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

Prospective observational study of the challenges in diagnosing common neonatal conditions in Nigeria and Kenya

OBJECTIVES

Accurate and timely diagnosis of common neonatal conditions is crucial for reducing neonatal deaths. In low/middle-income countries with limited resources, there is sparse information on how neonatal diagnoses are made. The aim of this study was to describe the diagnostic criteria used for common conditions in neonatal units (NNUs) in Nigeria and Kenya.

DESIGN

Prospective observational study. Standard case report forms for suspected sepsis, respiratory disorders, birth asphyxia and abdominal conditions were co-developed by the Neonatal Nutrition Network (https://www.lstmed.ac.uk/nnu) collaborators. Clinicians completed forms for all admissions to their NNUs. Key data were displayed using heatmaps.

SETTING

Five NNUs in Nigeria and two in Kenya comprising the Neonatal Nutrition Network.

PARTICIPANTS

2851 neonates, which included all neonates admitted to the seven NNUs over a 6-month period.

RESULTS

1230 (43.1%) neonates had suspected sepsis, 874 (30.6%) respiratory conditions, 587 (20.6%) birth asphyxia and 71 (2.5%) abdominal conditions. For all conditions and across all NNUs, clinical criteria were used consistently with sparse use of laboratory and radiological criteria.

CONCLUSION

Our findings highlight the reliance on clinical criteria and extremely limited use of diagnostic technologies for common conditions in NNUs in sub-Saharan Africa. This has implications for the management of neonatal conditions which often have overlapping clinical features. Strategies for implementation of diagnostic pathways and investment in affordable and sustainable diagnostics are needed to improve care for these vulnerable infants.

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.

Impact of Guidelines Publication on Acute Bronchiolitis Management: 10-Year Experience from a Tertiary Care Center in Italy

Bronchiolitis is the most common lower respiratory tract infection in infants. According to evidence-based guidelines, diagnosis is clinical, there is no need for routine use of laboratory or instrumental tests and therapy is primarily supportive, based on oxygen and adequate fluid supplementation. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. The aim of this retrospective cohort study was to evaluate how the management of bronchiolitis has changed in the last ten years in a Tertiary Care Center in Italy, assessing adherence to national guidelines. Considering the publication of the Italian inter-society consensus document in 2014, we compared patients admitted in the prior four epidemic seasons with patients admitted in the latter six epidemic seasons. The comparison between the two groups showed a significant reduction in the prescription of systemic corticosteroids (58.9% vs. 41.8%, p < 0.001), nebulized epinephrine (73.8% vs. 38.3%, p < 0.001) and antibiotics (59.5% vs. 42.3%, p < 0.001), together with a drastic decrease in the use of chest X-ray (92.2% vs. 54.4%, p < 0.001). On the contrary, the use of inhaled salbutamol remained substantially stable over time (39.4% vs. 37.6%, p = 0.505). Despite the encouraging results, further efforts are needed to limit the prescription of ineffective therapies like antibiotics and inhaled salbutamol.

Impact of bronchiolitis guidelines publication on primary care prescriptions in the Italian pediatric population

In Italy, two clinical practice guidelines for the diagnosis and treatment of bronchiolitis were published in October 2014 and December 2015. We evaluated prescriptions for bronchiolitis in children aged 0-24 months before (December 2012-December 2014), in between (December 2014-December 2015) and after (December 2015-December 2018) the guidelines publications. Data were retrieved from the Pedianet database; the measured outcomes were prescriptions rates of antibiotics, corticosteroids, β2-agonists, and other respiratory drugs. In 1011 out of 1581 episodes, patients received at least one treatment, with a total of 2003 prescriptions. The rate of treated bronchiolitis decreased from 66% to 57% (p < 0.001) after the publication of the second guideline; the highest reduction was in younger patients (from 57% to 44%, p = 0.013). Overall antibiotic prescriptions rate did not change, with 31.6% of the patients still receiving them. Our results confirm unnecessary non-evidence-based treatments in the primary care setting, with few changes after the guidelines publications.

Treatment for acute bronchiolitis before and after implementation of new national guidelines: a retrospective observational study from primary and secondary care in Oslo, Norway

BACKGROUND

Acute bronchiolitis treatment guidelines changed in Norway in 2013, no longer recommending the use of nebulised epinephrine. We aimed to assess whether these changes were successfully implemented in both primary and secondary care. Secondary aims were to compare the difference in management of acute bronchiolitis patients in primary and secondary care between 2009 and 2017.

METHODS

We retrospectively registered data on demographics, clinical features and management from electronic medical records of all infants (<12 months of age) diagnosed with acute bronchiolitis at a primary care centre (Oslo Accident and Emergency Outpatient Clinic) and a secondary care centre (Oslo University Hospital) in Norway in 2009, 2014 and 2017. All patient records were individually reviewed to ensure data accuracy.

RESULTS

We included 680 (36.3%) patients from primary care and 1195 (63.7%) from secondary care. There was a reduction in the use of nebulised epinephrine from 2009 to 2017 from 66.9% to 16.1% of cases (p<0.001) in primary care and from 59.1% to 4.9% (p<0.001) in secondary care. In parallel, there was an increase in the use of nebulised saline treatment, from 0.8% to 53.8% (p<0.001) in primary care and from 39.3% to 65.3% (p<0.001) in secondary care. The decrease in the use of nebulised racemic epinephrine occurred earlier in secondary care than in primary care; 13.4% vs 56.1%, respectively, in 2014.

CONCLUSIONS

Implementation of the new guidelines on the treatment of acute bronchiolitis was successfully implemented in both primary and secondary care.

High prescribing rates of third-generation cephalosporins in children hospitalized with acute lower respiratory infections at a university hospital

OBJECTIVE

Antibiotics are frequently prescribed for the treatment of acute lower respiratory infections (ALRI) in children ≤5 years of age, even though viral aetiologies are the most common. The aim of this study was to describe antibiotic prescribing rates and patterns in children ≤5 years of age hospitalized with ALRI.

METHODS

A retrospective study was conducted involving patients aged 1 month to 5 years hospitalized with ALRI at a university hospital. Patient demographics, ALRI diagnosis, microbiological data, antibiotics prescribed, and treatment outcomes were recorded and analysed.

RESULTS

A total of 1283 patients were enrolled. Their median age was 1.6 years (interquartile range 0.8-2.8 years). Thirty-six percent had a co-morbidity. The diagnosis at discharge was viral ALRI in 81% and bacterial pneumonia in 19%. The mortality rate was 0.4%. The overall antibiotic prescribing rate was 46% (95% confidence interval 43-49%). Antibiotic prescribing rates were higher among children with co-morbidities (65% vs 35%, p < 0.001) and older children (57% for >2-5 years vs 39% for ≤2 years, p < 0.001). Parenteral third-generation cephalosporins were prescribed in up to 68% of all prescriptions.

CONCLUSIONS

Nearly-half of hospitalized children with ALRI were prescribed antibiotics. The majority of prescribed antibiotics were third-generation cephalosporins. An antimicrobial stewardship programme and antibiotic guidelines should be implemented to promote the judicious use of antibiotics.