Researchers: Preschoolers with pneumonia undergo needless tests, receive unnecessary antibiotics
Tuesday, July 09, 2019
Preschool kids with community-acquired pneumonia (CAP) are undergoing needless tests and receiving unnecessary antibiotics from emergency departments and outpatient clinics, according to the results of a new study.
Accounting for approximately 1.5 million healthcare visits each in the United States, community-acquired pneumonia is one of the most common infections among the pediatric population.
In 2011, the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America issued clinical guidelines for community-acquired pneumonia in children. In their guidelines, the groups recommend against routine chest radiographs, complete blood counts (CBCs) and blood cultures — and against the routine prescription of antibiotics — for preschool children treated in outpatient facilities.
Specifically, the guidelines say that outpatient and emergency department physicians should not routinely perform blood cultures in nontoxic, fully immunized pediatric patients with CAP, and should only obtain blood cultures in children who fail to demonstrate clinical improvement and in those with progressive symptoms and deteriorating condition after undergoing antibiotic therapy. CBCs are only necessary in pediatric patients with severe pneumonia.
Routine chest radiography is not necessary for the confirmation in children with CAP. Posteroanterior and lateral X-rays should be obtained only in pediatric outpatients with significant respiratory distress, with suspected or documented hypoxemia and in those with failed antibiotic therapy.
The guidelines also say that antibacterial therapy is not necessary for pediatric CAP patients with a positive test for influenza virus in the absence of clinical, laboratory, or radiographic findings suggestive of a bacterial infection.
Todd Florin, MD, MSCE, from Ann & Robert H. Lurie Children’s Hospital of Chicago, and colleagues wanted to evaluate the effect of the guidelines. To do this, they took a national sample of more than 6 million pediatric patients, ages 1 to 6 years, with community-acquired pneumonia between 2008 and 2015. The research team found that the high use of nonrecommended antibiotics and diagnostics tests persisted throughout the entire study period.
They also determined that the 2011 guidelines had no effect on actual practice in outpatient settings.
Too Many Tests, Too Many Antibiotics
Viruses cause most cases of community acquired pneumonia in young children and antibiotics provide no benefits in viral infections, of course, yet the study found that clinicians prescribed antibiotics in nearly 74% of the outpatient visits reviewed in this study.
"It is concerning that so many young children with community-acquired pneumonia are receiving antibiotics that are not needed," says Dr. Florin in a press release. Florin heads the Grainger Initiative in Pediatric Emergency Medicine Research at Lurie Children's and is Associate Professor of Pediatrics at Northwestern University Feinberg School of Medicine. "In addition to going against evidence and clinical guidelines, overuse of antibiotics contributes to antibiotic resistance, which threatens future availability of effective treatments for bacterial infections, while also leading to antibiotic-associated side effects that can range from mild to life-threatening."
Physicians obtained chest X-rays in 43% of these visits, even though guidelines discourage the routine use of chest radiographs in these young pneumonia patients in an outpatient setting. The researchers also found that doctors obtained CBCs for 8.6% of the pediatric patients and radiography for 43 percent, and prescribed antibiotics 73.9% of the time. There were no changes in antibiotic use or testing over time.
"Focused quality-improvement efforts are needed to increase guideline adherence to ensure that these children are receiving appropriate, evidence-based care," says Dr. Florin. “We especially need to focus on reducing antibiotic overuse, which is critically important.”
The researchers published the results of the study in the Journal of the Pediatric Infectious Diseases Society.
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