John Murphy, MDLinx, 09/01/2016
Researchers in England have developed a simple 7-item checklist to help primary care practitioners decide whether a child with cough and a respiratory tract infection (RTI) is at risk for hospitalization. Identifying children at low risk would reduce the overprescribing of antibiotics in these young patients, the researchers predicted in their study in The Lancet Respiratory Medicine, published September 1, 2016.
RTIs account for about 75% of all antibiotics prescribed for children under age 12, yet one-third or more of those prescriptions are unnecessary, studies have found. Efforts to reduce unnecessary prescribing in the United States have shown success, but overprescribing of antibiotics is still a major problem.
“Excessive antibiotic use has contributed to the development of resistance to these drugs,” said lead author Alastair Hay, MBChB, MD, Professor of Primary Care at the University of Bristol, Bristol, UK.
“The aim of our study was to develop a simple, usable prediction tool based on symptoms and signs to help GPs and nurses identify children presenting in primary care at the lowest and highest risk of future complications and hospitalization, so that antibiotics can be targeted accordingly,” Dr. Hay explained.
The tool that the researchers developed can accurately distinguish a good prognosis from a poor one in a child with acute RTI and cough. It goes by the mnemonic STARWAVe and includes 7 identifying characteristics:
Short illness (less than 3 days)
Temperature (≥37.8°C/100.4°F on examination, or parent report of severe fever in the previous 24 hours)
Age (under 2)
Recession (intercostal or subcostal)
Wheeze
Asthma
Vomiting (in the previous 24 hours)
Each item on the checklist equals one point for the child’s risk for hospitalization. A total of 0 or 1 point equals low risk, 2 or 3 points is normal risk, and 4 or more points is high risk.
A “no antibiotic” prescribing strategy is safe for children at low risk of hospitalization, according to the researchers. A “no antibiotic or delayed antibiotic” treatment strategy is appropriate for normal-risk children (which is the same strategy recommended by the UK’s National Institute for Health and Care Excellence guidelines). Children at high risk should be closely monitored for signs of deterioration, followed up within 24 hours, and be immediately prescribed an antibiotic, the researchers recommended.
They estimated that if antibiotic prescribing in low-risk children can be reduced by 50%, while remaining status quo in normal-risk children, and even increased to 90% in high-risk children, overall antibiotic prescribing would be reduced by 10%—a reduction on par with other interventions used to combat antibiotic resistance.
To create the STARWAVe tool, Dr. Hay and colleagues collected data on nearly 8,400 children, between ages 3 months to 16 years, who presented with acute cough and respiratory tract infection to 247 general practices in England between July 2011 and May 2013. Of these children, 78 went on to be hospitalized.
“This is the first study of its kind, based on a large representative sample of children who visit the doctor with respiratory illness,” Dr. Hay noted.
The researchers then determined which of 50 symptoms and signs were the most likely to result in hospitalization for respiratory infection in the month following a visit to primary care. After analysis, they identified 7 characteristics that were independently associated with hospital admission, which they used to develop the 7-item STARWAVe scoring tool.
“We hope that our proposed clinical tool might eventually enable doctors to quickly and easily identify their lowest and highest risk patients, although more research will be needed to determine just how effective it is in clinical practice,” Dr. Hay said.
“The rule should supplement—not replace—clinical judgement, and doctors and nurses should still advise parents about the symptoms and signs they should look out for, and when to seek medical help,” he added.