November 25, 2016
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Ranking children's risk level for respiratory tract infection can reduce unnecessary antibiotic prescriptions

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Clinical characteristics can determine risk level of future hospital admission for respiratory tract infection in children, potentially reducing antibiotic prescriptions in primary care for children at very low risk, according to recent study results.

“Many clinicians report that they prescribe antibiotics just in case [particularly to children], to mitigate perceived risk of future hospital admission and complications, and that failing to provide a prescription for a child who subsequently becomes seriously unwell is professionally unacceptable,” Alastair D. Hay, MD, MRCP, FRCGP, professor of primary care at the University of Bristol, and colleagues report. “If primary care clinicians could identify children at low (or very low) risk [for] such future complications, the reduced clinical uncertainty could lead to a reduced use of antibiotics in these groups of patients.”

The researchers sought to reduce prescription uncertainty by developing a clinical rule to distinguish good from poor prognosis in children presenting with a respiratory tract infection at risk of future hospital admission. They performed a prognostic cohort study from 247 general practitioner practices in England, to study 8,394 children aged 3 months to 16 years presenting with acute cough — defined as lasting 28 or less days — and respiratory tract infection.

Hay and colleagues found 78 children (0.9%; 95% CI, 0.7-1.2) were admitted to the hospital, with 15 (19%) admitted on day 1; 33 (42%) on days 2-7; and 30 (39%) on days 8-30. The researchers associated seven characteristics (P < .01) with admission including age younger than 2 years, current asthma, illness duration of 3 days or less, parent-reported moderate or severe vomiting in the previous 24 hours, parent-reported severe fever in the previous 24 hours or a temperature of 100.4°F or higher at presentation, clinician-reported intercostal or subcostal recession, and clinician-reported wheeze on auscultation. 

The investigators assigned one point per characteristic. Using a points-based clinical rule consisting of short illness, temperature, age, recession, wheeze, asthma, and vomiting (mnemonic STARWAVe; AUROC 0.81, 0.76–0.85) the researchers distinguished three hospital admission risk levels: very low (0.3%, 0.2–0.4%) with 1 point or less, normal (1.5%, 1.0–1.9%) with 2 or 3 points, and high (11.8%, 7.3–16.2%) with 4 points or more.

“Rule constituents can be easily measured, taught, and remembered by a wide range of health care professionals, as well as incorporated into electronic health record templates and decisions tools,” Hay and colleagues wrote. “General practitioners and primary care nurses might find this clinical rule useful to reduce prescribing antibiotics in children at very low risk of future hospital admission.” – by Savannah Demko

Disclosure: The researchers report no relevant financial disclosures.