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

Abstract

Background Optimising the use of antibiotics is a key component of antibiotic stewardship. Respiratory tract infections (RTIs) are the most common reason for antibiotic prescription in children, even though most of these infections in children under 5 years are viral. This study aims to safely reduce antibiotic prescriptions in children under 5 years with suspected lower RTI at the emergency department (ED), by implementing a clinical decision rule. Methods and findings In a stepped-wedge cluster randomised trial, we included children aged 1-60 months presenting with fever and cough or dyspnoea to 8 EDs in The Netherlands. The EDs were of varying sizes, from diverse geographic and demographic regions, and of different hospital types (tertiary versus general). In the pre-intervention phase, children received usual care, according to the Dutch and NICE guidelines for febrile children. During the intervention phase, a validated clinical prediction model (Feverkidstool) including clinical characteristics and C-reactive protein (CRP) was implemented as a decision rule guiding antibiotic prescription. The intervention was that antibiotics were withheld in children with a low or intermediate predicted risk of bacterial pneumonia (�10%, based on Feverkidstool). Co-primary outcomes were antibiotic prescription rate and strategy failure. Strategy failure was defined

Development and validation of a prediction model for invasive bacterial infections in febrile children at European Emergency Departments: MOFICHE, a prospective observational study

“…9 11 Unlike our study, these models were not based on an European-wide ED population. We recommend to use the Feverkidstool to guide antibiotic prescription in suspected lower respiratory tract infections 18 and to use our model in febrile children to predict IBI. These two models, the original Feverkidstool and our model will be integrated in one electronic decision tool.…”

“…Several models yet exist for prediction of bacterial pneumonia and the impact of the original Feverkidstool on antibiotic use in respiratory tract infections is proven. 18 Therefore, another model for bacterial pneumonia is not required. Furthermore, prediction of urinary tract infections may be less relevant as sensitive laboratory tests (urinalysis) are readily available for accurate diagnosis at ED visit.…”

Effect of unifaceted and multifaceted interventions on antibiotic prescription control for respiratory diseases: a systematic review of randomized controlled trials

“…As shown in Table 1, of the 69 studies included, 29 were cluster randomized controlled trials (cRCT), 21 were randomized controlled trials (RCT), 10 [79][80][81][82][83][84][85][86][87][88] were factorial design RCT/cRCT/nRCT, and 9 [89][90][91][92][93][94][95][96][97] were non-randomised controlled trials (nRCT). Fifty-three [29, 30, 35-43, 45, 48-64, 68, 69, 71-75, 77-82, 85-88, 90-93, 95-97] studies were conducted in primary care settings (including general practice clinics, family practices and township hospitals) and there were 7 [31,32,34,44,66,67,70] hospital-based studies. Nine [33,46,47,65,76,83,84,89,94] studies were conducted in other settings including a health care center, nursing home and pharmacy.…”

“…(3) Health providers (HPs, n=5) [47,50,57,93,94] ; (4) Practice providers (PPs, n=1) [89] , which were faculties at a clinical practices center; (5) Nurses or nurse practitioners (n=2) [42,88] ; (6) All kinds of patients, caregivers and inhabitants (n=16) [29,31,40,42,45,46,52,54,67,71,73,85,86,88,94,97]. Fifty [30-36, 38, 41, 44, 45, 47-50, 53-64, 66, 68, 70-72, 74, 77, 79-86, 89-96] studies were for respiratory diseases in all patients, and the remaining 19 studies were of children (n=14) [29,39,40,42,43,46,51,52,65,67,69,73,76,87] and adults (n=5) [37,75,78,88,97] .…”

“…Sixty studies had positive results (+, The primary results in the intervention groups were superior to those in the control groups). Nine [31,35,65,72,73,78,87,89,92] studies had negative (-) or partially negative (±) results. The outcome variable for 37 [29-38, 40-42, 45, 47-51, 55-59, 61, 63, 66, 70, 74, 77-79, 84, 88, 92, 94, 96] studies was APR but details were available for the intervention groups and control groups in only 22 studies ( Table 2).…”