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Checklist may prompt cuts in unneeded antibiotic prescriptions

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STARWAVe will improve antimicrobial stewardship in primary care

There are few efficacious interventions for respiratory tract infection available to primary care clinicians beyond offering reassurance and self-management advice, so the modest benefit offered by antibiotics can persuade general practitioners to prescribe them.

To derive (and validate) a clinical prediction rule to improve targeted antibiotic prescribing in children with respiratory tract infections, Hay et al determined the seven characteristics independently associated (P less than .01 for all associations) with hospital admission for children presenting to primary care physicians with cough and respiratory tract infection (STARWAVe). Using this seven-item checklist to help structure point-of-care assessment for this patient population should predict the risk of hospital admission with remarkable accuracy (area under the received operating characteristic curve, 0.81; 95% CI, 0.76-0.85).

STARWAVe offers primary care clinicians an evidence-based practical tool to help guide antibiotic prescription decisions and, through shared decision-making, has the potential to reduce antibiotic prescription based on prognostic uncertainty or on nonmedical grounds.

If STARWAVe leads to an increase in antibiotic prescription (to 90%) in high-risk children and a parallel halving of prescription to those at low risk of hospital admission, it could achieve a 10% overall reduction in primary care antibiotic prescriptions for respiratory tract infections.

These comments are excerpted from a commentary by Dr. Christopher C. Winchester from Oxford PharmaGenesis and Durham University (England), Alison Chisholm, MSc, from the Respiratory Effectiveness Group in Cambridge (England), and Dr. David Price from the University of Aberdeen (Scotland) and the Observational and Pragmatic Research Institute in Singapore. Dr. Winchester and Dr. Price disclosed financial relationships with numerous industry sources; Ms. Chisholm indicated no financial relationships relevant to this article. Funded information was not provided. (Lancet Respir Med. 2016 Sep 1. doi: 10.1016/S2213-2600(16)30272-7).


 

FROM THE LANCET RESPIRATORY MEDICINE

References

Primary care practitioners’ use of a seven-item checklist may reduce the number of pediatric patients with respiratory tract infections who are prescribed unnecessary antibiotics, a prognostic cohort study suggests.

The study revealed short illness (a duration of illness of 3 days or less), temperature (a body temperature of 37.8°C or greater at presentation), age (being under 2 years), intercostal or subcostal recession, wheeze on auscultation, asthma, and vomiting (moderate or severe in the previous 24 hours) were each independently associated with hospital admission (P less than .01 for all associations).

©Devonyu/thinkstockphotos.com

The checklist includes these seven characteristics or risk variables (short illness, temperature, age, recession, wheeze, asthma, and vomiting [mnemonic STARWAVe]). To use the checklist, a primary care practitioner would assign one point for the presence of each item in a patient then add up all of the points to determine that patient’s risk level for future hospital admission for respiratory tract infection. A score of 1 point or less, observed in 5,593 (67%) cases would be considered indicative of a very low rate of risk for hospitalization (0.3%, 0.2%-0.4%). A score of 2 or 3 points, found for 2,520 (30%) children, would be considered as a normal level of risk (1.5%, 1.0%-1.9%), and a score of 4 or more points, seen in 204 (3%) children, would signify a high risk level (11.8%, 7.3%-16.2%).

Of the 8,394 children assessed, 78 (0.9%; 95% confidence interval, 0.7%-1.2%) were admitted to a hospital. Most were admitted on days 2-7 (33, 42%) and on days 8-30 (30, 39%) following recruitment. Only 15 (19%) were admitted on the day of recruitment (day 1).

“Many clinicians report that they prescribe antibiotics just in case, to mitigate perceived risk of future hospital admission and complications, and that failing to provide a prescription for a child who subsequently becomes seriously unwell is professionally unacceptable. If primary care clinicians could identify children at low (or very low) risk of such future complications, the reduced clinical uncertainty could lead to a reduced use of antibiotics in these groups of patients,” wrote first author Alastair Hay, MD, from the Centre for Academic Primary Care in the School of Social and Community Medicine at the University of Bristol (England), and his colleagues.

These researchers conducted the study based on a structured, blinded review of the medical records from children aged between 3 months and 16 years presenting with acute cough (less than or equal to 28 days) and respiratory tract infection treated by 519 general practitioners in 247 practices in England between July 2011 and June 2013. The primary study outcome was hospital admission for respiratory tract infection within 30 days.

Additionally, a multivariable model was employed to detect factors associated with increased risk of hospital admission. As measured by receiver operating characteristic curve analysis, the accuracy of the STARWAVe score checklist in predicting risk groups and associated risk of hospitalization was found to be high (0.81; 95% CI, 0.77-0.86). The suggested probability of hospital admission for children who did not have any of the seven characteristics included in the checklist was found to be exceptionally low (0.14%).

Significantly associated parent-reported variables included both moderate or severe vomiting and severe fever, each in the previous 24 hours. Significant clinician-reported variables included intercostal or subcostal recession and wheeze on auscultation.

“The main value of our results is to reduce clinical uncertainty and antibiotic use in children least likely to benefit from them, namely those at very low risk of future hospital admission,” Dr. Hay and his associates noted in The Lancet Respiratory Medicine (Lancet Respir Med. 2016 Sep 1. doi: 10.1016/S2213-2600(16)30223-5).

Funding for this study was provided by the National Institute for Health Research and sponsored by the University of Bristol. Only one of the study’s authors, Dr. Peter Muir, reported ties to industry sources.

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