Community-Based Antibiotic Prescribing Attributable to Respiratory Syncytial Virus and Other Common Respiratory Viruses in Young Children: A Population-Based Time-series Study of Scottish Children

Outpatient respiratory syncytial virus infections and novel preventive interventions

PURPOSE OF REVIEW

With interventions to prevent respiratory syncytial virus (RSV) infection within reach, this review aims to provide healthcare professionals with the latest information necessary to inform parents and assess the potential impact of RSV prevention on everyday practice. We address frequently asked questions for parental counseling.

RECENT FINDINGS

Numerous studies emphasize the major burden of RSV on young children, parents, healthcare and society. In the first year of life, about 14% of healthy term infants visit a doctor and 2% require hospitalization due to RSV. In older children (1--5 years), RSV infections and associated morbidity (wheeze, acute otitis media) are major drivers of outpatient visits. A novel maternal RSV vaccine and long-acting mAb can provide protection during infants' first months of life. This maternal vaccine showed 70.9% efficacy against severe RSV infection within 150 days after birth; the mAb nirsevimab reduces medically attended RSV infections by 79.5% within 150 days after administration. Both gained regulatory approval in the USA (FDA) and Europe (EMA).

SUMMARY

Novel RSV immunizations hold promise to reduce the RSV burden in infants, with substantial impact on everyday practice. Tailored parental guidance will be instrumental for successful implementation. Awaiting pediatric vaccines, RSV infections beyond infancy will still pose a significant outpatient burden.

Report of the WHO technical consultation on the evaluation of respiratory syncytial virus prevention cost effectiveness in low- and middle-income countries, April 7-8, 2022

Policymakers often rely on impact and cost-effectiveness evaluations to inform decisions about the introduction of health interventions in low- and middle-income countries (LMICs); however, cost-effectiveness results for the same health intervention can differ by the choice of parameter inputs, modelling assumptions, and geography. Anticipating the near-term availability of new respiratory syncytial virus (RSV) prevention products, WHO convened a two-day virtual consultation in April 2022 with stakeholder groups and global experts in health economics, epidemiology, and vaccine implementation. The objective was to review methods, parameterization, and results of existing cost-effectiveness analyses for RSV prevention in LMICs; identify the most influential inputs and data limitations; and recommend and prioritize future data gathering and research to improve RSV prevention impact estimates in LMICs. Epidemiological parameters identified as both influential and uncertain were those associated with RSV hospitalization and death, specifically setting-specific hospitalization rates and RSV-attributable death rates. Influential economic parameters included product price, delivery costs, willingness-to-pay for health on the part of potential donors, and the cost of RSV-associated hospitalization. Some of the influential parameters identified at this meeting should be more precisely measured by further research. Other influential economic parameters that are highly uncertain may not be resolved, and it is appropriate to use sensitivity analyses to explore these within cost-effectiveness evaluations. This report highlights the presentations and major discussions of the meeting.

Clinical characteristics of hospitalized children with community-acquired pneumonia and respiratory infections: Using machine learning approaches to support pathogen prediction at admission

BACKGROUND

Acute respiratory infections (ARIs) are common in children. We developed machine learning models to predict pediatric ARI pathogens at admission.

METHODS

We included hospitalized children with respiratory infections between 2010 and 2018. Clinical features were collected within 24 h of admission to construct models. The outcome of interest was the prediction of 6 common respiratory pathogens, including adenovirus, influenza virus types A and B, parainfluenza virus (PIV), respiratory syncytial virus (RSV), and Mycoplasma pneumoniae (MP). Model performance was estimated using area under the receiver operating characteristic curve (AUROC). Feature importance was measured using Shapley Additive exPlanation (SHAP) values.

RESULTS

A total of 12,694 admissions were included. Models trained with 9 features (age, event pattern, fever, C-reactive protein, white blood cell count, platelet count, lymphocyte ratio, peak temperature, peak heart rate) achieved the best performance (AUROC: MP 0.87, 95% CI 0.83-0.90; RSV 0.84, 95% CI 0.82-0.86; adenovirus 0.81, 95% CI 0.77-0.84; influenza A 0.77, 95% CI 0.73-0.80; influenza B 0.70, 95% CI 0.65-0.75; PIV 0.73, 95% CI 0.69-0.77). Age was the most important feature to predict MP, RSV and PIV infections. Event patterns were useful for influenza virus prediction, and C-reactive protein had the highest SHAP value for adenovirus infections.

CONCLUSION

We demonstrate how artificial intelligence can assist clinicians identify potential pathogens associated with pediatric ARIs upon admission. Our models provide explainable results that could help optimize the use of diagnostic testing. Integrating our models into clinical workflows may lead to improved patient outcomes and reduce unnecessary medical costs.

Available evidence and potential for vaccines for reduction in antibiotic prescriptions

Bacterial antibiotic resistance is a public health issue. It means that drugs become ineffective, infections persist and have a huge impact on the health of patients and their spreading increases. To address a complex threat such as bacterial antibiotic resistance different and integrated approaches are needed including discovery of new antibiotics, improvement of diagnostics tools and improvement of antibiotic stewardship. Absolutely relevant are prevention of infections as well as decrease in the use of antibiotics. Vaccines are an important tool in the fight against bacterial antibiotic resistance and can help prevent it in several ways. Indeed, vaccines are highly effective in preventing diseases that might otherwise require the use of antibiotics to treat symptoms and associated complications. Preventing infections through vaccination helps reduce the need for and widespread and inappropriate use of antibiotics, including for secondary bacterial infections.

Evaluating the impact of Respiratory Syncytial Virus immunisation strategies on antibiotic use and drug resistant bacterial infections in England

Background: Vaccines against viruses have been proposed as a novel means to reduce antibiotic use, which would, in turn, decrease selection for antibiotic resistant bacteria. However, the impact of this intervention is poorly quantified, and likely depends on setting-specific epidemiology. Therefore, with increasing confidence in a new vaccine against respiratory syncytial virus (RSV), it is important to quantify the impact of these vaccines on antibiotic prescribing and any downstream reduction in drug resistant bacterial infections. Methods: Here we integrate results from a dynamic transmission model of RSV and a statistical attribution framework to capture the impact of RSV vaccines on the reduction in antibiotic prescribing due to averted primary care visits in England. Results: Under base case assumptions, we find that the most impactful RSV vaccine strategy targets children aged 5–14 years, resulting in an annual reduction of 10.9 (8.0–14.2) antibiotic courses per 10,000 person years across the entire population, equivalent to reducing annual all-cause primary care prescribing by 0.23%. Our results suggest that this reduction in antibiotic use would gain 130 disability-adjusted life years and avert £51,000 associated with drug resistant bacterial infections. Seasonally administering monoclonal antibodies (mAbs) to high-risk infants under 6 months is the most efficient strategy, reducing per person year antibiotic prescribing by 2.6 (1.9–3.3) antibiotic courses per 1,000 mAb courses. Conclusions: Under optimistic conditions, the cost-effectiveness of RSV vaccine strategies in England would likely not be altered by integrating the benefits of preventing drug resistant infections in addition to RSV disease prevention.

Point-of-Care and Rapid Tests for the Etiological Diagnosis of Respiratory Tract Infections in Children: A Systematic Review and Meta-Analysis

Fever is one of the most common causes of medical evaluation of children, and early discrimination between viral and bacterial infection is essential to reduce inappropriate prescriptions. This study aims to systematically review the effects of point-of-care tests (POCTs) and rapid tests for respiratory tract infections on changing antibiotic prescription rate, length of stay, duration of therapy, and healthcare costs. Embase, MEDLINE, and Cochrane Library databases were systematically searched. All randomized control trials and non-randomized observational studies meeting inclusion criteria were evaluated using the NIH assessment tool. A meta-analysis was performed to assess the effects of rapid influenza diagnostic tests and film-array respiratory panel implementation on selected outcomes. From a total of 6440 studies, 57 were eligible for the review. The analysis was stratified by setting and POCT/rapid test type. The most frequent POCTs or rapid tests implemented were the Rapid Influenza Diagnostic Test and film-array and for those types of test a separate meta-analysis assessed a significant reduction in antibiotic prescription and an improvement in oseltamivir prescription. Implementing POCTs and rapid tests to discriminate between viral and bacterial infections for respiratory pathogens is valuable for improving appropriate antimicrobial prescriptions. However, more studies are needed to assess these findings in pediatric settings.

Prevention of antimicrobial prescribing among infants following maternal vaccination against respiratory syncytial virus

Strategies to reduce consumption of antimicrobial drugs are needed to contain the growing burden of antimicrobial resistance. Respiratory syncytial virus (RSV) is a prominent cause of upper and lower respiratory tract infections, as a single agent and in conjunction with bacterial pathogens, and may thus contribute to the burden of both inappropriately treated viral infections and appropriately treated polymicrobial infections involving bacteria. In a double-blind, randomized, placebo-controlled trial, administering an RSV vaccine to pregnant mothers reduced antimicrobial prescribing among their infants by 12.9% over the first 3 mo of life. Our findings implicate RSV as an important contributor to antimicrobial exposure among infants and demonstrate that this exposure is preventable by use of effective maternal vaccines against RSV.

Reductions in antimicrobial consumption are needed to mitigate the burden of antimicrobial resistance. Vaccines may have an important role to play in reducing antimicrobial consumption by preventing infections for which treatment is often prescribed, whether appropriately or inappropriately. However, limited understanding of the volume of antimicrobial treatment attributable to specific pathogens—and to viruses, in particular—presently hinders efforts to prioritize vaccines with the greatest potential to reduce antimicrobial consumption. In a double-blind trial undertaken across 11 countries, infants born to mothers who were randomized to receive an experimental vaccine against respiratory syncytial virus (RSV) experienced 12.9% (95% CI: 1.3 to 23.1%) lower incidence of antimicrobial prescribing over the first 3 mo of life than infants whose mothers were randomized to receive placebo. Vaccine efficacy against antimicrobial prescriptions associated with acute lower respiratory tract infections (LRTIs) was 16.9% (95% CI: 1.4 to 29.4%). Over the first 3 mo of life, maternal vaccination prevented 3.6 antimicrobial prescription courses for every 100 infants born in high-income countries and 5.1 courses per 100 infants in low- and middle-income countries, representing 20.2 and 10.9% of all antimicrobial prescribing in these settings, respectively. While LRTI episodes accounted for 69 to 73% of all antimicrobial prescribing prevented by maternal vaccination, striking vaccine efficacy (71.3% [95% CI: 28.1 to 88.6%]) was also observed against acute otitis media–associated antimicrobial prescription among infants in high-income countries. Our findings implicate RSV as a cause of substantial volumes of antimicrobial prescribing among young infants and demonstrate the potential for prevention of such prescribing through use of maternal vaccines against RSV.

Antibiotic prescribing across age groups in the Kaiser Permanente Northern California population in association with different diagnoses, and with influenza incidence, 2010-2018

There is limited information on the volume of antibiotic prescribing that is influenza-associated, resulting from influenza infections and their complications (such as streptococcal pharyngitis and otitis media). Here, we estimated age/diagnosis-specific proportions of antibiotic prescriptions (fills) for the Kaiser Permanente Northern California population during 2010-2018 that were influenza-associated. The proportion of influenza-associated antibiotic prescribing among all antibiotic prescribing was higher in children aged 5-17 years compared to children aged under 5 years, ranging from 1.4% [95% CI (0.7-2.1)] in aged <1 year to 2.7% (1.9-3.4) in aged 15-17 years. For adults aged over 20 years, the proportion of influenza-associated antibiotic prescribing among all antibiotic prescribing was lower, ranging from 0.7% (0.5-1) for aged 25-29 years to 1.6% (1.2-1.9) for aged 60-64 years. Most of the influenza-associated antibiotic prescribing in children aged under 10 years was for ear infections, while for age groups over 25 years, 45-84% of influenza-associated antibiotic prescribing was for respiratory diagnoses without a bacterial indication. This suggests a modest benefit of increasing influenza vaccination coverage for reducing antibiotic prescribing, as well as the potential benefit of other measures to reduce unnecessary antibiotic prescribing for respiratory diagnoses with no bacterial indication in persons aged over 25 years, both of which may further contribute to the mitigation of antimicrobial resistance.