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Burvenich R, De Boodt S, Lowie L, Janssens A, Beerten SG, Vaes B, Toelen J, Verbakel JY. Temporal trends in antibiotic prescribing and serious and nonserious infections in children presenting to general practice: a registry-based longitudinal cohort study of 162 507 individuals. J Antimicrob Chemother 2024; 79:1397-1406. [PMID: 38714502 DOI: 10.1093/jac/dkae117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/02/2024] [Indexed: 05/10/2024] Open
Abstract
BACKGROUND It is crucial to understand the trends in paediatric antibiotic prescribing and serious and nonserious infections to improve antibiotic prescribing practices for children in ambulatory care. OBJECTIVES Assessing trends in paediatric antibiotic prescribing and infection incidence in general practice from 2002 to 2022. METHODS In this retrospective cohort study using INTEGO network data from 162 507 patients in Flanders (Belgium), we calculated antibiotic prescribing rates and proportions alongside incidence rates of serious and nonserious infections, stratified by age (0-1, 2-6, 7-12 years) and municipality. We performed autoregressive moving average time-series analyses and seasonality analyses. RESULTS From 2002 to 2022, antibiotic prescribing rate decreased significantly: 584/1000 person-years (PY) (95% CI 571-597) to 484/1000PY (95% CI 478-491); so did antibiotic overall prescribing proportion: 46.3% (95% CI 45.1-47.6) to 23.3% (95% CI 22.9-23.7) (59.3% amoxicillin and 17.8% broad spectrum). Prescribing proportions dropped significantly for nonserious (45.6% to 20.9%) and increased for serious infections (64.1% to 69.8%). Proportions significantly dropped for acute suppurative otitis media (74.7% to 64.1%), upper respiratory tract infections (44.9% to 16.6%), bronchitis/bronchiolitis (73.6% to 44.1%) and acute tonsillopharyngitis (59.5% to 21.7%), while significantly increasing for pneumonia (65.2% to 80.2%). Nonserious and serious infection incidence rates increased from 785/1000PY and 34.2/1000PY to 1223/1000PY and 64.1/1000PY, respectively. Blood and CRP testing proportions increased significantly. CONCLUSIONS Antibiotic prescribing in general practice for children declined from 2002 to 2022. Further targeted antibiotic stewardship initiatives are needed to reduce the use of broad-spectrum antibiotics and antibiotic prescribing for conditions such as otitis media and bronchitis/bronchiolitis.
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Affiliation(s)
- Ruben Burvenich
- Department of Public Health and Primary Care, Leuven Unit for Health and Technology Assessment Research (LUHTAR), KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Department of Family Medicine and Primary Healthcare, Ghent University, 10 Corneel Heymanslaan, Ghent, 9000, Belgium
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania, 7000, Australia
| | - Sien De Boodt
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Lien Lowie
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Arne Janssens
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
| | - Simon Gabriël Beerten
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
| | - Jaan Toelen
- Woman and Child, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Jan Yvan Verbakel
- Department of Public Health and Primary Care, Leuven Unit for Health and Technology Assessment Research (LUHTAR), KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Department of Public Health and Primary Care, Academic Centre for General Practice, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare Medtech and IVD Cooperative, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
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Bos DAG, De Burghgraeve T, De Sutter A, Buntinx F, Verbakel JY. Clinical prediction models for serious infections in children: external validation in ambulatory care. BMC Med 2023; 21:151. [PMID: 37072778 PMCID: PMC10114467 DOI: 10.1186/s12916-023-02860-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/03/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Early distinction between mild and serious infections (SI) is challenging in children in ambulatory care. Clinical prediction models (CPMs), developed to aid physicians in clinical decision-making, require broad external validation before clinical use. We aimed to externally validate four CPMs, developed in emergency departments, in ambulatory care. METHODS We applied the CPMs in a prospective cohort of acutely ill children presenting to general practices, outpatient paediatric practices or emergency departments in Flanders, Belgium. For two multinomial regression models, Feverkidstool and Craig model, discriminative ability and calibration were assessed, and a model update was performed by re-estimation of coefficients with correction for overfitting. For two risk scores, the SBI score and PAWS, the diagnostic test accuracy was assessed. RESULTS A total of 8211 children were included, comprising 498 SI and 276 serious bacterial infections (SBI). Feverkidstool had a C-statistic of 0.80 (95% confidence interval 0.77-0.84) with good calibration for pneumonia and 0.74 (0.70-0.79) with poor calibration for other SBI. The Craig model had a C-statistic of 0.80 (0.77-0.83) for pneumonia, 0.75 (0.70-0.80) for complicated urinary tract infections and 0.63 (0.39-0.88) for bacteraemia, with poor calibration. The model update resulted in improved C-statistics for all outcomes and good overall calibration for Feverkidstool and the Craig model. SBI score and PAWS performed extremely weak with sensitivities of 0.12 (0.09-0.15) and 0.32 (0.28-0.37). CONCLUSIONS Feverkidstool and the Craig model show good discriminative ability for predicting SBI and a potential for early recognition of SBI, confirming good external validity in a low prevalence setting of SBI. The SBI score and PAWS showed poor diagnostic performance. TRIAL REGISTRATION ClinicalTrials.gov, NCT02024282. Registered on 31 December 2013.
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Affiliation(s)
- David A G Bos
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer block H - Box 7001, Leuven, 3000, Belgium.
| | - Tine De Burghgraeve
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer block H - Box 7001, Leuven, 3000, Belgium
| | - An De Sutter
- Department of Family Practice and Primary Health Care, Ghent University, Ghent, Belgium
| | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Research Institute Caphri, Maastricht University, Maastricht, The Netherlands
| | - Jan Y Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer block H - Box 7001, Leuven, 3000, Belgium
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Dillen H, Burvenich R, De Burghgraeve T, Verbakel JY. Using Belgian pharmacy dispensing data to assess antibiotic use for children in ambulatory care. BMC Pediatr 2022; 22:12. [PMID: 34980037 PMCID: PMC8720940 DOI: 10.1186/s12887-021-03047-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/30/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The desired effect of antibiotics is compromised by the rapid escalation of antimicrobial resistance. Children are particularly at high-risk for unnecessary antibiotic prescribing, which is owing to clinicians' diagnostic uncertainty combined with parents' concerns and expectations. Recent Belgian data on ambulatory antibiotic prescribing practices for children are currently lacking. Therefore, we aim to analyse different aspects of antibiotic prescriptions for children in ambulatory care. METHODS Pharmacy dispensing data on antibiotics for systematic use referring from 2010 to 2019 were retrieved from Farmanet, a database of pharmaceutical dispensations in community pharmacies. Population data were obtained from the Belgian statistical office (Statbel). Descriptive statistics were performed in Microsoft Excel. The Mann-Kendall test for trend analysis and the seasplot function for seasonality testing were conducted in R. RESULTS The past decade, paediatric antibiotic use and expenditures have relatively decreased in Belgian ambulatory care with 35.5% and 44.3%, respectively. The highest volumes of antibiotics for children are prescribed by GPs working in Walloon region and rural areas, to younger children, and during winter. The most prescribed class of antibiotics for children are the penicillins and the biggest relative reduction in number of packages is seen for the sulfonamides and trimethoprim and quinolone antibacterials. CONCLUSIONS Paediatric antibiotic use has decreased in Belgian ambulatory care. Further initiatives are needed to promote prudent antibiotic prescribing in ambulatory care.
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Affiliation(s)
- Hannelore Dillen
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium.
| | - Ruben Burvenich
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium
| | - Tine De Burghgraeve
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, 3000, Leuven, Belgium.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX26GG, UK
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A retrospective review of serious infections in febrile infants 0–90 days old. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/20101058211026003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Fever without source in infants is a common clinical problem that accounts for many ambulatory care visits and hospitalisations. Currently, there is no reliable method of identifying those at risk of serious infection (SI). Objective: The goal of this study was to determine the incidence and identify the predictors of SI in febrile infants who presented to the emergency department (ED). Methods: This was a single-centre retrospective cohort study of children presenting to a Singapore tertiary hospital paediatric unit between 1 July 2018 and 31 December 2018. Children were included if they were aged 0–90 days and presented to the ED with a fever. SI was defined as urinary tract infection (UTI), sepsis, bacteraemia, meningitis (viral and bacterial), enterocolitis, osteomyelitis, abscess or pneumonia. Results: Of the 659 infants, 161 (24.4%) were diagnosed with SI. Meningitis (49.7%) was the most common SI, followed by UTI (45.3%), enterocolitis (5.6%), sepsis (3.1%) and bacteraemia (2.5%). Factors significantly associated with SI were aged 29–60 days, male sex, Severity Index Score (SIS) <10, absolute neutrophil counts >10×109/L, C-reactive protein (CRP) >20 mg/L and procalcitonin >0.5 ng/mL. Multivariate analysis entering all these items retained only male sex, SIS <10 and CRP >20. Conclusion: Among hospitalised infants aged 0–90 days, the incidence of SI was 24.4%, and invasive bacterial infection was 0.6%. Meningitis was the most common SI followed by UTI. SIS and CRP can be used to predict SI in infants <90 days old.
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Lemiengre MB, Verbakel JY, Colman R, Van Roy K, De Burghgraeve T, Buntinx F, Aertgeerts B, De Baets F, De Sutter A. Point-of-care CRP matters: normal CRP levels reduce immediate antibiotic prescribing for acutely ill children in primary care: a cluster randomized controlled trial. Scand J Prim Health Care 2018; 36:423-436. [PMID: 30354904 PMCID: PMC6381547 DOI: 10.1080/02813432.2018.1529900] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Antibiotics are prescribed too often in acutely ill children in primary care. We examined whether a Point-of-Care (POC) C-reactive Protein (CRP) test influences the family physicians' (FP) prescribing rate and adherence to the Evidence Based Medicine (EBM) practice guidelines. DESIGN Cluster randomized controlled trial. SETTING Primary care, Flanders, Belgium. INTERVENTION Half of the children with non-severe acute infections (random allocation of practices to perform POC CRP or not) and all children at risk for serious infection were tested with POC CRP. SUBJECTS Acutely ill children consulting their FP. MAIN OUTCOME MEASURE Immediate antibiotic prescribing. RESULTS 2844 infectious episodes recruited by 133 FPs between 15 February 2013 and 28 February 2014 were analyzed. A mixed logistic regression analysis was performed. Compared to episodes in which CRP was not tested, the mere performing of POC CRP reduced prescribing in case EBM practice guidelines advise to prescribe antibiotics (adjusted odds ratio (aOR) 0.54 (95% Confidence Interval (CI) 0.33-0.90). Normal CRP levels reduced antibiotic prescribing, regardless of whether the advice was to prescribe (aOR 0.24 (95%CI 0.11-0.50) or to withhold (aOR 0.31 (95%CI 0.17-0.57)). Elevated CRP levels did not increase antibiotic prescribing. CONCLUSION Normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing. Key points What is previously known or believed on this topic •Antibiotics are prescribed too often for non-severe conditions. Point-of-care (POC) C-reactive Protein (CRP) testing without guidance does not reduce immediate antibiotic prescribing in acutely ill children in primary care. What this research adds •FPs clearly consider CRP once available: normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. •Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing.
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Affiliation(s)
- Marieke B. Lemiengre
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium;
- CONTACT Marieke B. Lemiengre Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, 6K3, 9000Ghent, Belgium
| | - Jan Y. Verbakel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK;
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium;
| | - Roos Colman
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium;
| | - Kaatje Van Roy
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium;
| | | | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium;
- Research Institute Caphri, Maastricht University, Maastricht, The Netherlands;
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium;
| | - Frans De Baets
- Department of Pediatric Pulmonology, Infection and Immune Deficiencies, Ghent University Hospital, Ghent, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium;
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Verbakel JY, Lemiengre MB, De Burghgraeve T, De Sutter A, Aertgeerts B, Bullens DMA, Shinkins B, Van den Bruel A, Buntinx F. Point-of-care C reactive protein to identify serious infection in acutely ill children presenting to hospital: prospective cohort study. Arch Dis Child 2018; 103:420-426. [PMID: 29269559 DOI: 10.1136/archdischild-2016-312384] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Acute infection is the most common presentation of children to hospital. A minority of these infections are serious, but early recognition and adequate management are essential. We aimed to develop improved tools to assess children attending ambulatory hospital care, integrating clinical features with point-of-care C reactive protein (CRP). DESIGN Prospective observational diagnostic study. SETTING AND PATIENTS 5517 acutely ill children (1 month-16 years) presenting to 106 paediatricians at six outpatient clinics and six emergency departments in Belgium. INDEX TEST Point-of-care CRP alongside vital signs and objective symptoms measurements. MAIN OUTCOME Hospital admission for >24 hours with a serious infection <5 days after presentation. RESULTS An algorithm was developed consisting of clinical features and CRP. This achieved 97.1% (95% CI 94.3% to 98.7%) sensitivity and 99.6% (95% CI 99.2% to 99.8%) negative predictive value, excluding serious infections in 36.4% of children. It stratifies patients into three groups based on CRP level: high-risk group with CRP >75 mg/L (26.8% risk of infection), intermediate-risk group with CRP 20-75 mg/L and at least one of seven clinical features (8.1%), and lower risk group with CRP <20 mg/L with at least one of the 11 features (3.8%). Children in intermediate-risk or low-risk groups with normal clinical assessment have 0.6% and 0.4% risk of serious infections, respectively. CONCLUSIONS Conducting a CRP test may first enable children to be stratified into three risk groups, guiding assessment of clinical features that could be performed by junior doctors or nurses. In one-third of acutely ill children, the algorithm could exclude serious infection. Prospective validation of the algorithm is needed. CLINICAL TRIAL REGISTRATION NCT02024282 (post-results).
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Affiliation(s)
- Jan Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marieke B Lemiengre
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | | | - An De Sutter
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Dominique M A Bullens
- Clinical Department of Paediatrics, University Hospitals Leuven, Leuven, Belgium.,Paediatric Immunology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Bethany Shinkins
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Research Institute CAPHRI, Maastricht University, Maastricht, The Netherlands
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Lang HJ, Tasker RC. Sepsis kills: suspect it, recognise it and be prompt with treatment. Arch Dis Child 2017; 102:2-4. [PMID: 27831911 DOI: 10.1136/archdischild-2016-311418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/30/2016] [Accepted: 10/02/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Hans-Joerg Lang
- Department of Paediatrics, Médecins Sans Frontières (Suisse), Operational Centre Genève, Genève, Switzerland
| | - Robert C Tasker
- Division of Critical Care Medicine, Departments of Neurology and Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Departments of Neurology and Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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Lemiengre MB, Verbakel JY, De Burghgraeve T, Aertgeerts B, De Baets F, Buntinx F, De Sutter A. Optimizing antibiotic prescribing for acutely ill children in primary care (ERNIE2 study protocol, part B): a cluster randomized, factorial controlled trial evaluating the effect of a point-of-care C-reactive protein test and a brief intervention combined with written safety net advice. BMC Pediatr 2014; 14:246. [PMID: 25277543 PMCID: PMC4287591 DOI: 10.1186/1471-2431-14-246] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 08/26/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Despite huge public campaigns, there is still overconsumption of antibiotics in children with self-limiting diseases. Possible explanations may be the physicians' and parents' uncertainty about the gravity of the disease and inadequate communication between physicians and parents leading to lack of reassurance for the parents. In this paper we describe the design and methods of a trial aiming to rationalize antibiotic prescribing by decreasing this uncertainty and parental anxiety. METHODS/DESIGN Acutely ill children without suspected serious disease consulting their family physician will be consecutively included in a four-armed cluster randomized factorial controlled trial. The intervention will consist a Point-of-Care C-reactive protein test and/or a brief intervention with safety net advice. The control group will receive usual care. We intend to include 2560 patients in 88 family practices. Patients will be followed up until cure. The primary outcome measure is the immediate antibiotic prescribing rate. Secondary outcomes are: comparison between groups of speed of clinical recovery, parental concern, parental perception of the quality of the communication, parental satisfaction, use of medication, use of diagnostic tests and medical services during the illness episode, and cost-effectiveness of the interventions. Besides this, we will observationally analyse data of the children included in the large ERNIE2-trial, but excluded in the cluster randomized trial, namely children suspected of serious disease presenting in primary care and children who initially present at the out-patient paediatric clinic or emergency department. We will search for predictors of antibiotic prescribing, speed of clinical recovery, parental concern, parental perception of communication, parental satisfaction, use of medication, diagnostic tests and medical services. DISCUSSION This is a unique multifaceted intervention, in that it targets both physicians and parents by aiming specifically at their uncertainty and concerns during the consultation. Both interventions are easy to implement without special training. When proven effective, they could offer a feasible way to decrease inappropriate antibiotic prescribing for children in family practice and thus avoid emergence of bacterial resistance, side effects and unnecessary healthcare costs. Moreover, the observational part of the study will increase our insight in the course, management and parent's concern of acute illness in children. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02024282.
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Affiliation(s)
- Marieke B Lemiengre
- />Department of Family Practice and Primary Health Care, Ghent University, De Pintelaan 185 6 K3, Ghent, 9000 Belgium
| | - Jan Y Verbakel
- />Department of General Practice, KU Leuven, Kapucijnenvoer 33, Leuven, 3000 Belgium
| | - Tine De Burghgraeve
- />Department of General Practice, KU Leuven, Kapucijnenvoer 33, Leuven, 3000 Belgium
| | - Bert Aertgeerts
- />Department of General Practice, KU Leuven, Kapucijnenvoer 33, Leuven, 3000 Belgium
| | - Frans De Baets
- />Department of Pediatric Pulmonology, Infection and Immune Deficiencies, Ghent University Hospital, De Pintelaan 185 K12D, Ghent, 9000 Belgium
| | - Frank Buntinx
- />Department of General Practice, KU Leuven, Kapucijnenvoer 33, Leuven, 3000 Belgium
- />Research Institute Caphri, Maastricht University, PB 313, Nl 6200 MD Maastricht, The Netherlands
| | - An De Sutter
- />Department of Family Practice and Primary Health Care, Ghent University, De Pintelaan 185 6 K3, Ghent, 9000 Belgium
| | - on behalf of the ERNIE 2 collaboration
- />Department of Family Practice and Primary Health Care, Ghent University, De Pintelaan 185 6 K3, Ghent, 9000 Belgium
- />Department of General Practice, KU Leuven, Kapucijnenvoer 33, Leuven, 3000 Belgium
- />Department of Pediatric Pulmonology, Infection and Immune Deficiencies, Ghent University Hospital, De Pintelaan 185 K12D, Ghent, 9000 Belgium
- />Research Institute Caphri, Maastricht University, PB 313, Nl 6200 MD Maastricht, The Netherlands
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