Factors predicting antibiotic prescription and referral to hospital for children with respiratory symptoms

Rebnord, I.K. et al. (2017) BMJ Open. 7:e012992.

Objectives: Acute respiratory infections and fever among children are highly prevalent in primary care. It is challenging to distinguish between viral and bacterial infections. Norway has a relatively low prescription rate of antibiotics, but it is still regarded as too high as the antimicrobial resistance is increasing. The aim of the study was to identify predictors for prescribing antibiotics or referral to hospital among children.

 

Conclusions: CRP values >20 mg/L, findings on ear examination, use of paracetamol and no vomiting in the past 24 hours were significantly associated with antibiotic prescription. Affected respiration was a predictor for referral to hospital. The parents’ assessment was also significantly associated with the outcomes.

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Close Follow-up in Children With Acute Otitis Media Initially Managed Without Antimicrobials

Uitti, J. et al. (2016) JAMA Pediatrics. 170 (11) pp. 1107-1108

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According to several national guidelines, close follow-up is required if initial observation without antimicrobial agents is chosen for the management of acute otitis media (AOM) in children.

The aim of this study was to examine whether close follow-up with reexamination is needed for children with AOM initially managed without antimicrobial agents who have symptomatic improvement during the first week after diagnosis, as assessed by their parents.

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Using a simple point-prevalence survey to define appropriate antibiotic prescribing in hospitalised children across the UK

Gharbi, M. et al. BMJ Open. 6:e012675

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Background: The National Health Service England, Commissioning for Quality and Innovation for Antimicrobial Resistance (CQUIN AMR) aims to reduce the total antibiotic consumption and the use of certain broad-spectrum antibiotics in secondary care. However, robust baseline antibiotic use data are lacking for hospitalised children. In this study, we aim to describe, compare and explain the prescription patterns of antibiotics within and between paediatric units in the UK and to provide a baseline for antibiotic prescribing for future improvement using CQUIN AMR guidance.

Methods: We conducted a cross-sectional study using a point prevalence survey (PPS) in 61 paediatric units across the UK. The standardised study protocol from the Antibiotic Resistance and Prescribing in European Children (ARPEC) project was used. All inpatients under 18 years of age present in the participating hospital on the day of the study were included except neonates.

Results: A total of 1247 (40.9%) of 3047 children hospitalised on the day of the PPS were on antibiotics. The proportion of children receiving antibiotics showed a wide variation between both district general and tertiary hospitals, with 36.4% ( 95% CI 33.4% to 39.4%) and 43.0% (95% CI 40.9% to 45.1%) of children prescribed antibiotics, respectively. About a quarter of children on antibiotic therapy received either a medical or surgical prophylaxis with parenteral administration being the main prescribed route for antibiotics (>60% of the prescriptions for both types of hospitals). General paediatrics units were surprisingly high prescribers of critical broad-spectrum antibiotics, that is, carbapenems and piperacillin-tazobactam.

Conclusions: We provide a robust baseline for antibiotic prescribing in hospitalised children in relation to current national stewardship efforts in the UK. Repeated PPS with further linkage to resistance data needs to be part of the antibiotic stewardship strategy to tackle the issue of suboptimal antibiotic use in hospitalised children.

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Decision-making tool may help doctors cut unnecessary antibiotic prescribing

ScienceDaily | Published online: 1 September 2016

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Respiratory tract infections (RTI) with cough are the most common reason children are prescribed antibiotics by their doctors, but up to a third of prescriptions may be unnecessary. A new study of over 8000 children has identified seven key predictors which could help general practitioners (GPs) and nurses in primary care identify low risk children who are less likely to need antibiotics, according to new research published in The Lancet Respiratory Medicine.

The authors estimate that if antibiotic prescribing in this low risk group was halved, and even if it increased to 90% in high risk patients, the new tool could reduce antibiotic prescribing to children with RTI and coughs by 10% overall, similar to other interventions used to combat antibiotic resistance.

The proposed tool called STARWAVe uses seven predictors of future hospitalization that can be easily identified by doctors and nurses during a patient visit — short illness (less than 3 days), high temperature (?37.8°C on examination or parent reported severe fever in the previous 24 hours), aged under 2 years, respiratory distress, wheeze, asthma, and moderate/severe vomiting in the previous 24 hours. Children presenting with no more than one of these items are deemed at very low risk of future complications. The authors say that the rule now needs externally validating in a randomised trial, but could be a useful tool to improve the targeting of antibiotics to reduce the growing threat of antibiotic resistance.

View the original research articles here and here.

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Compliance with the current recommendations for prescribing antibiotics for paediatric community-acquired pneumonia is improving

Launay, E. at al. BMC Pediatrics | Published online: 12 August 2016

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Image shows electron micrograph of klebsiella pneumoniae bacteria 

Background: Lower respiratory tract infection is a common cause of consultation and antibiotic prescription in paediatric practice. The misuse of antibiotics is a major cause of the emergence of multidrug-resistant bacteria. The aim of this study was to evaluate the frequency, changes over time, and determinants of non-compliance with antibiotic prescription recommendations for children admitted in paediatric emergency department (PED) with community-acquired pneumonia (CAP).

Methods: We conducted a prospective two-period study using data from the French pneumonia network that included all children with CAP, aged one month to 15 years old, admitted to one of the ten participating paediatric emergency departments. In the first period, data from children included in all ten centres were analysed. In the second period, we analysed children in three centers for which we collected additional data. Two experts assessed compliance with the current French recommendations. Independent determinants of non-compliance were evaluated using a logistic regression model. The frequency of non-compliance was compared between the two periods for the same centres in univariate analysis, after adjustment for confounding factors.

Results: A total of 3034 children were included during the first period (from May 2009 to May 2011) and 293 in the second period (from January to July 2012). Median ages were 3.0 years [1.4–5] in the first period and 3.6 years in the second period. The main reasons for non-compliance were the improper use of broad-spectrum antibiotics or combinations of antibiotics. Factors that were independently associated with non-compliance with recommendations were younger age, presence of risk factors for pneumococcal infection, and hospitalization. We also observed significant differences in compliance between the treatment centres during the first period. The frequency of non-compliance significantly decreased from 48 to 18.8 % between 2009 and 2012. The association between period and non-compliance remained statistically significant after adjustment for confounding factors. Amoxicillin was prescribed as the sole therapy significantly more frequently in the second period (71 % vs. 54.2 %, p < 0.001).

Conclusions: We observed a significant increase in the compliance with recommendations, with a reduction in the prescription of broad-spectrum antibiotics, efforts to improve antibiotic prescriptions must continue.

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Community-acquired pneumonia in children: what to do when there is no response to standard empirical treatment?

Shanthikumar S, Clifford A, Massie J, et al. Thorax Published Online First: 8 August 2016 doi:10.1136/thoraxjnl-2016-208787

This case highlights a stepwise approach to managing patients who do not respond to standard therapy. Current international guidelines recommend empiric antibiotic treatment for the first 48hrs; however, there are no published guidelines on managing cases that do not respond.

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Antibiotics for otitis media with effusion in children

Venekamp RP, Burton MJ, van Dongen TMA, van der Heijden GJ, van Zon A, Schilder AGM. Antibiotics for otitis media with effusion in children. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD009163. DOI: 10.1002/14651858.CD009163.pub3.

Background: Otitis media with effusion (OME) is characterised by an accumulation of fluid in the middle ear behind an intact tympanic membrane, without the symptoms or signs of acute infection. Since most cases of OME will resolve spontaneously, only children with persistent middle ear effusion and associated hearing loss potentially require treatment. Previous Cochrane reviews have focused on the effectiveness of ventilation tube insertion, adenoidectomy, nasal autoinflation, antihistamines, decongestants and corticosteroids in OME. This review, focusing on the effectiveness of antibiotics in children with OME, is an update of a Cochrane review published in 2012.

Objectives: To assess the benefits and harms of oral antibiotics in children up to 18 years with OME.

Search methods: 
The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 3); PubMed; Ovid EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 April 2016.
Selection criteria: Randomised controlled trials comparing oral antibiotics with placebo, no treatment or therapy of unproven effectiveness in children with OME.

Main results:  
Twenty-five trials (3663 children) were eligible for inclusion. Two trials did not report on any of the outcomes of interest, leaving 23 trials (3258 children) covering a range of antibiotics, participants, outcome measures and time points for evaluation. Overall, we assessed most studies as being at low to moderate risk of bias.

We found moderate quality evidence (six trials including 484 children) that children treated with oral antibiotics are more likely to have complete resolution at two to three months post-randomisation (primary outcome) than those allocated to the control treatment (risk ratio (RR) 2.00, 95% confidence interval (CI) 1.58 to 2.53; number needed to treat to benefit (NNTB) 5). However, there is evidence (albeit of low quality; five trials, 742 children) indicating that children treated with oral antibiotics are more likely to experience diarrhoea, vomiting or skin rash (primary outcome) than those allocated to control treatment (RR 2.15, 95% CI 1.29 to 3.60; number needed to treat to harm (NNTH) 20).

In respect of the secondary outcome of complete resolution at any time point, we found low to moderate quality evidence from five meta-analyses, including between two and 14 trials, of a beneficial effect of antibiotics, with a NNTB ranging from 3 to 7. Time periods ranged from 10 to 14 days to six months.

In terms of other secondary outcomes, only two trials (849 children) reported on hearing levels at two to four weeks and found conflicting results. None of the trials reported data on speech, language and cognitive development or quality of life. Low quality evidence did not show that oral antibiotics were associated with a decrease in the rate of ventilation tube insertion (two trials, 121 children) or in tympanic membrane sequelae (one trial, 103 children), while low quality evidence indicated that children treated with antibiotics were less likely to have acute otitis media episodes within four to eight weeks (five trials, 1086 children; NNTB 18) and within six months post-randomisation (two trials, 199 children; NNTB 5). It should, however, be noted that the beneficial effect of oral antibiotics on acute otitis media episodes within four to eight weeks was no longer significant when we excluded studies with high risk of bias.

Authors’ conclusions: This review presents evidence of both benefits and harms associated with the use of oral antibiotics to treat children up to 16 years with OME. Although evidence indicates that oral antibiotics are associated with an increased chance of complete resolution of OME at various time points, we also found evidence that these children are more likely to experience diarrhoea, vomiting or skin rash. The impact of antibiotics on short-term hearing is uncertain and low quality evidence did not show that oral antibiotics were associated with fewer ventilation tube insertions. Furthermore, we found no data on the impact of antibiotics on other important outcomes such as speech, language and cognitive development or quality of life.

Even in situations where clear and relevant benefits of oral antibiotics have been demonstrated, these must always be carefully balanced against adverse effects and the emergence of bacterial resistance. This has specifically been linked to the widespread use of antibiotics for common conditions such as otitis media.

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