Reducing unnecessary chest X-rays, antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline

Reducing unwarranted chest x-rays in bronchiolitis: Importance of a robust analysis

AIM

Bronchiolitis is the commonest reason for hospitalisation amongst infants and is often a target for low-value care (LVC) reduction. We aimed to assess the impact of a multifaceted intervention (clinician education, parent engagement, audit-feedback) on rates of chest x-rays (CXR) in bronchiolitis.

METHODS

Longitudinal study of CXRs ordered in infants (1-12 months) diagnosed with bronchiolitis in the Emergency Department (ED) of an Australian paediatric hospital between May 2016 and February 2023. We used logistic regression to measure the impact of the intervention on unwarranted CXR orders, controlling for other potential impacting variables such as time, patient characteristics (age/sex), clinical variables (fever, hypoxia, tachypnoea), seasonal factors (month, day of the week, business hours) and time passed since intervention.

RESULTS

Ten thousand one hundred and nine infants were diagnosed with bronchiolitis in the ED over the study period, with 939 (9.3%) receiving a CXR, of which 69% (n = 651) were considered unwarranted. Rates of unwarranted CXRs reduced from 7.9% to 5.4% post-intervention (P < 0.0001). Logistic regression showed the intervention had no significant effect (OR 0.89, 95% CI 0.65-1.23) once other variables and underlying time-based trends were accounted for.

CONCLUSIONS

Although pre-post rates appeared significantly improved, a robust analysis demonstrated that our multi-faceted intervention was not effective in reducing CXRs in bronchiolitis. The decision to order CXR was associated with clinical features that overlap with pneumonia suggesting ongoing misconceptions regarding the role of CXR for this indication. Our study highlights the value of large electronic medical record datasets and robust methodology to avoid falsely attributing underlying trends to the LVC intervention.

UPDATE - 2022 Italian guidelines on the management of bronchiolitis in infants

Bronchiolitis is an acute respiratory illness that is the leading cause of hospitalization in young children. This document aims to update the consensus document published in 2014 to provide guidance on the current best practices for managing bronchiolitis in infants. The document addresses care in both hospitals and primary care. The diagnosis of bronchiolitis is based on the clinical history and physical examination. The mainstays of management are largely supportive, consisting of fluid management and respiratory support. Evidence suggests no benefit with the use of salbutamol, glucocorticosteroids and antibiotics with potential risk of harm. Because of the lack of effective treatment, the reduction of morbidity must rely on preventive measures. De-implementation of non-evidence-based interventions is a major goal, and educational interventions for clinicians should be carried out to promote high-value care of infants with bronchiolitis. Well-prepared implementation strategies to standardize care and improve the quality of care are needed to promote adherence to guidelines and discourage non-evidence-based attitudes. In parallel, parents' education will help reduce patient pressure and contribute to inappropriate prescriptions. Infants with pre-existing risk factors (i.e., prematurity, bronchopulmonary dysplasia, congenital heart diseases, immunodeficiency, neuromuscular diseases, cystic fibrosis, Down syndrome) present a significant risk of severe bronchiolitis and should be carefully assessed. This revised document, based on international and national scientific evidence, reinforces the current recommendations and integrates the recent advances for optimal care and prevention of acute bronchiolitis.

Factors associated with nonadherence to the American Academy of Pediatrics 2014 bronchiolitis guidelines: A retrospective study

The latest guideline from the American Academy of Pediatrics for the management of bronchiolitis has helped reduce unnecessary interventions and costs. However, data on patients still receiving interventions are missing. In patients with acute bronchiolitis whose management was assessed and compared with current achievable benchmarks of care, we aimed to identify factors associated with nonadherence to guideline recommendations. In this single-centre retrospective study the management of bronchiolitis pre-guideline (Period 1: 2010 to 2012) was compared with two periods post-guideline (Period 2: 2015 to 2016, early post-guideline; and Period 3: 2017 to 2018, late post-guideline) in otherwise healthy infants aged less than 1 year presenting at the Children's University Hospitals of Geneva (Switzerland). Post-guideline, bronchodilators were more frequently administered to older (>6 months; OR 25.8, 95%CI 12.6-52.6), and atopic (OR 3.5, 95%CI 1.5-7.5) children with wheezing (OR 5.4, 95%CI 3.3-8.7). Oral corticosteroids were prescribed more frequently to older (>6 months; OR 5.2, 95%CI 1.4-18.7) infants with wheezing (OR 4.9, 95% CI 1.3-17.8). Antibiotics and chest X-ray were more frequently prescribed to children admitted to the intensive care unit (antibiotics: OR 4.2, 95%CI 1.3-13.5; chest X-ray: OR 19.4, 95%CI 7.4-50.6). Latest prescription rates were all below the achievable benchmarks of care. In summary, following the latest American Academy of Pediatrics guideline, older, atopic children with wheezing and infants admitted to the intensive care unit were more likely to receive nonevidence-based interventions during an episode of bronchiolitis. These patient profiles are generally excluded from bronchiolitis trials, and therefore not specifically covered by the current guideline. Further research should focus on the benefit of bronchiolitis interventions in these particular populations.

International variation in evidence-based emergency department management of bronchiolitis: a retrospective cohort study

OBJECTIVES

We aimed to evaluate the international variation in the use of evidence-based management (EBM) in bronchiolitis. We hypothesised that management consistent with full-EBM practices is associated with the research network of care, adjusted for patient-level characteristics. Secondary objectives were to determine the association between full-EBM and (1) hospitalisation and (2) emergency department (ED) revisits resulting in hospitalisation within 21 days.

DESIGN

A secondary analysis of a retrospective cohort study.

SETTING

38 paediatric EDs belonging to the Paediatric Emergency Research Network in Canada, USA, Australia/New Zealand UK/Ireland and Spain/Portugal.

PATIENTS

Otherwise healthy infants 2-11 months old diagnosed with bronchiolitis between 1 January 2013 and 31 December, 2013.

OUTCOME MEASURES

Primary outcome was management consistent with full-EBM, that is, no bronchodilators/corticosteroids/antibiotics, no chest radiography or laboratory testing. Secondary outcomes included hospitalisations during the index and subsequent ED visits.

RESULTS

1137/2356 (48.3%) infants received full-EBM (ranging from 13.2% in Spain/Portugal to 72.3% in UK/Ireland). Compared with the UK/Ireland, the adjusted ORs (aOR) of full-EBM receipt were lower in Spain/Portugal (aOR 0.08, 95% CI 0.02 to 0.29), Canada (aOR 0.13 (95% CI 0.06 to 0.31) and USA (aOR 0.16 (95% CI 0.07 to 0.35). EBM was less likely in infants with dehydration (aOR 0.49 (95% CI 0.33 to 0.71)), chest retractions (aOR 0.69 (95% CI 0.52 to 0.91)) and nasal flaring (aOR 0.69 (95% CI 0.52 to 0.92)). EBM was associated with reduced odds of hospitalisation at the index visit (aOR 0.77 (95% CI 0.60 to 0.98)) but not at revisits (aOR 1.17 (95% CI 0.74 to 1.85)).

CONCLUSIONS

Infants with bronchiolitis frequently do not receive full-EBM ED management, particularly those outside of the UK/Ireland. Furthermore, there is marked variation in full-EBM between paediatric emergency networks, and full-EBM delivery is associated with lower likelihood of hospitalisation. Given the global bronchiolitis burden, international ED-focused deimplementation of non-indicated interventions to enhance EBM is needed.

Is slide-based or video-based eLearning better at achieving behavioural change in bronchiolitis management? A cluster-based randomised control trial

AIM

This cluster-based randomised control trial examines the comparative efficacy of two eLearning programs that teach clinicians evidence-based bronchiolitis management for children less than 12 months of age.

METHODS

Six hospitals, matched for size, were randomly allocated to either video-based (arm A) or slide-based (arm B) eLearning programs. To assess behavioural change, participants (doctors and nurses) were asked to declare how they would manage a video scenario of an infant with bronchiolitis, before and after either eLearning method. Measured outcomes included the number of investigations and treatments ordered, admissions to hospital and discharge planning. Confidence scores and change in understanding for bronchiolitis management were also measured.

RESULTS

Both methods of eLearning instruction resulted in reductions in unnecessary investigations and treatments performed, as well as improved confidence and understanding of bronchiolitis management on the video scenario. Video-based eLearning instruction additionally demonstrated a significant reduction in unnecessary hospital admissions and better discharge planning, based on learners' declarations to the video scenario, relative to slide-based learning.

CONCLUSION

Slide-based and video-based eLearning both demonstrate improvements in reported bronchiolitis management. However, video-based eLearning may yield more significant practice changes, improved clinician confidence in management, as well as improved patient experience.

Expected Impact of Universal Immunization With Nirsevimab Against RSV-Related Outcomes and Costs Among All US Infants in Their First RSV Season: A Static Model

BACKGROUND

Respiratory syncytial virus (RSV) is associated with substantial morbidity in the United States, especially among infants. Nirsevimab, an investigational long-acting monoclonal antibody, was evaluated as an immunoprophylactic strategy for infants in their first RSV season and for its potential impact on RSV-associated, medically attended lower respiratory tract illness (RSV-MALRTI) and associated costs.

METHODS

A static decision-analytic model of the US birth cohort during its first RSV season was developed to estimate nirsevimab's impact on RSV-related health events and costs; model inputs included US-specific costs and epidemiological data. Modelled RSV-related outcomes included primary care and emergency room visits, hospitalizations including intensive care unit admission and mechanical ventilations, and RSV-related mortality.

RESULTS

Under current standard of care, RSV caused 529 915 RSV-MALRTIs and 47 281 hospitalizations annually, representing $1.2 billion (2021 US dollars [USD]) in costs. Universal immunization of all infants with nirsevimab is expected to reduce 290 174 RSV-MALRTI, 24 986 hospitalizations, and expenditures of $612 million 2021 USD.

CONCLUSIONS

An all-infant immunization strategy with nirsevimab could substantially reduce the health and economic burden for US infants during their first RSV season. While this reduction is driven by term infants, all infants, including palivizumab-eligible and preterm infants, would benefit from this strategy.

Local healthcare professionals need to work together to implement bronchiolitis guidelines that stop unnecessary tests and treatments

AIM

This mini review summarised studies published over a 10-year period on the impact of guidelines for diagnosing and managing bronchiolitis in children, with a special focus on interventions that enhanced adherence during implementation.

METHODS

PubMed was searched from 1 December 2011 to 31 November 2021 for papers published in English that used the terms bronchiolitis, child or infant, guidelines and either implementation or impact. After the exclusion criteria had been applied, 27 articles were reviewed in more detail. Eight described protocols without any comparisons and were excluded. Ten of the 19 remaining studies evaluated the impact of bronchiolitis guidelines, and 9 examined the effects of interventions linked to their publication.

RESULTS

Just releasing evidence-based guidelines had a poor impact, but this improved when local tailored current care, clinical practice or best-practice guidelines were issued. Even better results were achieved when all the staff treating bronchiolitis patients participated in the preparation and implementation of local guidelines. Adherence to the guidelines was as high as 85% when multidisciplinary, and multifaceted interventions were used to complement the publication of guidelines.

CONCLUSION

Healthcare professionals need to work together to avoid children receiving bronchiolitis management that is unnecessary and not based on evidence.

Rapid Viral Testing and Antibiotic Prescription in Febrile Children With Respiratory Symptoms Visiting Emergency Departments in Europe

BACKGROUND

Inappropriate antibiotic prescribing often occurs in children with self-limiting respiratory tract infections, contributing to antimicrobial resistance. It has been suggested that rapid viral testing can reduce inappropriate antibiotic prescribing. We aimed to assess the association between rapid viral testing at the Emergency Department (ED) and antibiotic prescription in febrile children.

METHODS

This study is part of the MOFICHE study, which is an observational multicenter study including routine data of febrile children (0-18 years) attending 12 European EDs. In children with respiratory symptoms visiting 6 EDs equipped with rapid viral testing, we performed multivariable logistic regression analysis regarding rapid viral testing and antibiotic prescription adjusted for patient characteristics, disease severity, diagnostic tests, focus of infection, admission, and ED.

RESULTS

A rapid viral test was performed in 1061 children (8%) and not performed in 11,463 children. Rapid viral test usage was not associated with antibiotic prescription (aOR 0.9, 95% CI: 0.8-1.1). A positive rapid viral test was associated with less antibiotic prescription compared with children without test performed (aOR 0.6, 95% CI: 0.5-0.8), which remained significant after adjustment for CRP and chest radiograph result. Twenty percent of the positively tested children received antibiotics. A negative rapid viral test was not associated with antibiotic prescription (aOR 1.2, 95% CI: 1.0-1.4).

CONCLUSIONS

Rapid viral test usage did not reduce overall antibiotic prescription, whereas a positive rapid viral test did reduce antibiotic prescription at the ED. Implementation of rapid viral testing in routine emergency care and compliance to the rapid viral test outcome will reduce inappropriate antibiotic prescribing at the ED.

Management of Hospitalized Respiratory Syncytial Virus Bronchiolitis in the Pediatric Ward in Spain: Assessing the Impact of a New Clinical Practice Protocol

BACKGROUND

Bronchiolitis caused by the respiratory syncytial virus (RSV) is the main reason for hospitalization in infants. Supportive care is the mainstay of treatment, and tests are restricted to a few indications. During 2015, our hospital bronchiolitis protocol (2015 HBP) was updated according to the latest practice guidelines.

OBJECTIVE

The objective of this study was to assess implementation of the 2015 HBP and the clinical outcome of children aged ≤ 24 months with RSV bronchiolitis admitted to a pediatric ward.

METHODS

We compared the use of treatments and tests, hospital length of stay (LOS), and oxygen requirements before implementation of the 2015 HBP (2014-2015 and 2015-2016 seasons) and after implementation (2016-2017 and 2017-2018 seasons).

RESULTS

The study population comprised 251 children (44.90%) in the first period and 308 (55.10%) in the second (median age 99 days, interquartile range 44-233). After implementation of the 2015 HBP, a statistically significant reduction was found in the percentage of patients undergoing the following treatments or diagnostic tests: salbutamol, from 57.77 to 31.17% (p < 0.001); epinephrine, from 61.75 to 1.30% (p < 0.001); 3% hypertonic saline, from 70.12 to 6.82% (p < 0.001); antibiotics, from 33.07 to 23.05% (p = 0.008); and chest X-ray, from 43.82 to 31.17% (p = 0.001). No statistically significant reductions were observed in the use of corticosteroids and blood tests. Hospital LOS and oxygen requirements were similar in each period.

CONCLUSIONS

Appropriate implementation of the 2015 HBP in the pediatric ward improves the use of medication and chest X-ray without modifying clinical outcomes. However, further efforts are needed to reduce the use of salbutamol, corticosteroids, and blood tests.

Interventions to reduce low-value imaging - a systematic review of interventions and outcomes

BACKGROUND

It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging.

METHODS

An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed.

RESULTS

The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase.

CONCLUSIONS

Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.

Exploring Information Available to and Used by Physicians on Antibiotic Use and Antibiotic Resistance in Jordan

Evidence based information sources for physicians are needed for informed antibiotic prescribing practices. The aim of this study was to explore physicians' preferred sources of information and evaluate physicians' awareness of available information and initiatives on prudent antibiotic prescribing in Jordan. A cross-sectional study was conducted utilizing an online questionnaire and included physicians (n = 409) from all sectors and specialties in Jordan. Published guidelines (31.8%), the workplace (25.7%), colleagues or peers (20.0%), group or conference training (18.3%), and the medical professional body (18.1%) were the main sources of information about avoiding unnecessary antibiotic prescribing, with the influence of these sources on changing prescribers' views being 34.7%, 17.1%, 11%, 13.4%, and 7.6%, respectively. One-third of physicians (33.7%) reported no knowledge of any initiatives on antibiotic awareness and resistance. Regarding awareness of national action plans on antimicrobial resistance, 10.5%, 34%, and 55.5% of physicians were aware, unaware, and unsure of the presence of any national action plans, respectively. Physicians showed interest in receiving more information on resistance to antibiotics (58.9%), how to use antibiotics (42.2%), medical conditions for which antibiotics are used (41.3%), prescribing of antibiotics (35.2%), and links between the health of humans, animals, and the environment (19.8%). The findings can inform interventions needed to design effective antimicrobial stewardship, enabling physicians to prescribe antibiotics appropriately.

Lung ultrasound to predict pediatric intensive care admission in infants with bronchiolitis (LUSBRO study)

It is extremely difficult to stratify bronchiolitis and predict the need for admission to the pediatric intensive care unit (PICU). We aimed to evaluate the capacity of a new lung ultrasound score (LUSBRO) to predict the need for admission to the PICU compared to a clinical score. This was a prospective observational single-center study that includes infants < 6 month of age admitted to a hospital due to acute bronchiolitis. Both scores were calculated at admission. The main outcome was PICU admission. Second endpoints were the need for mechanical ventilation, respiratory support duration, and the length of stay in the hospital. Eighty patients were included, with a median age of 53 days (IQR 29-115). Forty-four patients (55%) required PICU admission. LUSBRO score showed a better AUC compared to the clinical score to predict PICU admission: 0.932 (95% CI 0.873-0.990) vs. 0.675 (95% CI 0.556-0.794) and a positive correlation with the hospital length of stay. The best cut-off point for predicting the need for PICU admission for LUSBRO score was 6, showing a sensitivity of 90.91% and a specificity of 88.89%.Conclusions: The LUSBRO score is a useful tool to predict the need for admission to the PICU. What is Known • It is extremely difficult to stratify which patients affected by bronchiolitis should be precociously transferred to a third level hospital and will require pediatric intensive care unit (PICU) admission. • Clinical scores have been created but neither of them is accurate. What is New • The LUSBRO score is a useful tool to predict the need for admission to the PICU of patients with bronchiolitis and, consequently, to predict the patients who should be transferred to a tertiary hospital to optimize respiratory support.

National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed

AIM

Our aim was to evaluate the impact of the 2014 Finnish Current Care Guidelines for paediatric lower respiratory tract infections (LRTIs), particularly on taking of chest radiographs.

METHODS

This study used official national data and regional (Pirkanmaa) data on children aged 0-16 years who underwent chest radiographs in 2011 and 2015. We also collected data for LRTI diagnoses from local registers, including prescribed antibiotics and taking of chest radiographs. The local cohort comprised children aged 0-15 who presented to the primary care emergency room or to the hospital emergency department (Tampere university hospital) in November-December 2012-2015.

RESULTS

Chest radiographs for Finnish children aged 0-16 fell from 2011 to 2015: by 15.9% nationally and by 16.9% in Pirkanmaa. When asylum seekers with chest radiographs for tuberculosis screening were excluded, the estimated national reduction was 29.9%. In the local cohort, chest radiographs increased from 82 to 139 (69.5%) between 2012/2013 and 2014/2015 as the occurrence of community-acquired pneumonia (CAP) increased. However, the proportion of patients with CAP who had chest radiograph taken tended to decrease from 84.6% to 71.3% (p = 0.078).

CONCLUSION

Decreases in national and regional chest imaging trends were observed after the 2014 guidance for children`s LRTI was introduced.

Trends Over Time in Use of Nonrecommended Tests and Treatments Since Publication of the American Academy of Pediatrics Bronchiolitis Guideline

IMPORTANCE

Acute viral bronchiolitis is a common and costly pediatric condition for which clinical practice guidelines discourage use of diagnostic tests and therapies.

OBJECTIVE

To evaluate trends over time for use of nonrecommended services for bronchiolitis since publication of the American Academy of Pediatrics clinical practice guideline on bronchiolitis (originally published in October 2006 and updated in November 2014).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using interrupted time-series regression analysis adjusting for the hospital providing service, patient demographic characteristics, and payer, with 2014 guideline update publication as the event point. Included patients were children younger than 2 years old discharged from the emergency department (ED) or hospital inpatient setting with a primary diagnosis of bronchiolitis at US Children's Hospitals contributing data to the Pediatric Health Information Systems database. Data were analyzed from June through December 2020.

MAIN OUTCOMES AND MEASURES

Rates of nonrecommended tests (ie, chest radiography, viral testing, and complete blood cell count) and treatments (ie, bronchodilators, corticosteroids, antibiotics) were measured.

RESULTS

Among 602 375 encounters involving children with a primary diagnosis of bronchiolitis, 404 203 encounters (67.1%) were ED discharges and 198 172 encounters (32.9%) were inpatient discharges; 468 226 encounters (77.7%) involved children younger than 12 months, and 356 796 encounters (59.2%) involved boys. In the period after initial guideline publication (ie, November 2006 to November 2014), a negative use trajectory was found in all measures except viral testing in the ED group. Using the 2014 guideline update as the event point, several measures showed decreased use between study time periods. The greatest decrease was in bronchodilator use, which changed by -13.5 percentage points in the ED group (95% CI, -15.2 percentage points to -11.8 percentage points) and -11.3 percentage points in the inpatient group (95% CI, -13.1 percentage points to -9.4 percentage points). In the period after the 2014 guideline update (ie, December 2014 to December 2019), bronchodilators also showed the greatest change in usage trajectory, steepening more than 2-fold in both groups. In the ED group, the negative trajectory steepened from -0.11% monthly (95% CI, -0.13% to -0.09%) in the first guideline period to a new mean monthly slope of -0.26% (95% CI, -0.30% to -0.23%). In the inpatient group, the mean monthly slope steepened from -0.08% (95% CI, -0.10 to -0.05%) to -0.26% (95% CI, 0.30% to -0.22%). Length of stay decreased from 2.0 days (95% CI, 1.9 days to 2.1 days) to 1.7 days (95% CI, 1.7 days to 1.8 days). Hospital admission rate decreased from 18.0% (95% CI, 13.8% to 22.2%) to 17.8% (95% CI, 13.6 to 22.1%).

CONCLUSIONS AND RELEVANCE

This cohort study with interrupted time-series analysis found that use of most nonrecommended bronchiolitis services decreased continuously after 2006. The rate of decline in bronchodilator use increased more than 2-fold after the 2014 guideline update. These findings support potential associations of practice guidelines with improved bronchiolitis care.

Variation in Early Inflammatory Marker Testing for Infection-Related Hospitalizations in Children

BACKGROUND AND OBJECTIVES

Inflammatory marker testing in children has been identified as a potential area of overuse. We sought to describe variation in early inflammatory marker (C-reactive protein and erythrocyte sedimentation rate) testing for infection-related hospitalizations across children's hospitals and to determine its association with length of stay (LOS), 30-day readmission rate, and cost.

METHODS

We conducted a cross-sectional study of children aged 0 to 17 years with infection-related hospitalizations using the Pediatric Health Information System. After adjusting for patient characteristics, we examined rates of inflammatory marker testing (C-reactive protein or erythrocyte sedimentation rate) during the first 2 days of hospitalization. We used k-means clustering to assign each hospital to 1 of 3 groups on the basis of similarities in adjusted diagnostic testing rates across 12 infectious conditions. Multivariable regression was used to examine the association between hospital testing group and outcomes.

RESULTS

We included 55 771 hospitalizations from 48 hospitals. In 7945 (14.3%), there was inflammatory marker testing in the first 2 days of hospitalization. We observed wide variation in inflammatory marker testing rates across hospitals and infections. Group A hospitals tended to perform more tests than group B or C hospitals (37.4% vs 18.0% vs 10.4%; P < .001) and had the longest adjusted LOS (3.2 vs 2.9 vs 2.8 days; P = .01). There was no significant difference in adjusted 30-day readmission rates or costs.

CONCLUSIONS

Inflammatory marker testing varied widely across hospitals. Hospitals with higher inflammatory testing for one infection tend to test more frequently for other infections and have longer LOS, suggesting opportunities for diagnostic stewardship.

Group-facilitated audit and feedback to improve bronchiolitis care in the emergency department

Objective

Despite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies show that patients still receive low-value care (e.g., respiratory viral testing, salbutamol, chest radiography). Our objective was to decrease low-value care by delivering individual physician reports, in addition to group-facilitated feedback sessions to pediatric emergency physicians.

Methods

Our cohort included 3,883 patients ≤ 12 months old who presented to pediatric emergency departments in Calgary, Alberta, with a diagnosis of bronchiolitis from April 1, 2013, to April 30, 2018. Using administrative data, we captured baseline characteristics and therapeutic interventions. Consenting pediatric emergency physicians received two audit and feedback reports, which included their individual data and peer comparators. A multidisciplinary group-facilitated feedback session presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention and was analysed using statistical process control charts.

Results

Seventy-eight percent of emergency physicians consented to receive their audit and feedback reports. Patient characteristics were similar in the baseline and intervention period. Following the baseline physician reports and the group feedback session, low-value care decreased from 42.6% to 27.1% (absolute difference: −15.5%; 95% CI: −19.8% to −11.2%) and 78.9% to 64.4% (absolute difference: −14.5%; 95% CI: −21.9% to −7.2%) in patients who were not admitted and admitted, respectively. Balancing measures, such as intensive care unit admission and emergency department revisit, were unchanged.

Conclusion

The combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.

Identifying and managing bronchiolitis

Bronchiolitis is a common viral illness that affects the lower respiratory tract of infants and young children. The disease is characterized by wheezing and increased mucus production and can range from mild to severe in terms of respiratory distress. This article reviews the epidemiology, clinical presentation, and treatment of bronchiolitis.

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

BACKGROUND AND OBJECTIVES

International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics.

METHODS

We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR).

RESULTS

In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently.

CONCLUSIONS

The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.

[The chest x-ray in acute bronchiolitis: Technical quality, findings, and an assessment of its reliability]

INTRODUCTION

Despite the recommendations of the current Clinical Practice Guidelines, the chest x-ray continues to be a widely used diagnostic test in the assessment of infants with acute bronchiolitis (AB). However, there have not been many studies that have assessed its reproducibility in these patients. In the present study, an evaluation is made on the radiographs, describing their quality, their radiological findings, and provides new evidence on the agreement between observers.

METHOD

Out of a total of 281 infants admitted due to acute bronchiolitis, 140 chest x-rays were performed. Twelve doctors from different specialities evaluated the presence or absence of 10 radiological signs previously agreed by consensus. The level of agreement between 2 observers, and in groups of 3 or more, were analysed using the Cohen and Fleiss kappa index, respectively.

RESULTS

Only 8.5% of the radiographs showed evidence of a complicated AB. The between-observer agreement in groups of 3 or more was medium, and with little variability (kappa: 0.20-0.40). However, between 2 observers, each observer against radiologist, the variability was wider, (kappa: -0.20-0.60). This level of agreement was associated with factors including, the sign to evaluate, the medical specialty, and level of professional experience.

CONCLUSION

The low levels of agreement between observers and the wide variability, makes the chest x-ray an unreliable diagnostic tool, and is not recommended for the assessment of infants with AB.

Conditions of vulnerability to the inadequate treatment of bronchiolitis

SUMMARY OBJECTIVE To analyze clinical and demographic variables possibly associated with the prescriptions of non-recommended but routinely used therapies for infants with acute viral bronchiolitis. METHODS A cross-sectional study included hospitalized infants with bronchiolitis caused by the respiratory syncytial virus. Those with other associated infections and/or morbidities were excluded. The data were collected from medical records. RESULTS Among 120 cases, 90% used inhaled beta-agonists, 72.5% corticosteroids, 40% antibiotics, and 66.7% inhaled hypertonic saline solution. The use of bronchodilators did not present an independent association with another variable. More frequent use of corticosteroids was associated with low oximetry, longer hospitalization time, and age>3 months. Antibiotic therapy was associated with the presence of fever, longer hospitalization, and age>3 months. Inhaled hypertonic saline solution was associated with longer hospitalization time. CONCLUSIONS Non-recommended prescriptions were frequent. Corticosteroid and antibiotic therapy were associated with signs of severity, as expected, but interestingly, they were more frequently used in infants above 3m, which suggested less safety in the diagnosis of viral bronchiolitis in these patients. The use of bronchodilators was even more worrying since they were indiscriminately used, without association with another variable related to the severity or characteristics of the host. The use of the inhaled hypertonic solution, although not associated with severity, seems to have implied a longer hospitalization time. The identification of these conditions of greater vulnerability to the prescription of inappropriate therapies contributes to the implantation of protocols for the bronchiolitis treatment, for continuing education and for analysis of the effectiveness of the strategies employed.

Bronchiolitis at a specialist paediatric centre: The electronic medical record helps to evaluate low-value care

AIM

Low-value care (LVC) is common. We aimed, using infants presenting to a major tertiary paediatric hospital with bronchiolitis between April 2016 and July 2018, to: (i) assess rates of chest X-ray (CXR) and medication use; (ii) identify associated factors; and (iii) measure the harm of not performing these practices.

METHODS

We extracted data from the electronic medical record for all children aged 1-12 months given a diagnosis of bronchiolitis in the emergency department. Factors potentially associated with LVC practices were extracted, including patient demographics, ordering physician characteristics, order indication, medications prescribed and admission ward. To assess for harm, a radiologist, blinded to CXR indication, reviewed all CXRs ordered over the winter of 2017 for infants with bronchiolitis.

RESULTS

A CXR was ordered for 439 (11.2%) infants, most commonly to rule out consolidation and collapse (65%). CXRs were more likely to be ordered for admitted infants (40.9% admitted to the general medical ward), and 62% were ordered by emergency department staff. Salbutamol was prescribed for 9.3% (n = 199). Amongst those who had a CXR, 28% were prescribed an antibiotic compared to 2.1% for those who did not. In an audit of 98 CXRs ordered over the winter of 2017, there were no CXR findings that meaningfully affected patient outcomes.

CONCLUSION

Using electronic medical record data, we found that CXR and medication use in bronchiolitis were higher than expected given our hospital guideline advice. Future research needs to understand why and develop interventions to reduce LVC.

Bronchiolitis clinical practice guidelines implementation: surveillance study of hospitalized children in Jordan

INTRODUCTION

Bronchiolitis is a leading cause of hospital admissions and death in young children. Clinical practice guidelines (CPG) to diagnose and manage bronchiolitis have helped healthcare providers to avoid unnecessary investigations and interventions and to provide evidence-based treatment. Aim of this study is to determine the effect of implementing CPG for the diagnosis and management of bronchiolitis in a tertiary hospital in Jordan.

METHODS

The study compared children (age <24 months) diagnosed with bronchiolitis and who required admission to King Abdullah University Hospital in Irbid during the winter of 2017 (after CPG implementation) and age-matched children admitted in the winter of 2016. The proportion of patients receiving diagnostic tests and treatments in the two groups were compared.

RESULTS

Eighty-eight and 91 patients were diagnosed with bronchiolitis before and after CPG implementation, respectively. Respiratory syncytial virus rapid antigen detection testing decreased after CPG implementation [n=64 (72.7%) vs n=46 (50.5%), p=0.002]. However, there was no significant change in terms of other diagnostic tests. The use of nebulized salbutamol [n=44 (50%) vs n=29 (31.9%), p=0.01], hypertonic saline [n=39 (44.3%) vs n=8 (8.8%), p<0.001], and inappropriate antibiotics [n=31 (35.2%) vs n=15 (16.5%), p=0.004] decreased after CPG implementation. There was no difference in mean LOS (standard deviation; SD) between the pre- and post-CPG groups [3.5(2) vs 4 (3.4) days, p=0.19]. The mean cost of stay (SD) was 449.4 (329.1) US dollars for pre-CPG compared to 507.3 (286.1) US dollars for the post-CPG group (p=0.24).

CONCLUSION

We observed that the implementation of CPG for bronchiolitis diagnosis and management helped change physicians' behavior toward evidence-based practices. However, adherence to guidelines must be emphasized to improve practices in developing countries, focusing on the rational use of diagnostic testing, and avoiding use of unnecessary medications when managing children with a diagnosis of bronchiolitis.

Antibiotic Use for Inpatient Bronchiolitis: Did National Guidelines Impact Practice at a Pediatric Hospital?

BACKGROUND AND OBJECTIVES

Bronchiolitis is a common lower respiratory tract infection that affects infants and young children. Because of variability in physician practice, inpatient management varies among pediatricians. In 2014, the Canadian Pediatric Society published national guidelines aimed at standardizing the inpatient management of this illness, which included recommending against the need for antibiotics for most patients. The study objective was to evaluate antibiotic prescription and supportive investigations for inpatient management of bronchiolitis before and after the publication of national guidelines.

METHODS

This study was a single-center retrospective chart review of inpatients with bronchiolitis. We included healthy children 1 to 24 months of age who were admitted from November 2011 to October 2016. Those admitted before December 2014 were analyzed in the preguidelines cohort; the remaining, in the postguidelines cohort. The main outcome was antibiotic prescription. The secondary outcome was the frequency of chest radiographs, nasopharyngeal swabs, and blood cultures.

RESULTS

A total of 131 patients were included in the first cohort; 71, in the second cohort. The rates of antibiotic initiation were almost equal in both cohorts (∼44%; P = .98). More antibiotics were discontinued during hospitalization in the second cohort compared with the first cohort (10% vs 20%; P = .001). Significantly fewer patients were discharged with antibiotics in the second cohort (31% vs 16%; P = .02).

CONCLUSIONS

Our study revealed a reduction in antibiotic use after the release of national guidelines, illustrating that antibiotic prescribing practices can change. However, there is still a pressing need for local initiatives to continue to reduce the unnecessary use of antibiotics within the pediatric setting.

Increased Detection of Viruses in Children with Respiratory Tract Infection Using PCR

Respiratory viruses are a common cause of respiratory tract infection (RTI), particularly in neonates and children. Rapid and accurate diagnosis of viral infections could improve clinical outcomes and reduce the use of antibiotics and treatment sessions. Advances in diagnostic technology contribute to the accurate detection of viruses. We performed a multiplex real-time polymerase chain reaction (PCR) to investigate the viral etiology in pediatric patients and compared the detection rates with those determined using traditional antigen tests and virus cultures. Fifteen respiratory viruses were included in our investigation: respiratory syncytial virus A/B (RSV), influenza virus A (FluA) and influenza virus B (FluB), human metapneumovirus (MPV), enterovirus (EV), human parainfluenza virus (PIV) types 1-4, human rhinovirus (RV), human coronavirus OC43, NL63, and 229E, human adenovirus (ADV), and human bocavirus (Boca). In total, 474 specimens were collected and tested. Respiratory viruses were detected more frequently by PCR (357, 75.3%) than they were by traditional tests (229, 49.3%). The leading pathogens were RSV (113, 23.8%), RV (72, 15.2%), PIV3 (53, 11.2%), FluA (51, 10.8%), and ADV (48, 10.1%). For children younger than 5 years, RSV and RV were most prevalent; for children older than 5 years, FluA and ADV were the most frequently detected. Of the specimens, 25.8% (92/357) were coinfected with two or more viruses. RV, Boca, PIV2, FluB, and PIV4 had higher rates of coinfection; MPV and PIV1 had the lowest rates of coinfection (9.1% and 5.3%). To conclude, the detection power of PCR was better than that of traditional antigen tests and virus cultures when considering the detection of respiratory viruses. RSV and RV were the leading viral pathogens identified in the respiratory specimens. One-quarter of the positive specimens were coinfected with two or more viruses. In the future, further application of PCR may contribute to the rapid and accurate diagnosis of respiratory viruses and could improve patient outcomes.

Overtesting and overtreatment-statement from the European Academy of Paediatrics (EAP)

Child health has improved considerably, partly due to increased availability of appropriate disease surveillance and treatment. Inappropriate testing and treatment may impose a risk. There is a large and unexplained variation in the use of tests and treatments for children between and within countries. This suggests that non-scientific factors determine their use. In an era of increasing availability of health services, pediatricians have an important role in balancing risks and benefits of available tests and treatments. Examples from the medical literature of overtesting and overtreatment challenge us to reconsider current practices. Antibiotic overuse, overtreatment of bronchiolitis, and non-indicated radiological procedures are found in common practice across Europe. Choosing Wisely is an initiative to improve the quality of care by reducing unnecessary testing and treatment.Conclusion: Clinicians have the challenge to find the optimal balance between too much and too little medicine-just appropriate.

Assessing physical and respiratory distress in children with bronchiolitis admitted to a community hospital emergency department: A retrospective chart review

Introduction

Bronchiolitis is a leading cause of infant hospitalization with wide variation in its diagnosis and management, especially in smaller community hospitals. The objective of this study is to describe children admitted to a community-based hospital emergency department (ED) for bronchiolitis and explore alternate assessments of illness severity.

Methods

A retrospective chart review (January to September 2014) of 100 children, < 2 years old and meeting International Classification of Diseases 10 for bronchiolitis. Outcomes included demographics, symptoms, and interventions. In addition, the Respiratory Distress Assessment Instrument (RDAI) score was calculated using documented assessments of wheezing and retractions. Descriptive and comparative statistics were completed with p < 0.05 considered significant.

Results

The mean (standard deviation) age 10.6 (8.4) months, n = 41 females. Sixty-seven percent had a chest X-ray (CXR), 17% oral antibiotics, 65% bronchodilators, and 19% oral steroids; 19% were admitted in hospital. There was a significant difference in RDAI score between those given oral antibiotics (mean (95% CI), 6.35 (4.96–7.75)) versus not (4.70 (4.20–5.20)), p = 0.01. Those who received a CXR had a significantly higher oxygen flowrate (1.4 (0.6–2.1) litres per minute (lpm)) and worse physical appearance (tri-pod position, head bobbing) versus those who did not (0.15 (–0.05 to 0.35) lpm), p = 0.002 and p = 0.04, respectively.

Conclusions

A large number of children admitted to a community-based ED for bronchiolitis received unnecessary CXR and medications. Assessing physical and respiratory distress may be more effective at determining illness severity compared with radiological or laboratory testing. Local clinical practice guidelines may aid in optimal management of bronchiolitis for community-based EDs.

Antibiotic Treatment in Patients with Bronchiolitis

This study seeks to define the indications and the economic impact of the use of antibiotics in infants hospitalized due to bronchiolitis during 2010-2017. There were 459 children with bronchiolitis, median age of 2.2 months, 390 infections with respiratory syncytial virus (RSV), and 69 were non-RSV. Twenty two percent of all these children (102/459) required a workup toward urinary tract co-infections (UTI). A control group, consisting of 8,456 children without bronchiolitis, was created to assess UTI frequency in the general population. We found that 16.0% (73/459) children with bronchiolitis received antibiotics; 63 (13.7%) due to respiratory infection and 9 due to UTI. A time-trend analysis showed a decreasing use of antibiotics, from 57.0% in 2010 to 13.7% in 2017, with the lowest value of 6.4% noticed in 2014. Children treated with antibiotics required a 4-day longer hospitalization than those untreated (p < 0.01), but there were no other clinically relevant differences. After excluding the first 2 years with the highest antibiotic ordering, antibiotics, on average, were used in 9.8% of children with bronchiolitis. Frequency of UTI accompanying bronchiolitis was comparable to that in the control group (8.9% vs. 10.9%, respectively). Specificity of urine culture was 71%, with 100% sensitivity assumed, while the positive predicted value of only 41%. The unnecessary costs of urine cultures, if performed in each patient, would have been €2,236, and with additional laboratory tests in each case of a false positive result it would have reached €5,448. We conclude that antibiotics should be used for bronchiolitis only in justified cases, and their use should not exceed 10% of patients. Since UTI is no more frequent in bronchiolitis than in the general children's population, urine cultures should not be performed routinely.

Nutritional management of young infants presenting with acute bronchiolitis in Belgium, France and Switzerland: survey of current practices and documentary search of national guidelines worldwide

Feeding difficulties are common in young infants presenting with acute bronchiolitis, but limited data is available to guide clinicians adapting nutritional management. We aimed to assess paediatricians' nutritional practices among Western Europe French speaking countries. A survey was disseminated to describe advice given to parents for at home nutritional support, in hospital nutritional management, and preferred methods for enteral nutrition and for intravenous fluid management. A documentary search of international guidelines was concomitantly conducted. Ninety-three (66%) contacted physicians responded. Feeding difficulties were a common indication for infants' admission. Written protocols were rarely available. Enteral nutrition was favoured most of the time when oral nutrition was insufficient and might be withheld in case of severe dyspnoea to decrease respiratory workload. Half of physicians were aware of hyponatremia risk and pathophysiology, and isotonic intravenous solutions were used in less than 15% of centres. International guideline search (23 countries) showed a lack of detailed nutritional management recommendations in most of them.Conclusion: practices were inconsistent among physicians. Guidelines detailed nutritional management poorly. Awareness of hyponatremia risk in relation to intravenous hypotonic fluids and of the safety of enteral hydration and nutrition is insufficient. New guidelines including detailed nutritional management recommendations are urgently needed. What is Known? • Infants presenting with acute bronchiolitis face feeding difficulties. • Underfeeding may promote undernutrition, and intravenous hydration with hypotonic fluids may induce hyponatremia. What is New? • Physicians' nutritional practices are inconsistent and awareness of hyponatremia risk and pathophysiology is insufficient among physicians. • Awareness of hyponatremia risk and pathophysiology is insufficient among physicians. • The reasons for enteral nutrition withholding in bronchiolitis infants are not evidence based, and national guidelines of acute bronchiolitis across the world are elusive regarding nutritional management. • National guidelines of acute bronchiolitis across the world are elusive regarding nutritional management.

Diversity in the emergency care for febrile children in Europe: a questionnaire study

OBJECTIVE

To provide an overview of care in emergency departments (EDs) across Europe in order to interpret observational data and implement interventions regarding the management of febrile children.

DESIGN AND SETTING

An electronic questionnaire was sent to the principal investigators of an ongoing study (PERFORM (Personalised Risk assessment in Febrile illness to Optimise Real-life Management), www.perform2020.eu) in 11 European hospitals in eight countries: Austria, Germany, Greece, Latvia, the Netherlands, Slovenia, Spain and the UK.

OUTCOME MEASURES

The questionnaire covered indicators in three domains: local ED quality (supervision, guideline availability, paper vs electronic health records), organisation of healthcare (primary care, immunisation), and local factors influencing or reflecting resource use (availability of point-of-care tests, admission rates).

RESULTS

Reported admission rates ranged from 4% to 51%. In six settings (Athens, Graz, Ljubljana, Riga, Rotterdam, Santiago de Compostela), the supervising ED physicians were general paediatricians, in two (Liverpool, London) these were paediatric emergency physicians, in two (Nijmegen, Newcastle) supervision could take place by either a general paediatrician or a general emergency physician, and in one (München) this could be either a general paediatrician or a paediatric emergency physician. The supervising physician was present on site in all settings during office hours and in five out of eleven settings during out-of-office hours. Guidelines for fever and sepsis were available in all settings; however, the type of guideline that was used differed. Primary care was available in all settings during office hours and in eight during out-of-office hours. There were differences in routine immunisations as well as in additional immunisations that were offered; immunisation rates varied between and within countries.

CONCLUSION

Differences in local, regional and national aspects of care exist in the management of febrile children across Europe. This variability has to be considered when trying to interpret differences in the use of diagnostic tools, antibiotics and admission rates. Any future implementation of interventions or diagnostic tests will need to be aware of this European diversity.

Overview of prevention and management of acute bronchiolitis due to respiratory syncytial virus

INTRODUCTION

Respiratory Syncytial Virus (RSV) is the most common cause of Acute Bronchiolitis (AVB) in infants. AVB causes significant morbidity and mortality worldwide, most deaths occurring in the developing world. AVB causes respiratory distress in infants, leading to respiratory failure in some cases. Disease is more severe in infants with risk factors, such as prematurity, chronic cardiac and lung disease and immunodeficiency. Areas covered: Despite major advances in supportive care in the developed world, which has led to a significant reduction in mortality, treatment remains symptomatic and supportive. No specific antiviral treatment has yet proven to be effective. Prevention of disease with monoclonal antibodies has proven to reduce illness severity in those with risk factors, however, this is prohibitively expensive, particularly for the developing world. Prospects for vaccine development are improving. However, because most disease is in young infants, maternal immunization is necessary. However, due to the transient nature of RSV immunity and the circulation of multiple subtypes, vaccines proven to be effective in adult challenge models have yet to be translated to protection in infants. Expert commentary: Despite advances in preventative treatments, adherence to evidence-based guidelines provides the best prospect for successful reduction in morbidity and mortality.

National treatment guidelines decreased the use of racemic adrenaline for bronchiolitis in four Finnish university hospitals

AIM

Inhaled racemic adrenaline was used for bronchiolitis in many hospitals in Finland prior to new national current care guidelines for bronchiolitis in 2014, which limited its recommendations to on-demand rescue therapy. We studied the drug's use before and after the new guidelines to gauge changes in prescribing habits.

METHODS

This 2012-2016 study analysed how many 0.5 mL doses of racemic adrenaline were used for children by emergency rooms, paediatric wards and paediatric intensive care units at four university hospitals and estimated drug and staff costs.

RESULTS

There were substantial differences in the yearly consumption of racemic adrenaline between the hospitals before and after the bronchiolitis guidelines were published, with reductions in drug costs and staff time. The overall use more than halved during the study period, particularly in two hospitals where baseline consumptions were highest, but not in a third where baseline consumption was already low. In the fourth, the baseline consumption was modest and there was a constant decrease during the study years.

CONCLUSION

The current care guidelines for bronchiolitis had some impact on clinical practice, as the overall use of racemic adrenaline more than halved, but considerable differences remained in the four study hospitals after their publication.

Interventions to reduce inappropriate prescribing of antibiotics for acute respiratory tract infections: summary and update of a systematic review

Objective

Antibiotic overuse contributes to antibiotic resistance and adverse consequences. Acute respiratory tract infections (RTIs) are the most common reason for antibiotic prescribing in primary care, but such infections often do not require antibiotics. We summarized and updated a previously performed systematic review of interventions to reduce inappropriate use of antibiotics for acute RTIs.

Methods

To update the review, we searched MEDLINE®, the Cochrane Library (until January 2018), and reference lists. Two reviewers selected the studies, extracted the study data, and assessed the quality and strength of evidence.

Results

Twenty-six interventions were evaluated in 95 mostly fair-quality studies. The following four interventions had moderate-strength evidence of improved/reduced antibiotic prescribing and low-strength evidence of no adverse consequences: parent education (21% reduction, no increase return visits), combined patient/clinician education (7% reduction, no change in complications/satisfaction), procalcitonin testing for adults with RTIs of the lower respiratory tract (12%–72% reduction, no increased adverse consequences), and electronic decision support systems (24%–47% improvement in appropriate prescribing, 5%–9% reduction, no increased complications).

Conclusions

The best evidence supports use of specific educational interventions, procalcitonin testing in adults, and electronic decision support to reduce inappropriate antibiotic prescribing for acute RTIs without causing adverse consequences.