Antibiotic misuse in respiratory tract infections in children and adults—a prospective, multicentre study (TAILORED Treatment)

Abstract

Respiratory tract infections (RTI) are more commonly caused by viral pathogens in children than in adults. Surprisingly, little is known about antibiotic use in children as compared to adults with RTI. This prospective study aimed to determine antibiotic misuse in children and adults with RTI, using an expert panel reference standard, in order to prioritise the target age population for antibiotic stewardship interventions. We recruited children and adults who presented at the emergency department or were hospitalised with clinical presentation of RTI in The Netherlands and Israel. A panel of three experienced physicians adjudicated a reference standard diagnosis (i.e. bacterial or viral infection) for all the patients using all available clinical and laboratory information, including a 28-day follow-up assessment. The cohort included 284 children and 232 adults with RTI (median age, 1.3 years and 64.5 years, respectively). The proportion of viral infections was larger in children than in adults (209(74%) versus 89(38%), p < 0.001). In case of viral RTI, antibiotics were prescribed (i.e. overuse) less frequently in children than in adults (77/209 (37%) versus 74/89 (83%), p < 0.001). One (1%) child and three (2%) adults with bacterial infection were not treated with antibiotics (i.e. underuse); all were mild cases. This international, prospective study confirms major antibiotic overuse in patients with RTI. Viral infection is more common in children, but antibiotic overuse is more frequent in adults with viral RTI. Together, these findings support the need for effective interventions to decrease antibiotic overuse in RTI patients of all ages. Electronic supplementary material The online version of this article (10.1007/s10096-018-03454-2) contains supplementary material, which is available to authorized users.

Evaluation of a clinical decision rule to guide antibiotic prescription in children with suspected lower respiratory tract infection in The Netherlands: A stepped-wedge cluster randomised trial

“…Future research should focus on the safety of higher decision thresholds and on the impact in settings with higher antibiotic prescription rates at baseline, or with a larger proportion of low-risk children. Our observed 30% antibiotic prescription rate at baseline for suspected lower RTIs is lower than what has been described in other European EDs, where antibiotic prescription rates range from 52% to 78% [5,6,13,32]. Even though the populations in many studies cannot be directly compared, a recent paper showed that after adjustment for differences in population, large variability in antibiotic prescription remains [1].…”

“…Next, not all eligible children could be included in the trial. Doctors in the ED often are under time pressure, leaving insufficient time or attention to recruit patients for a trial, as has been acknowledged by other paediatric ED trials [5,23]. Comparison of the included and non-included children showed that severely ill children were included more frequently.…”

“…Although mortality caused by lower RTIs has decreased significantly over the past decades (currently 1.7 per 100,000 people in Western Europe) [3], antimicrobial resistance due to unnecessary antibiotic prescription is increasing [4]. High variability in antibiotic prescription in children with RTIs in primary as well as hospital care throughout Europe highlights the need for better targeting of antibiotic prescriptions in this patient group [1,5,6]. One of the main challenges when attempting to safely reduce antibiotic prescriptions for lower RTIs in children is the absence of a gold standard for the diagnosis of bacterial pneumonia.…”

Viral etiologies of acute respiratory tract infections among hospitalized children – A comparison between single and multiple viral infections

“…Therefore, accurate and timely identification of the responsible viral pathogen could reduce unnecessary use of antibiotics and length of hospital stay. 4 Multiple viral infections are more commonly seen in pediatric patients than in adults. 5 Multiple viral infections were reported to be associated with increased hospital admissions, intensive care unit admissions, lengthened duration of hospitalization, and prolonged mechanical ventilation use.…”

Analysis of antibiotic treatment of children in a Shanghai tertiary hospital based on point prevalence surveys

“…If the patient’s inflammation is caused by viral infection, anti-inflammatory effects are often not achieved with antibiotics, and even more serious consequences can result. Van Houten et al found that children admitted to the PICU were more often to receive antibiotics for viral respiratory tract infections [ 10 ]. A recent study indicate a significant association between irrational use of antibiotics and death in children [ 11 ].…”