Rule guides antibiotic prescribing

3 minute read

Which children with respiratory infections can safely be treated without antibiotics?


A team of GPs has developed a way to identify which children with respiratory infections can safely be treated without antibiotics

Using clinical characteristics, the authors say they can classify children into those at low, medium and high risk of hospitalisation for respiratory tract infection.

The rule, called STARWAVe, could also reduce antibiotic prescribing in primary care for children at very low risk of complications from their respiratory illness, said the authors of the trial published in the Lancet.

Dr Bastian Seidel, RACGP board representative of the National Asthma Council, said the study had the potential to influence prescribing habits with regards to antibiotics in children and teenagers.

“We can now safely identify a group that does not benefit from antibiotics at all. And we now have a tool that allows GPs to communicate that with carers much better,” Dr Seidel said.

Antibiotics were often prescribed to mitigate the perceived risk of future hospital admission and complications, but this study directly addressed the likelihood of these outcomes, Dr Seidel said.

The study looked at 8394 children aged between three months and 16 years old who presented to a general practice with acute cough lasting 28 days or less, or with a respiratory tract infection.

“Our previous systematic review suggests that this is the largest and most rigorous prognostic study of children with respiratory tract infections in primary care,” the authors wrote.

The UK and US researchers identified seven clinical symptoms and examination findings that were directly associated with a higher risk of hospitalisation.

These are short illness duration (?3 days); temperature of 37.8C; age (<2 years); chest recession; wheeze; asthma; and vomiting – hence the mnemonic STARWAVe.

Each factor is worth one point, stratifying children into very low (0 or 1 point), normal (2 or 3 points) or high risk (4 or more) of admission. Of the 78 children hospitalised, most were for lower respiratory tract infection, bronchiolitis or viral wheeze. Only one quarter suggested a bacterial cause that would have been helped by antibiotics, the authors wrote. A third of the very-low risk group received antibiotics.

“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,” the authors said.

Because most children in the study were very-low risk (67%), even halving antibiotic prescribing rates in this group and increasing antibiotic prescriptions to 90% in the high-risk group would reduce overall prescribing by 10%, they said.

A no-antibiotic strategy would be safe in the low risk group, and those in the normal-risk group were best treated with no antibiotic or delayed antibiotic prescribing, the authors said.

The high-risk group should be monitored closely for signs of deterioration, “with consideration given to proactively arrange same-day or next-day follow-up and prescribe an immediate antibiotic”, they wrote.

“The interesting part is that they did not incorporate laboratory tests (swab results, CRP), which makes it much more practical and valid for real life application in an Australian general practice setting,” Dr Seidel said.

“The lead research team consists of GPs, the setting is general practice. The cohort recruited is representational. The exclusion criteria are limited. It’s a real-world study,” Dr Seidel said.

Blacktown GP, Associate Professor Michael Fasher, said while the research was interesting, more work would need to be done to validate the STARWAVe rule.

Professor Fasher said he agreed with the authors’ conclusions that at this stage, “this rule should supplement clinical decision making and not supplant it”.

Lancet Respir Med; online 1 September

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