In the Journals

Children often receive unnecessary diagnostic tests, treatment for pneumonia

Todd Florin (2019)
Todd A. Florin

Children presenting to EDs and other outpatient settings with community-acquired pneumonia, or CAP, often receive unnecessary diagnostic interventions and treatments, including chest X-rays and antibiotic therapy, according to research published in the Journal of the Pediatric Infectious Disease Society.

Study researcher Todd A. Florin, MD, MSCE, an attending physician at the Ann and Robert H. Lurie Children’s Hospital of Chicago and an associate professor of pediatrics at the Northwestern University Feinberg School of Medicine, told Infectious Diseases in Children that there are numerous consequences to unnecessary testing and treatment in children.

“Unnecessary testing often leads to more testing, unnecessary treatment, more cost and increased hospitalization, without clear benefit,” he said. “Unnecessary antibiotics in children who do not require them have substantial implications, most importantly the promotion of the spread of antimicrobial resistance, but also antibiotic-associated adverse effects (which lead to more health care visits), severe antibiotic-associated complications (such as C. diff colitis), changes to the host microbiome, increased cost, and decreased short-term quality of life.”

The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America released guidelines in 2011 that recommend against routinely performing chest X-rays, obtaining complete blood count (CBC) or blood cultures, and prescribing antibiotics in preschool-aged outpatients with CAP.

“We know that simply publishing a guideline does very little to change physician behavior, particularly when there is diagnostic uncertainty,” Florin said. “When a diagnosis is not clear, in this case bacterial vs. viral pneumonia, many physicians are understandably reluctant to withhold antibiotics or limit testing that they may think will improve the outcome, even if the guideline provides a strong recommendation.”

Infographic of unnecesary treatment and diagnostic testing for community-acquired pneumonia in children 

The researchers conducted a cross-sectional study that included data from the nationally representative 2008-2015 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Specifically, they focused on children aged 1 year to younger than 6 years with CAP (n = 601).

Florin and colleagues estimated that 6.3 million pediatric visits for CAP (95% CI, 5.3-7.4 million) occurred during the 8-year study period. Most children were treated in clinics (65.1%), and 34.9% were treated in EDs.

CBCs were ordered for 8.6% of all cases, a chest X-ray in 43%, and a blood culture in 11.1%. According to the researchers, 73.9% of cases were prescribed antibiotics, and when antibiotics were prescribed, second-line, broad-spectrum agents like cephalosporins and macrolides were most often used.

Florin and colleagues noted that the PIDS/IDSA guidelines specifically recommend the use of narrow-spectrum penicillins as a first-line antibiotic treatment.

The researchers found no difference in CBC, chest X-ray and blood culture orders, as well as antibiotic prescribing, before and after guidelines were implemented. During the study period, EDs were more likely to order CBCs and chest X-rays compared with clinics, but there were no significant differences between these settings related to antibiotic prescribing or the type of antibiotic used. 

“The most successful initiatives to improve guideline adherence occur through local or collaborative quality improvement efforts that use an intensive approach to de-implementing unnecessary resource use and improving guideline-concordant testing and treatment,” Florin said.  by Katherine Bortz

Disclosures: The authors report no relevant financial disclosures.

Todd Florin (2019)
Todd A. Florin

Children presenting to EDs and other outpatient settings with community-acquired pneumonia, or CAP, often receive unnecessary diagnostic interventions and treatments, including chest X-rays and antibiotic therapy, according to research published in the Journal of the Pediatric Infectious Disease Society.

Study researcher Todd A. Florin, MD, MSCE, an attending physician at the Ann and Robert H. Lurie Children’s Hospital of Chicago and an associate professor of pediatrics at the Northwestern University Feinberg School of Medicine, told Infectious Diseases in Children that there are numerous consequences to unnecessary testing and treatment in children.

“Unnecessary testing often leads to more testing, unnecessary treatment, more cost and increased hospitalization, without clear benefit,” he said. “Unnecessary antibiotics in children who do not require them have substantial implications, most importantly the promotion of the spread of antimicrobial resistance, but also antibiotic-associated adverse effects (which lead to more health care visits), severe antibiotic-associated complications (such as C. diff colitis), changes to the host microbiome, increased cost, and decreased short-term quality of life.”

The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America released guidelines in 2011 that recommend against routinely performing chest X-rays, obtaining complete blood count (CBC) or blood cultures, and prescribing antibiotics in preschool-aged outpatients with CAP.

“We know that simply publishing a guideline does very little to change physician behavior, particularly when there is diagnostic uncertainty,” Florin said. “When a diagnosis is not clear, in this case bacterial vs. viral pneumonia, many physicians are understandably reluctant to withhold antibiotics or limit testing that they may think will improve the outcome, even if the guideline provides a strong recommendation.”

Infographic of unnecesary treatment and diagnostic testing for community-acquired pneumonia in children 

The researchers conducted a cross-sectional study that included data from the nationally representative 2008-2015 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Specifically, they focused on children aged 1 year to younger than 6 years with CAP (n = 601).

Florin and colleagues estimated that 6.3 million pediatric visits for CAP (95% CI, 5.3-7.4 million) occurred during the 8-year study period. Most children were treated in clinics (65.1%), and 34.9% were treated in EDs.

CBCs were ordered for 8.6% of all cases, a chest X-ray in 43%, and a blood culture in 11.1%. According to the researchers, 73.9% of cases were prescribed antibiotics, and when antibiotics were prescribed, second-line, broad-spectrum agents like cephalosporins and macrolides were most often used.

Florin and colleagues noted that the PIDS/IDSA guidelines specifically recommend the use of narrow-spectrum penicillins as a first-line antibiotic treatment.

The researchers found no difference in CBC, chest X-ray and blood culture orders, as well as antibiotic prescribing, before and after guidelines were implemented. During the study period, EDs were more likely to order CBCs and chest X-rays compared with clinics, but there were no significant differences between these settings related to antibiotic prescribing or the type of antibiotic used. 

“The most successful initiatives to improve guideline adherence occur through local or collaborative quality improvement efforts that use an intensive approach to de-implementing unnecessary resource use and improving guideline-concordant testing and treatment,” Florin said.  by Katherine Bortz

Disclosures: The authors report no relevant financial disclosures.