Self-reported pediatricians' management of the well-appearing young child with fever without a source: first survey in an European country in the anti-pneumococcal vaccine era

Chiappini, Elena; Galli, Luisa; Bonsignori, Francesca; Venturini, Elisabetta; Principi, Nicola; Martino, Maurizio de

doi:10.1186/1471-2458-9-300

Cited by 7 publications

(5 citation statements)

References 21 publications

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“…Not only Lab-score recommendations, but also classical guidelines concerning FWS management are poorly observed. Indeed, now that the incidence of SBI has dropped following widespread pneumococcal vaccination [28] , [29] , a more conservative approach of well appearing infants or young children with FWS is frequently adopted [2] , [30] – [32] . A recent study observed a decrease in ordering a complete blood count between 2004 and 2009 [2] .…”

Section: Discussionmentioning

confidence: 99%

Impact of the Lab-Score on Antibiotic Prescription Rate in Children with Fever without Source: A Randomized Controlled Trial

et al. 2014

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BackgroundThe Lab-score, based on the combined determination of procalcitonin, C-reactive protein and urinary dipstick results, has been shown accurate in detecting serious bacterial infections (SBI) in children with fever without source (FWS) on retrospective cohorts. We aimed to prospectively assess the utility of the Lab-score in safely decreasing antibiotic prescriptions in children with FWS and to determine its diagnostic characteristics compared to common SBI biomarkers.MethodsRandomized controlled trial in children 7 days to 36 months old with FWS, allocated either to the Lab-score group (Lab-score reported, blinded WBC count) or to the control group (WBC, bands and C-reactive protein determined, blinded procalcitonin and Lab-score), followed up until recovery. Demographic data, antibiotic prescription rate, admission rate and diagnostic properties of the Lab-score were analyzed.Results271 children were analyzed. No statistically significant difference concerning antibiotic prescription rate was observed: 41.2% (54 of 131) in the Lab-score group and 42.1% (59 of 140) in the control group (p = 1.000). If recommendations based on the Lab-score had been strictly applied, a hypothetical 30.6% treatment rate would have been encountered, compared to the overall 41.7% observed rate (p = 0.0095). A Lab-score ≥3 showed the following characteristics: sensitivity 85.1% (95% CI: 76.5–93.6%), specificity 87.3% (95% CI: 82.7–91.8%), positive predictive value 68.7% (95% CI: 58.7–78.7%), negative predictive value 94.1% (95% CI: 91.5–97.9%), positive and negative likelihood ratios: 6.68 and 0.17 respectively. Area under the receiver operating characteristic curve was best for the Lab-score (0.911, 95% CI: 0.871–0.950).DiscussionNo difference regarding antibiotic treatment rate was observed when using the Lab-score, due to lack of adherence to the related recommendations. However, if strictly followed, a significant 26.5% reduction of antibiotic prescriptions would have been encountered. Medical education needs to be reinforced in order to observe rather than treat low-risk well-appearing children with FWS.Trial RegistrationClinicalTrials.gov NCT02179398

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Section: Discussionmentioning

confidence: 99%

Impact of the Lab-Score on Antibiotic Prescription Rate in Children with Fever without Source: A Randomized Controlled Trial

et al. 2014

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“…Gabriel et al found that pediatricians and emergency department physicians would order fewer tests and would prescribe less antibiotics to febrile children who have been vaccinated previously with pneumoccoal conjugate vaccine [ 18 ]. Chiappini et al found that the management of well-appearing febrile infants varies across pediatricians in Italy after the introduction of the pneumococcal conjugate vaccine [ 13 ]. Although most pediatricians in our study reported some reliance on the fever management guidelines set forth by the American Academy of Pediatrics (AAP), it is apparent that the general attitude of pediatricians towards fever management has been changing since the introduction of the pneumococcal conjugate vaccine.…”

Section: Discussionmentioning

confidence: 99%

“…Such work evaluating physicians' perception and approach to the management of fever in infants is now quite dated, however [ 10 - 12 ]. Beliefs among some pediatricians have changed after the introduction of pneumococcal conjugate vaccines [ 13 ]. Because of the high efficacy of the pneumococcal vaccine against invasive infections of Streptococcus pneumoniae , some pediatricians have practiced less intensive diagnostic procedures for the standard work-up of fever [ 13 ].…”

Section: Introductionmentioning

confidence: 99%

Perception and management of fever in infants up to six months of age: A survey of US pediatricians

Khoury

Durden

et al. 2010

BMC Pediatr

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BackgroundA fever is an increase in the body's temperature above normal. This study examined how US pediatricians perceive and manage fever generally versus fever occurring after vaccination in infants up to six months of age.MethodsA web-based survey of 400 US pediatricians subscribing to the Physician Desk Reference was conducted in December 2008. Data were collected on the respondents' socio-demographics, number of years in practice, type of practice, their definition of fever severity in infants, and their recommendations for managing fever. Generalized Estimating Equations were used to estimate the odds of a pediatrician recommending an emergency room visit (ER) or a hospital admission, office visits, or other treatment option, as a function of infant's age, temperature, whether the infant has recently received a vaccine, and whether the fever was reported during or after office hours, adjusting for practice type and socio-demographic variables.ResultsOn average, the 400 responding pediatricians' (64% were female, average age of 49 years, years in practice = 20 years) threshold for extremely serious fever was ≥39.5°C and ≥ 40.0°C for infants 0-2 month and >2-6 month of age respectively. Infants were more likely to be referred to an ER or hospital admission if they were ≤ 2 months of age (Odds Ratio [OR], 29.13; 95% Confidence interval [95% CI], 23.69-35.82) or >2-4 months old (OR 3.37; 95% CI 2.99-3.81) versus > 4 to 6 months old or if they had a temperature ≥ 40.0°C (OR 21.06; 95% CI 17.20-25.79) versus a temperature of 38.0-38.5°C. Fever after vaccination (OR 0.29; 95% CI 0.25-0.33) or reported during office hours (OR 0.17; 95% CI 0.15-0.20) were less likely to result in referral to ER or hospital admission.ConclusionWithin this sample of US pediatricians, perception of the severity of fever in infants, as well as the response to infant fever are likely to depend on the infant's age. Recommendations for the management of fever in infants are likely to depend on fever severity level, the infant age, timing in relation to recent vaccination, and the time of day fever is reported. Our results indicate that US pediatricians are more concerned about general fever than fever following vaccination.

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“…The arrival of Hib and pneumococcal conjugate vaccines in Japan will influence the methods used for ruling out the indication for antibiotics. A previous study showed that physicians prescribe antibiotics less frequently in vaccinated patients than in patients who have not been vaccinated 89) . The vaccines may contribute not only to decrease the incidence of invasive diseases caused by S. pneumoniae and H. influenzae but also to decrease antibiotic prescription for pediatric patients.…”

Section: The Introduction Of Vaccines Against S Pneumoniae and H Inmentioning

confidence: 98%

A Challenge to Appropriate Antibiotic Use in Children With Respiratory Infections: A 5-Year Single-Institution Experience

Matsumoto

Hashimoto

Kawasaki

2011

FJMS

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: BackgroundWe have studied the rate of emergence of anitibiotic -resistant Streptococcus pneumoniae (S. pneumoniae) and Haemophilus influenzae (H. influenzae) and the subsequent antibiotic use in host patients of those isolates at the Department of Pediatrics, Soma General Hospital, Fukushima. Moreover, we carried out several studies investigating the risks and benefits of antibioticfree treatment for children with respiratory infections. In this report, we summarize our research and suggest better treatment options for pediatric patients with respiratory infections. MethodsWe investigated the necessity of antibiotic use in the treatment of pediatric inpatients with respiratory syncytial virus (RSV) infection, and tested our hypothesis that antibiotic -free treatment for common cold will reduce the number of resistant S. pneumoniae strains in the pediatric nasopharynx. Therefore, we restricted prescribing antibiotics for pediatric patients with respiratory infections. The rates of resistant S. pneumoniae and H. influenzae and the medication history of the host patients before and after the intervention were compared. ResultsWe found that most of the RSV -infected patients recovered without antibiotic treatment, and that the antibiotic -free treatment inhibited the emergence of antibiotic -resistant strains. The rate of penicillin -resistant S. pneumoniae decreased but the rate of ampicillin -resistant H. influenzae did not change significantly during the study. ConclusionWe concluded that patients with respiratory infections can be treated without antibiotics, under careful examination and observation. Continued monitoring of such new interventions as well as recommending their use to other caregivers and physicians will help inhibit the spread of resistant strains.

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Self-reported pediatricians' management of the well-appearing young child with fever without a source: first survey in an European country in the anti-pneumococcal vaccine era

Cited by 7 publications

References 21 publications

Impact of the Lab-Score on Antibiotic Prescription Rate in Children with Fever without Source: A Randomized Controlled Trial

Impact of the Lab-Score on Antibiotic Prescription Rate in Children with Fever without Source: A Randomized Controlled Trial

Perception and management of fever in infants up to six months of age: A survey of US pediatricians

A Challenge to Appropriate Antibiotic Use in Children With Respiratory Infections: A 5-Year Single-Institution Experience

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