Guideline Adoption for Community-Acquired Pneumonia in the Outpatient Setting

Ambroggio, Lilliam; Mangeot, Colleen; Kurowski, Eileen Murtagh; Graham, Camille; Korn, Paul; Strasser, Marcie; Cavallo, Charles; Brady, Katherine; Campanella, Suzanne; Clohessy, Caitlin; Brinkman, William B.; Shah, Samir S.

doi:10.1542/peds.2018-0331

Cited by 18 publications

(12 citation statements)

References 25 publications

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“…In general, adherence to the medical guidelines has varied substantially and the best way to implement scientific evidence in clinical practice is still unclear. Local education programmes often increase adherence to guidelines, 8 but previous studies have reported controversial results on the impact of pneumonia guidelines 18‐20,22 . Many factors, in addition to clinical signs and symptoms, can lead to chest imaging.…”

Section: Discussionmentioning

confidence: 99%

“…One study showed an association between taking more images and prescribing more antibiotics, 5 while another found that more images resulted in fewer antibiotics 17 . Only a few studies have specifically evaluated whether clinicians followed recommendations not to take chest radiographs if they suspected the child had pneumonia 18‐20 . It has already been demonstrated that the Finnish 2014 guidelines for LRTIs in children decreased the use of racemic adrenaline in bronchiolitis 21 …”

Section: Introductionmentioning

confidence: 99%

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National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed

et al. 2020

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Aim Our aim was to evaluate the impact of the 2014 Finnish Current Care Guidelines for paediatric lower respiratory tract infections (LRTIs), particularly on taking of chest radiographs. Methods This study used official national data and regional (Pirkanmaa) data on children aged 0‐16 years who underwent chest radiographs in 2011 and 2015. We also collected data for LRTI diagnoses from local registers, including prescribed antibiotics and taking of chest radiographs. The local cohort comprised children aged 0‐15 who presented to the primary care emergency room or to the hospital emergency department (Tampere university hospital) in November‐December 2012‐2015. Results Chest radiographs for Finnish children aged 0‐16 fell from 2011 to 2015: by 15.9% nationally and by 16.9% in Pirkanmaa. When asylum seekers with chest radiographs for tuberculosis screening were excluded, the estimated national reduction was 29.9%. In the local cohort, chest radiographs increased from 82 to 139 (69.5%) between 2012/2013 and 2014/2015 as the occurrence of community‐acquired pneumonia (CAP) increased. However, the proportion of patients with CAP who had chest radiograph taken tended to decrease from 84.6% to 71.3% (p = 0.078). Conclusion Decreases in national and regional chest imaging trends were observed after the 2014 guidance for children`s LRTI was introduced.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed

et al. 2020

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“…23-25 Determining appropriate antibiotic use for outpatient PNA remains challenging for several reasons, including difficulties distinguishing viral from bacterial etiologies, and that recent data suggests Mycoplasma may underlie more cases than Streptococcus pneumoniae across pediatric age groups. 12,26-28…”

Section: Discussionmentioning

confidence: 99%

“…[23][24][25] Determining appropriate antibiotic use for outpatient PNA remains challenging for several reasons, including difficulties distinguishing viral from bacterial etiologies, and that recent data suggests Mycoplasma may underlie more cases than Streptococcus pneumoniae across pediatric age groups. 12,[26][27][28] This study is among the first to report pediatric management practices specifically from private UCCs. 29 Outpatient health care outside of the traditional settings of medical offices and EDs-specifically in retails clinics and UCC in what is often called convenience care-is a rapidly expanding market, that had a 1725% increase in claims lines between 2007 and 2016.…”

Section: Discussionmentioning

confidence: 99%

Guideline Adherence and Antibiotic Utilization by Community Pediatricians, Private Urgent Care Centers, and a Pediatric Emergency Department

Islam

Mannix

Breuer

et al. 2019

Clin Pediatr (Phila)

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Pediatric antibiotic prescriptions originate from an increasingly broad range of ambulatory settings. In this retrospective study, pharyngitis, otitis media, sinusitis, pneumonia, and upper respiratory infection cases, at 11 primary care offices, 2 independent urgent care centers (UCCs), and a pediatric emergency department in Western New York, were analyzed relative to medical society practice guidelines and antibiotic utilization. Of 2358 eligible visits across all sites, 25% were for study diagnoses, with 38% at UCC ( P < .01). Across all sites, 26% of pharyngitis cases given antibiotics did not have diagnostic evidence of bacterial infection. At primary care offices and UCCs, guideline recommended first-line agents for pharyngitis and otitis media were used in only 58% and 63% of treated cases, respectively. Overall, an estimated 9855 to 12 045 avoidable antibiotic and 8030 non-guideline antibiotic courses annually are represented by the 14 sites studied. These and other study findings highlight numerous opportunities for outpatient pediatric antibiotic stewardship.

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“…In 2011, guidelines for the management of childhood CAP were published in Europe and the USA [5,6], recommending against routine use of CXR in most children in the outpatient setting, and restricting the use of CXR to children with moderate to severe signs and symptoms of CAP at risk of developing complications. Some studies have evaluated the impact of the CAP guidelines on diagnosis and treatment of childhood CAP, and did not find significant changes in CXR performance rates [11][12][13][14]. However, their study populations were limited to children with a confirmed diagnosis of CAP rather than those with signs and symptoms of a lower RTI, and they did not evaluate the impact of CXR results on antibiotic treatment.…”

Section: Introductionmentioning

confidence: 99%

The influence of chest X-ray results on antibiotic prescription for childhood pneumonia in the emergency department

et al. 2021

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The aim of this study is to evaluate the influence of chest X-ray (CXR) results on antibiotic prescription in children suspected of lower respiratory tract infections (RTI) in the emergency department (ED). We performed a secondary analysis of a stepped-wedge, cluster randomized trial of children aged 1 month to 5 years with fever and cough/dyspnoea in 8 EDs in the Netherlands (2016–2018), including a 1-week follow-up. We analysed the observational data of the pre-intervention period, using multivariable logistic regression to evaluate the influence of CXR result on antibiotic prescription. We included 597 children (median age 17 months [IQR 9–30, 61% male). CXR was performed in 109/597 (18%) of children (range across hospitals 9 to 50%); 52/109 (48%) showed focal infiltrates. Children who underwent CXR were more likely to receive antibiotics, also when adjusted for clinical signs and symptoms, hospital and CXR result (OR 7.25 [95% CI 2.48–21.2]). Abnormalities on CXR were not significantly associated with antibiotic prescription.Conclusion: Performance of CXR was independently associated with more antibiotic prescription, regardless of its results. The limited influence of CXR results on antibiotic prescription highlights the inferior role of CXR on treatment decisions for suspected lower RTI in the ED. What is Known:• Chest X-ray (CXR) has a high inter-observer variability and cannot distinguish between bacterial or viral pneumonia.• Current guidelines recommend against routine use of CXR in children with uncomplicated respiratory tract infections (RTIs) in the outpatient setting. What is New:• CXR is still frequently performed in non-complex children suspected of lower RTIs in the emergency department• CXR performance was independently associated with more antibiotic prescriptions, regardless of its results, highlighting the inferior role of chest X-rays in treatment decisions.

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Guideline Adoption for Community-Acquired Pneumonia in the Outpatient Setting

Cited by 18 publications

References 25 publications

National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed

National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed

Guideline Adherence and Antibiotic Utilization by Community Pediatricians, Private Urgent Care Centers, and a Pediatric Emergency Department

The influence of chest X-ray results on antibiotic prescription for childhood pneumonia in the emergency department

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