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FANG H, HONG Z, LI D, ZHANG H, SHI Y, LI X, SUN Z, CHEN W, ZHANG C, ZU Y. Formulation of international standards of Chinese medicine technology: clinical practice guide of Chinese medicine for cough. J TRADIT CHIN MED 2024; 44:396-402. [PMID: 38504546 PMCID: PMC10927410 DOI: 10.19852/j.cnki.jtcm.20231016.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 04/27/2023] [Indexed: 03/21/2024]
Abstract
OBJECTIVE To formulate the first clinical practice guideline for the treatment of cough using Chinese medicine based on the grading of recommendations assessment, development, and evaluation (GRADE) systematic approach, including clinical evidence, evaluation of ancient literature, and expert consensus. METHODS In the process of development, the regulation of "evidence-based, consensus-assisted, and empirical" was followed, and a comprehensive systematic approach of recommendation assessment, GRADE, evidence-based evaluation, expert consensus, and the Delphi method was used. In the process of guideline development, evidence-based evaluation of ancient literature was included for the first time, and clinical evidence was fully integrated with clinical expert consensus. RESULTS The clinical practice guidelines for the treatment of cough with Chinese herbal medicine were developed after a comprehensive consideration of evidence-based evaluation and expert opinions. The guideline recommendations focused on recommending herbal compound decoctions and Chinese patent medicines for cough in different conditions. Based on the GRADE systematic approach, we conducted an evidence-based evaluation of the recommended Chinese patent medicines one by one; meanwhile, the expert consensus method was used to unify the recommendations of both. CONCLUSION Based on clinical evidence, ancient literature evaluation, and expert consensus, a clinical practice guideline for Traditional Chinese Medicine (TCM) in the treatment of cough was developed, providing the first current clinical practice guideline for domestic and foreign TCM and Western medicine practitioners, especially respiratory professionals at home and abroad.
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Affiliation(s)
- Hanyu FANG
- 1 Beijing University of Chinese medicine, Beijing 100029, China
- 2 Department of Traditional Chinese Medicine for Pulmonary Diseases, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029
- 3 National Center for Respiratory Medicine, Beijing 100029, China
| | - Zheng HONG
- 1 Beijing University of Chinese medicine, Beijing 100029, China
- 2 Department of Traditional Chinese Medicine for Pulmonary Diseases, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029
- 3 National Center for Respiratory Medicine, Beijing 100029, China
| | - Deming LI
- 4 Department of Traditional Chinese Medicine for Pulmonary Diseases, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Hongchun ZHANG
- 1 Beijing University of Chinese medicine, Beijing 100029, China
- 2 Department of Traditional Chinese Medicine for Pulmonary Diseases, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029
- 3 National Center for Respiratory Medicine, Beijing 100029, China
| | - Yihang SHI
- 5 Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
- 6 Second Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300250, China
| | - Xiaojuan LI
- 5 Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
- 6 Second Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300250, China
| | - Zengtao SUN
- 5 Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
- 6 Second Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300250, China
| | - Wei CHEN
- 7 Center for Evidence-based Medicine, Beijing University of Chinese Medicine, Beijing 100029, China
| | - Chuchu ZHANG
- 8 Institute of Information on Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Yaqi ZU
- 8 Institute of Information on Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing 100700, China
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Atto B, Anteneh Y, Bialasiewicz S, Binks MJ, Hashemi M, Hill J, Thornton RB, Westaway J, Marsh RL. The Respiratory Microbiome in Paediatric Chronic Wet Cough: What Is Known and Future Directions. J Clin Med 2023; 13:171. [PMID: 38202177 PMCID: PMC10779485 DOI: 10.3390/jcm13010171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 01/12/2024] Open
Abstract
Chronic wet cough for longer than 4 weeks is a hallmark of chronic suppurative lung diseases (CSLD), including protracted bacterial bronchitis (PBB), and bronchiectasis in children. Severe lower respiratory infection early in life is a major risk factor of PBB and paediatric bronchiectasis. In these conditions, failure to clear an underlying endobronchial infection is hypothesised to drive ongoing inflammation and progressive tissue damage that culminates in irreversible bronchiectasis. Historically, the microbiology of paediatric chronic wet cough has been defined by culture-based studies focused on the detection and eradication of specific bacterial pathogens. Various 'omics technologies now allow for a more nuanced investigation of respiratory pathobiology and are enabling development of endotype-based models of care. Recent years have seen substantial advances in defining respiratory endotypes among adults with CSLD; however, less is understood about diseases affecting children. In this review, we explore the current understanding of the airway microbiome among children with chronic wet cough related to the PBB-bronchiectasis diagnostic continuum. We explore concepts emerging from the gut-lung axis and multi-omic studies that are expected to influence PBB and bronchiectasis endotyping efforts. We also consider how our evolving understanding of the airway microbiome is translating to new approaches in chronic wet cough diagnostics and treatments.
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Affiliation(s)
- Brianna Atto
- School of Health Sciences, University of Tasmania, Launceston, TAS 7248, Australia;
| | - Yitayal Anteneh
- Child and Maternal Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0811, Australia; (Y.A.); (M.J.B.); (J.W.)
| | - Seweryn Bialasiewicz
- Australian Centre for Ecogenomics, School of Chemistry and Molecular Biosciences, The University of Queensland, St. Lucia, QLD 4072, Australia;
| | - Michael J. Binks
- Child and Maternal Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0811, Australia; (Y.A.); (M.J.B.); (J.W.)
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia
| | - Mostafa Hashemi
- Department of Chemical and Biological Engineering, The University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (M.H.); (J.H.)
| | - Jane Hill
- Department of Chemical and Biological Engineering, The University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (M.H.); (J.H.)
- Spire Health Technology, PBC, Seattle, WA 98195, USA
| | - Ruth B. Thornton
- Centre for Child Health Research, University of Western Australia, Perth, WA 6009, Australia;
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, WA 6009, Australia
| | - Jacob Westaway
- Child and Maternal Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0811, Australia; (Y.A.); (M.J.B.); (J.W.)
- Centre for Tropical Bioinformatics and Molecular Biology, James Cook University, Cairns, QLD 4811, Australia
| | - Robyn L. Marsh
- School of Health Sciences, University of Tasmania, Launceston, TAS 7248, Australia;
- Child and Maternal Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0811, Australia; (Y.A.); (M.J.B.); (J.W.)
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Staiano A, Bjerrum L, Llor C, Melbye H, Hopstaken R, Gentile I, Plate A, van Hecke O, Verbakel JY. C-reactive protein point-of-care testing and complementary strategies to improve antibiotic stewardship in children with acute respiratory infections in primary care. Front Pediatr 2023; 11:1221007. [PMID: 37900677 PMCID: PMC10602801 DOI: 10.3389/fped.2023.1221007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
This paper provides the perspective of an international group of experts on the role of C-reactive protein (CRP) point-of-care testing (POCT) and complementary strategies such as enhanced communication skills training and delayed prescribing to improve antibiotic stewardship in the primary care of children presenting with an acute illness episode due to an acute respiratory tract infection (ARTI). To improve antibiotics prescribing decisions, CRP POCT should be considered to complement the clinical assessment of children (6 months to 14 years) presenting with an ARTI in a primary care setting. CRP POCT can help decide whether a serious infection can be ruled out, before deciding on further treatments or management, when clinical assessment is unconclusive. Based on the evidence currently available, a CRP value can be a valuable support for clinical reasoning and facilitate communication with patients and parents, but the clinical assessment should prevail when making a therapy or referral decision. Nearly half of children tested in the primary care setting can be expected to have a CRP value below 20 mg/l, in which case it is strongly suggested to avoid prescribing antibiotics when the clinical assessment supports ruling out a severe infection. For children with CRP values greater than or equal to 20 mg/l, additional measures such as additional diagnostic tests, observation time, re-assessment by a senior decision-maker, and specialty referrals, should be considered.
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Affiliation(s)
- Annamaria Staiano
- Department of Translational Medical Sciences, University of Naples “Federico II”, Naples, Italy
| | - Lars Bjerrum
- Centre for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- Department of Public Health and Primary Care, University of Southern Denmark, Odense, Denmark
| | - Hasse Melbye
- General Practice Research Unit, Department of Community Medicine, The Arctic University of Norway, Tromso, Norway
| | - Rogier Hopstaken
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ivan Gentile
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Andreas Plate
- Institute of Primary Care, University and University Hospital Zurich, Zurich, Switzerland
| | - Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jan Y. Verbakel
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- EPI-Centre, Department of Public Health and Primary Care, Academisch Centrum Voor Huisartsgeneeskunde, Leuven & NIHR Community Healthcare Medtech and IVD cooperative, Leuven, Belgium
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Kuitunen I, Renko M. Honey for acute cough in children - a systematic review. Eur J Pediatr 2023; 182:3949-3956. [PMID: 37355498 PMCID: PMC10570220 DOI: 10.1007/s00431-023-05066-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 02/11/2023] [Accepted: 06/14/2023] [Indexed: 06/26/2023]
Abstract
To analyze the efficacy of using honey to treat acute cough in children. Systematic review, synthesis without meta-analysis. We searched PubMed, Scopus, CENTRAL, CINAHL, and Web of Science databases on August 15, 2022, for words honey and cough. Randomized controlled trials conducted in children were included. Risk-of-bias and evidence quality were assessed. Studies were not pooled due to lack of key information. Instead, we provided the range of observed effects for the main outcomes. Three hundred ninety-six papers were screened, and 10 studies were included. Two studies had high risk-of-bias and six had some concerns. Honey seemed to decrease cough frequency more than placebo/no treatment (range of observed effect 0.0-1.1 points) and cough medication (0.2-0.9 points). Sleep improved more often in the honey group (range of effect was 0.0-1.1) compared to placebo/no treatment and (- 0.2-1.1 points) compared to cough medication. Quality of the evidence was low to very low. CONCLUSION We found low quality evidence that honey may be more effective than cough medication or placebo/no treatment in relieving symptoms and improving sleep in children with acute cough. Better quality randomized, placebo-controlled blinded trials are needed to confirm the effectiveness of honey in treating acute cough in children. TRIAL REGISTRATION CRD42022369577. WHAT IS KNOWN • Honey has been suggested to be effective as a symptomatic treatment in acute cough. • Prior randomized trials have had conflicting results and thus an overview of the literature was warranted. WHAT IS NEW • Based on low quality evidence honey may be more effective than placebo or over-the-counter medications for acute symptom reliwef in cough. • Future studies with better reporting are needed to confirm the results.
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Affiliation(s)
- Ilari Kuitunen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Yliopistonranta 2, 70211, Kuopio, Finland.
- Department of Pediatrics, Mikkeli Central Hospital, Mikkeli, Finland.
| | - Marjo Renko
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Yliopistonranta 2, 70211, Kuopio, Finland
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
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Kraman SS, Pasterkamp H, Wodicka GR. Smart Devices Are Poised to Revolutionize the Usefulness of Respiratory Sounds. Chest 2023; 163:1519-1528. [PMID: 36706908 PMCID: PMC10925548 DOI: 10.1016/j.chest.2023.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/10/2023] [Accepted: 01/17/2023] [Indexed: 01/26/2023] Open
Abstract
The association between breathing sounds and respiratory health or disease has been exceptionally useful in the practice of medicine since the advent of the stethoscope. Remote patient monitoring technology and artificial intelligence offer the potential to develop practical means of assessing respiratory function or dysfunction through continuous assessment of breathing sounds when patients are at home, at work, or even asleep. Automated reports such as cough counts or the percentage of the breathing cycles containing wheezes can be delivered to a practitioner via secure electronic means or returned to the clinical office at the first opportunity. This has not previously been possible. The four respiratory sounds that most lend themselves to this technology are wheezes, to detect breakthrough asthma at night and even occupational asthma when a patient is at work; snoring as an indicator of OSA or adequacy of CPAP settings; cough in which long-term recording can objectively assess treatment adequacy; and crackles, which, although subtle and often overlooked, can contain important clinical information when appearing in a home recording. In recent years, a flurry of publications in the engineering literature described construction, usage, and testing outcomes of such devices. Little of this has appeared in the medical literature. The potential value of this technology for pulmonary medicine is compelling. We expect that these tiny, smart devices soon will allow us to address clinical questions that occur away from the clinic.
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Affiliation(s)
- Steve S Kraman
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, Lexington, KY.
| | - Hans Pasterkamp
- University of Manitoba, Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - George R Wodicka
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN
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Mao H, Wei YH, Su HM, Jiang ZY, Li X. Pediatric Tui Na for cough in children: A systematic review and meta-analysis of randomized controlled trials. Complement Ther Med 2022; 71:102882. [PMID: 36031023 DOI: 10.1016/j.ctim.2022.102882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/21/2022] [Accepted: 08/24/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To evaluate the effectiveness and safety of pediatric Tui Na for the treatment of cough in children under seven years of age. DESIGN Systematic review and meta-analysis of randomized controlled trials. METHODS We searched seven major databases and two ongoing trial registers before November 2021 for randomized controlled trials (RCTs) on pediatric Tui Na for cough in children. Main outcome measures were cough related status (such as cough frequency, severity, and duration), use of western medicines, quality of life, medical costs, recurrence rate, adverse events and acceptance. Two reviewers independently selected studies and extracted data. Results were presented by RevMan 5.4 as risk ratios (RRs) and mean differences (MDs), both with 95 % confidence intervals (CIs). Risk of bias were assessed using ROB tools and quality of evidence by GRADE. RESULTS Sixteen RCTs involving 1502 participants were included in this review. Most trials were poor in quality for not reporting allocation concealment, blinding of outcomeassessment or outcome data completeness. The pooled results demonstrated that pediatric Tui Na alone (2 RCTs, 205 participants; MD -2.22, 95 %CI -3.71 to -0.73; P = 0.004; I 2 = 90 %; low certainty) or combined with conventional treatment (7 RCTs, 668 participants; MD -1.66, 95 %CI -2.89 to -0.44; P = 0.008; I 2 = 98 %; low certainty) shortened cough duration. The combined treatment also decreased the recurrence rate of cough (3 RCTs, 135 participants; RR 0.35, 95 %CI 0.21-0.58; P < 0.0001; I 2 = 0 %; moderate certainty). There were insufficient data on adverse events. CONCLUSIONS This review indicates that pediatric Tui Na may shorten the course and decrease the recurrence rate of cough in children, and appears to be relatively safe. However, large-sample, multi-center and high-quality RCTs are warranted to confirm these findings.
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Affiliation(s)
- Hui Mao
- School of Humanities, Beijing University of Chinese Medicine, Beijing 100029, China.
| | - Yue-Hui Wei
- School of Humanities, Beijing University of Chinese Medicine, Beijing 100029, China.
| | - Hui-Ming Su
- Beijing Universality of Chinese Medicine Third Affiliated Hospital, Beijing 100029, China.
| | - Zi-Yun Jiang
- School of Management, Beijing University of Chinese Medicine, Beijing 100029, China.
| | - Xun Li
- Centre for Evidence-Based Chinese Medicine, Beijing 100029, China.
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7
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Jiang ZY, Gatcliffe C, Mai T, Huang Z. Aerodigestive Approach to Pediatric Chronic Cough. Otolaryngol Clin North Am 2022; 55:1233-1242. [DOI: 10.1016/j.otc.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Shen HQ, Zhang YH, Zhang J, Sheng QM. Process of diagnosis and treatment of chronic cough in children at primary hospitals. Front Pediatr 2022; 10:1018924. [PMID: 36589155 PMCID: PMC9795405 DOI: 10.3389/fped.2022.1018924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE This study aimed to establish a process for the diagnosis and treatment of chronic cough in children suitable at primary hospitals and improve the treatment efficacy rate and improve health economic indicators. METHODS Children who visited the Department of Pediatrics, Affiliated Zhou Pu Hospital of the Shanghai Health Medical College from January to December 2021 were randomly assigned to the intervention group (n = 206), in which the diagnosis and treatment process proposed here was applied, and a control group (n = 211) that did not follow the intervention pathway and followed a pathway with the doctors usual practice based on his/her previous experience. Patients were followed up and data were collected at weeks 0 (time of enrollment), 2, 4, 8, and 12 to evaluate the efficacy rate and clinical value. RESULTS (1) No significant differences were detected between the two groups in baseline characteristics, including gender, age, duration of cough (weeks), history of allergy in children and parents, and smoking of family members living in the same household (p > 0.05); (2) During the follow-up, all cough symptom scores of the intervention group were lower than the control group. Additionally, at week 12, the treatment efficacy rate of the intervention group (91.70%) was significantly higher than the control group (69.20%) (p < 0.05); (3) The quality of life of children in both groups at week 12 was improved compared to the first visit. However, the total score of the intervention group was significantly higher than the control group (p < 0.05); (4) At week 12, the referral rate was significantly lower in the intervention group (11.17%) than in the control group (21.33%); (5) The intervention group was better than the control group for the mean monthly medication costs, number of days on errors in childhood, and number of days mistakenly worked by family members at week 12 (p < 0.05). CONCLUSION The current process of diagnosis and treatment of chronic cough in children at primary hospitals can improve the effective diagnosis and treatment rate, the quality of life, and other parameters, with good effectiveness and feasibility.
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Affiliation(s)
- Hua-Qin Shen
- Department of Pediatric Medicine, Affiliated Zhou Pu Hospital of the Shanghai Health Medical College, Shanghai, China
| | - Yan-Han Zhang
- Department of Pediatric Medicine, Affiliated Zhou Pu Hospital of the Shanghai Health Medical College, Shanghai, China
| | - Jing Zhang
- Department of Respiratory Medicine for Children, Shanghai Children's Medical Center Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qiu-Ming Sheng
- Department of Pediatric Medicine, Affiliated Zhou Pu Hospital of the Shanghai Health Medical College, Shanghai, China
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Porcaro F, Cutrera R. Editorial: Insights in pediatric pulmonology 2021. Front Pediatr 2022; 10:1093793. [PMID: 36507150 PMCID: PMC9727373 DOI: 10.3389/fped.2022.1093793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long Term Ventilation Unit, Academic Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long Term Ventilation Unit, Academic Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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10
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Jankauskaite L, Oostenbrink R. Childhood lower respiratory tract infections: more evidence to do less. Lancet 2021; 398:1383-1384. [PMID: 34562390 DOI: 10.1016/s0140-6736(21)01955-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/06/2021] [Indexed: 01/21/2023]
Affiliation(s)
- Lina Jankauskaite
- Department of Paediatrics, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia, Rotterdam 3015 GD, Netherlands.
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Little P, Francis NA, Stuart B, O'Reilly G, Thompson N, Becque T, Hay AD, Wang K, Sharland M, Harnden A, Yao G, Raftery J, Zhu S, Little J, Hookham C, Rowley K, Euden J, Harman K, Coenen S, Read RC, Woods C, Butler CC, Faust SN, Leydon G, Wan M, Hood K, Whitehurst J, Richards-Hall S, Smith P, Thomas M, Moore M, Verheij T. Antibiotics for lower respiratory tract infection in children presenting in primary care in England (ARTIC PC): a double-blind, randomised, placebo-controlled trial. Lancet 2021; 398:1417-1426. [PMID: 34562391 PMCID: PMC8542731 DOI: 10.1016/s0140-6736(21)01431-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/07/2021] [Accepted: 06/17/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Antibiotic resistance is a global public health threat. Antibiotics are very commonly prescribed for children presenting with uncomplicated lower respiratory tract infections (LRTIs), but there is little evidence from randomised controlled trials of the effectiveness of antibiotics, both overall or among key clinical subgroups. In ARTIC PC, we assessed whether amoxicillin reduces the duration of moderately bad symptoms in children presenting with uncomplicated (non-pneumonic) LRTI in primary care, overall and in key clinical subgroups. METHODS ARTIC PC was a double-blind, randomised, placebo-controlled trial done at 56 general practices in England. Eligible children were those aged 6 months to 12 years presenting in primary care with acute uncomplicated LRTI judged to be infective in origin, where pneumonia was not suspected clinically, with symptoms for less than 21 days. Patients were randomly assigned in a 1:1 ratio to receive amoxicillin 50 mg/kg per day or placebo oral suspension, in three divided doses orally for 7 days. Patients and investigators were masked to treatment assignment. The primary outcome was the duration of symptoms rated moderately bad or worse (measured using a validated diary) for up to 28 days or until symptoms resolved. The primary outcome and safety were assessed in the intention-to-treat population. The trial is registered with the ISRCTN Registry (ISRCTN79914298). FINDINGS Between Nov 9, 2016, and March 17, 2020, 432 children (not including six who withdrew permission for use of their data after randomisation) were randomly assigned to the antibiotics group (n=221) or the placebo group (n=211). Complete data for symptom duration were available for 317 (73%) patients; missing data were imputed for the primary analysis. Median durations of moderately bad or worse symptoms were similar between the groups (5 days [IQR 4-11] in the antibiotics group vs 6 days [4-15] in the placebo group; hazard ratio [HR] 1·13 [95% CI 0·90-1·42]). No differences were seen for the primary outcome between the treatment groups in the five prespecified clinical subgroups (patients with chest signs, fever, physician rating of unwell, sputum or chest rattle, and short of breath). Estimates from complete-case analysis and a per-protocol analysis were similar to the imputed data analysis. INTERPRETATION Amoxicillin for uncomplicated chest infections in children is unlikely to be clinically effective either overall or for key subgroups in whom antibiotics are commonly prescribed. Unless pneumonia is suspected, clinicians should provide safety-netting advice but not prescribe antibiotics for most children presenting with chest infections. FUNDING National Institute for Health Research.
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Affiliation(s)
- Paul Little
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK.
| | - Nick A Francis
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Beth Stuart
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Gilly O'Reilly
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Natalie Thompson
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Taeko Becque
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Kay Wang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Michael Sharland
- Institute of Infection and Immunity, St George's University London, London, UK
| | - Anthony Harnden
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Guiqing Yao
- Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - James Raftery
- Health Economics Analysis Team, University of Southampton, Southampton, UK
| | - Shihua Zhu
- Health Economics Analysis Team, University of Southampton, Southampton, UK
| | - Joseph Little
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Charlotte Hookham
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Kate Rowley
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Joanne Euden
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Kim Harman
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Samuel Coenen
- Department of Family Medicine and Population Health and Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Robert C Read
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK; National Institute of Health Research Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Catherine Woods
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Saul N Faust
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK; National Institute of Health Research Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Geraldine Leydon
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Mandy Wan
- Evelina Pharmacy, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Kerenza Hood
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | | | - Samantha Richards-Hall
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Peter Smith
- Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Michael Thomas
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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