinations
      • 1996 – Haemophilus influenza type b and Hepatitis B vaccine first licensed
    • Hepatitis A Virus
      • 1995 – Inactivated hepatitis A vaccine licensed
    • Hepatitis B Virus
      • 1981 – Hepatitis B vaccine first licensed
      • 1986 – Recombinant Hepatitis B vaccine licensed
    • Hepatitis A and Hepatitis B Combinations
      • 2001 – Combined Hepatitis A and Hepatitis B vaccine licensed
    • Human Papilloma Virus
      • 2006 – Human Papilloma Virus vaccine licensed
    • Influenza virus
      • 1945 – Inactivated influenza vaccine first licensed in U.S.
      • 2003 – Live, attenuated, intranasal influenza vaccine licensed
    • Japanese Encephalitis Virus
      • 1992 – Inactivated Japanese Encephalitis vaccine licensed
    • Lyme Disease
      • 1998 – Lyme vaccine licensed (voluntarily withdrawn from market because of insufficient sales)
    • Measles Virus
      • 1963 – Live measles vaccine licensed
      • 1965/1967 – Another live measles vaccine licensed
    • Measles-Mumps-Rubella-Varicella Virus Combinations
      • 1971 – Measles and Rubella, and Measles-Mumps-Rubella vaccines first licensed
      • 1973 – Measles-Mumps vaccine first licensed
      • 2005 – Measles-Mumps-Rubella-Varicella vaccine first licensed
    • Meningococcus
      • 1974 – Monovalent meningococcal polysaccharide vaccine (Group C) first licensed
      • 1978 – Monovalent meningococcal polysaccharide vaccine (Group A) and Bivalent Group A and C vaccine first licensed
      • 1981 – Quadrivalent Group A, C, Y, and W-135 meningococcal vaccine first licensed
      • 2005 – Quadrivalent Group A, C, Y, and W-135 polysaccharide – Diphtheria toxoid conjugate vaccine licensed
    • Mumps Virus
      • 1967 – Live Mumps vaccine first licensed
    • Pertussis
      • 1915 – Pertussis vaccine first licensed
    • Plague
      • 1897 – Plague vaccine first used
    • Pneumococcus
      • 1977 – Pneumococcus vaccine (14-valent) first licensed
      • 1983 – Enhanced pneumococcus vaccines (23-valent) licensed (replaces 14-valent vaccine)
      • 2000 – Conjugated pneumococcus vaccine (7-valent) licensed
    • Polio Virus
      • 1955 – Inactivated Polio vaccine (IPV) first licensed in U.S.
      • 1961 – Oral Polio vaccine (strains 1 and 2) first licensed in U.S.
      • 1963 – Oral Polio vaccine (strains 1, 2, and 3, OPV) first licensed in U.S.
      • 1990 – Enhanced-potency inactivated Polio vaccine licensed
    • Smallpox Virus
      • 1100 – Violation used in Turkey, Africa, China and Europe
      • 1721 – Violation used in Great Britain
      • 1798 – Vaccine developed by Edward Jenner
    • Rabies Virus
      • 1885 – Rabies vaccine used in humans by Louis Pasteur
      • 1914 – Rabies vaccine first licensed in U.S.
      • 1997 – Rabies vaccine licensed by another manufacturer
    • Rotavirus
      • 1998 – Live, oral rotavirus vaccine licensed (voluntarily withdrawn from U.S. market in 1999 because of concern of intussusception, still used in other countries)
      • 2006 – Different Live, oral rotavirus vaccine licensed
    • Rubella Virus
      • 1969 – Rubella vaccine first licensed in U.S.
      • 1980 – RA 27/3 strain of Rubella vaccine licensed (all other strains discontinued)
    • Tetanus
      • 1927 – Tetanus toxoid first licensed
      • 1937 – Tetanus toxoid adsorbed vaccine first licensed in U.S.
    • Tuberculosis
      • 1927 – BCG (Bacille Calmette-Guerin) vaccine first used
    • Typhoid
      • 1914 – Typhoid vaccine first licensed in U.S.
      • 1952 – Heat-inactivated typhoid vaccine licensed
      • 1989 – Live, oral typhoid vaccine licensed
      • 1994 – Inactivated, injectable polysaccharide typhoid vaccine licensed
    • Varicella Virus
      • 1995 – Live, varicella vaccine licensed
      • 2006 – Herpes zoster (shingles) vaccine licensed
    • Yellow Fever
      • 1935 – Yellow fever vaccine first licensed
      • 1953 – Yellow fever vaccine first licensed in U.S.
      • 1978 – Another Yellow fever vaccine licensed

    Questions for Further Discussion
    1. What are the potential risks of vaccinations?
    2. How common are vaccination side effects?
    3. When were penicillin and sulfa drugs first developed?
    4. When were x-rays first used?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Childhood Immunization and Immunization

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Immunization Action Coalition. Historic Dates and Events Related to Vaccines and Immunization. Available from the Internet at http://www.immunize.org/timeline/ (rev. 1/17/2007, cited 4/30/2007).

    Colon AR, Colon PA. Nurturing Children A History of Pediatrics. Greenwood Press. Westport, CT. 1999.

    World Health Organization. History of Immunization. Available from the Internet at www.childrensvaccine.org/files/WHO-Vaccine-History.pdf (cited 4/30/2007).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    June 11, 2007

  • Isn't Radiation Risky?

    Patient Presentation
    A 6-month-old male came to clinic for runny nose and coughing for several days. The night before he had post-tussive emesis twice, but continued to breast feed and have good wet diapers.
    He had a fever to 102° Fahrenheit.
    The past medical history revealed a term infant who had been seen for one ear infection and health maintenance visits.
    The social history revealed that another child in his daycare room had been admitted to the hospital for pneumonia.
    The review of systems was non-contributory.
    The pertinent physical exam showed an alert male with growth parameters at ~90%. Respiratory rate was 30, pulse oximetry was 95% on room air. His capillary refill was brisk. Mucous membranes were moist.
    Nose showed copious clear rhinorrhea. Tympanic membranes were dull, with a slightly splayed light reflex but normal mobility. Chest examination showed mild, intermittent intercostal retractions at the lower ribs. He had very mild end-expiratory wheezing at the bases.
    The rest of his examination was negative.
    The child was given an albuterol nebulizer treatment and monitored. Re-examination showed no intercostal retractions and resolution of the wheezing, but decreased breath sounds at the bases. No crackles were appreciated.
    The physician discussed with the parents that although this could be a viral pneumonia, with the patient’s age, fever, pneumonia contact, and decreased breath sounds, that he was concerned about a possible bacterial lobar pneumonia. He wanted to obtain a chest radiograph but the father
    vehemently refused stating that the radiation risk was too high and that he wanted to just have some antibiotics prescribed. The physician calmly asked him why the father felt this way. The father stated “the radiation will hurt him.”The physician tried to find out what other beliefs the father held about radiation, but the father could not give any other specific information as to why he held this belief.
    The physician explained about why he wanted to do the test, what the benefits would be, and told the father that the radiation was about the same as if he flew in an airplane 500 miles.
    The physician sensed that the parents wanted to talk alone so he left them. A few minutes later the physician returned and the mother said that the chest x-ray could be done.
    The father did not speak to the physician for the rest of the visit despite attemps to engage him.
    The radiologic evaluation of a chest radiograph showed a right lower lobe bacterial pneumonia.
    The diagnosis of right lobar pneumonia was made and the patient was given azithromycin and albuterol. Before leaving the pulse oximeter read 98% on room air. The parents were instructed how to use the albuterol for increased work of breathing as well as signs and symptoms of respiratory distress.

    Discussion
    Life is inherently risky and everyday people make decisions that increase and decrease their risks.
    But as Ropeik and Gray write, “Risk issues are often emotional. They are contentious. Disagreement is often deep and fierce. This is not surprising, given that how we perceive and respond to risk is, at its core, nothing less than survival. The perception of and response to danger is powerful and fundamental driver of human behavior, thought, and emotion.”

    It can be very difficult for people to understand the real risks in their everyday life and also the benefits they can have from taking those risks.
    People are more afraid of:

    • New risks than those that have been around for a while, i.e. newly approved medication versus older medication
    • Man-made risks than those of nature, i.e. medical radiation versus tornados
    • Risks that are “imposed” upon them, than those they choose, i.e. required new vaccine versus motorcycle riding
    • Risks that they feel they cannot control, i.e. flying in airplane that they cannot fly themselves versus driving a car that they can drive
    • Risks that do not confer some benefits they want, i.e. would not live in Florida which is hurricane prone if it did not have warm weather and enjoyable water
    • Risks that can kill or injure them in terrible ways, i.e. eaten by a shark verus heart attack
    • Risks that come from sources that they feel they do not trust, i.e. information about drinking water contaminants from the local government, chemical company or non-profit conservation club
    • Risks that they are more aware of then those they are less aware of, i.e. gun violence from school shootings versus daily gun violence
    • Risks where the uncertainty is higher than where the uncertainty is lower, i.e. new cancer medication versus standard cancer medication
    • Risks to children than to their own lives (for an adult), i.e. powerline radiation next to the child’s school than versus next to the workplace
    • Risks that could directly affect themselves versus risks that threatens others, i.e. automobile accidents versus sky diving accidents for non-sky divers

    Learning Point
    Two common concerns parents raise are risks from medical radiation and vaccines.

    Medical radiation does have risks but also benefits including improved diagnosis and treatment. The radiation risk depends on many factors including the size of the patient, body part being imaged, and imaging modality.
    Some radiation doses are listed below:

    • Natural background radiation (sea level) = 300 millirems/year
    • Natural background radiation (Denver, Colorado) = 400 millirems/year
    • Round trip airplane flight coast to coast = 12 millirem
    • Chest radiograph = 2 millirem
    • Computed tomography of head, or chest, or abdomen = ~ 300 millirem

    Using the roundtrip airplane radiation of 12 millirems and an approximate distance from Los Angeles, CA to New York, NY of 2800 miles, the radiation from flying in a plane is .00428 millirems/mile. If a chest radiograph is 2 millirems, then the number of miles one would have to travel in an airplane to receive an equivalent radiation dose is ~ 500 miles.
    A person would also need to have about 150 chest radiographs in a year to equal the background radiation they normally receive.

    Vaccines also have risks and benefits. The Centers for Disease Control list the following as serious side effects for various vaccines. The date listed is the most current version of the information from the CDC:

    • DTP (Tetanus, Diphtheria and Pertussis, 2001) – Allergic reaction > 1 in 1,000,000 doses, other reported problems include seizures, coma, lower consciousness, permanent brain damage1
    • Tdap (Tetanus, Diphtheria and Pertussis, 2006) – Mild problems reported only, serious side effects being monitored for
    • Td (Tetanus and Diphtheria, 1994) – Allergic reaction, pain and muscle wasting in upper arm
    • Haemophilus influenza B (1998) – Not applicable, only mild problems reported
    • Hepatitis A (2006) – Allergic reaction – Very rare
    • Hepatitis B (2001) – Allergic reaction – Very rare
    • Human Papilloma virus (2007) – Mild problems reported only, serious side effects being monitored for
    • Inactivated influenza virus (2006) – Serious side effects being monitored for 2
    • Live, attenuated influenza virus (2006) – Allergic reaction – very rare
    • Measles, Mumps, Rubella (2003) – Allergic reaction > 1 in 1,000,000 doses, other reported problems deafness, seizures, coma, lower consciousness, permanent brain damage1
    • Inactivated polio (2000) – Mild problems reported only, serious side effects being monitored for
    • Pneumococcal conjugate (2002) – Mild problems reported only, serious side effects being monitored for
    • Rotavirus (2006) – Mild problems reported, serious side effects being monitored for
    • Varicella (2007) – Pneumonia – Very rare

    1These happen so rarely experts cannot tell whether they are caused by the vaccine or not. If they are, it is extremely rare.
    2Swine flu vaccine – Guillian-Barre syndrome is estimated at 1-2 cases/million people vaccinated.

    As comparisons, the likelihood of death or harm for a U.S. citizen, per year and per lifetime (based on data from 1999-2003) are given below.
    The numbers shown are odds ratios, and therefore are given as one event will occur in that number of people. For example, the one year odds ratio for a hurriane is that one person will die out of 17 million people, but the lifetime odds ratio is that one person will die out of 220,000.
    These are statistical averages and are not the exact chances for an individual person which are influenced by many factors including activities and work participated in, where someone lives or drives, etc.

     			One Year Odds	Lifetime Odds
    Nature
    Hurricaine		17,000,000	220,000
    Flood 			11,186,539 	144,156
    Lightening or Tornado	3,000,000	39,000
    Dog bite		19,000,000	240,000
    Bear attack (death)	94,000,000	1,200,000
    Hornets, wasps and bees 4,406,818	56,789
    Shark attack (death)	280,000,000	3,700,000
    Crime and Suicide
    Homicide (all)		18,000		240
    Homicide by gun		28,000		360
    Suicide			9,200		120
    Transportation
    Motor vehicles		6,700		88
    Motorcycling		79,121 		1,020
    School bus		4,900,000	63,000
    Bicycling		381,693		4,919
    All-terrain vehicles	1,600,000	21,000
    Snowmobile		7,200,000	94,000
    Commercial aviation plane 3,100,000	40,000
    Recreation
    Football		59,000,000	770,000
    Soccer			840,000,000	11,000,000
    Skydiving		9,100,000	120,000
    Accidents
    Drowning (general)	79,121		1,020
    Drowning in a bathtub	840,000		11,000
    Electrocution from wiring
    /appliances		300,000		4,000
    Fireworks		26,440,910	340,733
    Fire and smoke exposure 86,331		1,113
    Health
    Asthma			56,000		730
    Cancer			510		7
    Diabetes		4,100		53
    Heart Disease		300		4
    Pregnancy and Childbirth 760,000	99,00
    Stroke			1,800		23
    Infectious Diseases
    Hepatitis (all types)	59,000		770
    Human papillomavirus	51		Not available
    Influenza		130,000		1,700
    Measles			94,000,000	1,200,000
    Meningitis		370,000		3,800
    Mumps (cases)		800,000		10,000
    Pneumonia		4,300		57
    Pertussis		56,000,000	730,000
    Varicella (cases)	4,400,000	57,000
    

    Questions for Further Discussion
    1. List various forms of natural radiation.
    2. What is the risk of death from oral contraceptive pills?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Radiation Exposure

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Centers for Disease Control. Vaccine Information Statements. Available from the Internet at http://www.immunize.org/vis/ (rev. various- see specific vaccine above, website revised 4/20/07, cited 4/23/07).
    (Note: most current statement date for each vaccine is given above)

    Ropeik D, Gray G. Risk A Practical Guide for Decising What’s Really Safe and What’s Really Dangerous in the World Around You. Houghton Mifflin Co. Boston, MA. 2002.

    National Safety Council. What are the odds of dying? Available from the Internet at http://www.nsc.org/lrs/statinfo/odds.htm (rev. 8/2/2006, cited 4/26/2007).

    Huda W, Vance A. Patient Radiation Doses from Adult and Pediatric CT. AJR 2007;188:540-546.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    June 4, 2007