International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

Abstract

BACKGROUND AND OBJECTIVES: International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics. METHODS:We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR).RESULTS: In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had $1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P , .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently.

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

“… 28–30 Our results showed a very low use of antibiotics, consistently below 5%, compared with other countries, where rates in the range of 3.5%–11.1% are reported. 28 …”

“…24 25 Antibiotic treatment is not recommended for acute bronchiolitis, 9 26 27 and overuse is a known problem. [28][29][30] Our results showed a very low use of antibiotics, consistently below 5%, compared with other countries, where rates in the range of 3.5%-11.1% are reported. 28 We found a steady rise in the use of highflow oxygen in the hospital setting.…”

Global Collaborative Research Informs Wise Use of Tests and Antibiotics for Bronchiolitis

“…Schuh et al 6 demonstrated in a prospective cohort that routinely obtaining a radiograph led clinicians to make pneumonia diagnoses that radiology review did not support and to prescribe antibiotics that did not appear to benefit patients. Zipursky et al, 3 in their multicenter study, similarly find that radiograph use was associated with antibiotic prescription, and the network in the United Kingdom and Ireland had the lowest rates for both laboratory testing and antibiotic use. Assignment of diagnosis codes may also vary because of different definitions of the condition.…”

“…2 Specific recommendations vary, but research consistently shows that many of these interventions are unnecessary and may cause unwarranted cost and the potential for harm because of associated radiation, antibiotic exposure, and other effects. In this issue of Pediatrics, Zipursky et al 3 analyze testing protocols at a higher level by comparing trends across countries using a retrospective data set from the Pediatric Emergency Research Network (PERN), which combines 6 multicenter networks including 38 emergency departments from 8 countries in North America, Europe, the United Kingdom, Australia, and New Zealand. Authors of previous analyses addressed respiratory treatments 4 and prediction of severe disease, 5 but in this study, the investigators focus on antibiotics and laboratory testing.…”

“…Coronaviruses have always been a cause of bronchiolitis hospitalizations, and the PERN network is currently conducting an international prospective study that will help assess pediatric disease related to the new viral strain. 11 Among other tests, Zipursky et al 3 also found that urinalysis and urine cultures were obtained at a measurable rate, even in afebrile infants, although recent reviews suggest that urinary tract infection is uncommon in bronchiolitis using updated guidelines for screening. 12 The PERN collaboration of international networks of pediatric emergency providers is an encouraging sign of potential opportunities to come, for bronchiolitis and other conditions.…”