Research News

New rule could help identify children with cough who need antibiotics

BMJ 2016; 354 doi: (Published 02 September 2016) Cite this as: BMJ 2016;354:i4763
  1. Susan Mayor
  1. London

Asthma, respiratory distress, young age, and short duration of illness are among seven characteristics associated with increased risk of admission in children with acute respiratory infection and cough, a large primary care study in England has shown. Researchers said that scoring these characteristics may help GPs decide when to prescribe antibiotics.

More than 80% of NHS antibiotics are prescribed by GPs, who have reported prescribing some antibiotics to reduce the risk of children with respiratory tract infections becoming seriously ill and requiring hospital admission.

The study, reported in Lancet Respiratory Medicine,1 aimed to develop a clinical rule to reduce uncertainty by stratifying the risk of future hospital admission in children with respiratory tract infections. Researchers recruited 8394 children aged 3 months to 16 years presenting with acute cough and respiratory tract infection to 247 general practices in England.

GPs and practice nurses collected information on each child’s pre-specified sociodemographic details and past medical history, parent reported symptoms, physical examination signs, and prescription of antibiotics. Children were also assessed for current asthma.

Researchers analysed hospital admissions for respiratory tract infection in the 30 days after children were recruited to the study and looked at the association with the baseline characteristics. A total of 78 children (0.9% of the study population) were admitted to hospital, with a median time to hospital admission of 2 days (interquartile range 1 to 11 days) after seeing a GP or practice nurse.

Seven characteristics emerged as being independently associated (P<0.01) with hospital admission: age under 2 years; current asthma; illness duration of 3 days or less; parent reported moderate or severe vomiting in the previous 24 hours; parent reported severe fever in the previous 24 hours; a body temperature of 37.8°C or more at presentation; and clinician reported wheeze on auscultation.

Assigning one point to each of these characteristics gave a points based clinical rule consisting of short illness, temperature, age, recession (signs of respiratory distress), wheeze, asthma, and vomiting, given the mnemonic STARWAVe (area under receiver operating characteristics curve 0.81 (1.0 equating to a perfect predictor) (95% confidence interval 0.76 to 0.85)).

Using this rule sorted children into three risk categories for hospital admission: children with one point or less had very low risk (0.3% (0.2% to 0.4%)); those with two or three points had normal risk (1.5% (1.0% to 1.9%)), and those with four points or more had high risk (11.8% (7.3% to 16.2%)).

The researchers said that a “no antibiotic” prescribing strategy would be appropriate for low risk children, while a “no antibiotic or delayed antibiotic” approach would be best for those with normal risk. Children considered to be at high risk of admission should be closely monitored for signs of deterioration and followed up within 24 hours, the team recommended.

“This is the first study of its kind, based on a large representative sample of children who visit the doctor with respiratory illness,” said the lead author, Alastair Hay, from the University of Bristol. “We hope that our proposed clinical tool might eventually enable doctors to quickly and easily identify their lowest and highest risk patients.”

But he warned that more research was needed to determine how effective the rule is in clinical practice, adding that it should not replace clinical judgment. “Doctors and nurses should still advise parents about the symptoms and signs they should look out for, and when to seek medical help,” he concluded.


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