Not All Clinicians Adhere to Pediatric Pneumonia Guidelines, Study Finds

Children with community-acquired pneumonia (CAP) are routinely put through unnecessary tests and antimicrobial therapy as outpatients despite Pediatric Infectious Diseases Society (PIDS)/Infectious Diseases Society of America (IDSA) guidelines against doing so, according to a new study.

The study, published in The Journal of Pediatric Infectious Diseases Society, found that 43% of children with CAP between the ages of 1 and 6 years underwent a chest x-ray, despite the fact that guidelines recommend against routine use of x-rays in such cases. According to the study, 74% of outpatients were prescribed antibiotics despite guidelines advising the opposite, raising concerns about antimicrobial resistance. The figure is even more significant as CAP is one of the most common childhood infections, leading to 1.5 million health care visits each year.

“This is particularly true for broad-spectrum antibiotics, which we know are not necessary in the vast majority of children with pneumonia, even if the pneumonia is due to a bacterial organism where narrow-spectrum antibiotics (ie, amoxicillin) will suffice,” Todd Florin, MD, MSCE, from Ann & Robert H. Lurie Children's Hospital of Chicago, who led the study, told Contagion®.

In addition to antimicrobial resistance, there is mounting evidence that exposure to antibiotics early in life could lead to choric illnesses later on in life, such as obesity and asthma, according to Florin.

Other effects of unnecessary testing and antibiotic use is cost and parental anxiety. With antibiotic use also carries the risk of side effects, which Florin says can range from mild reactions such as rash, to severe reactions including anaphylaxis.

The study, which was conducted between 2008-2015, consisted of a review of national data representing 6.3 million pediatric CAP visits to outpatient clinics and emergency departments. Overall, the study was designed to determine the effectiveness of the 2011 PIDS/IDSA guidelines. The investigators write that they observed “no significant demographic differences in the study population before and after guideline publication.”

The investigators observed that hospitals obtained a complete blood count (CBC) in 8.6% of cases. According to Florin, in most cases, CBC is not useful in determining disease severity or pneumonia etiology.

He elaborates that he believes the overuse exists because pneumonia is difficult to definitively diagnose. “There is no non-invasive test that accurately tells clinicians what organism(s) is causing a child’s pneumonia. This diagnostic uncertainty often leads clinicians to opt for more testing and more antibiotics ‘just in case’ a child’s pneumonia is due to bacteria or might get severe. Addressing this diagnostic uncertainty is a critical piece of solving this puzzle.”

When asked about how to decrease inappropriate use of tests and antibiotics, the authors indicate that hospitals and practitioners can undertake “multifaceted and multidisciplinary quality improvement initiatives” to reduce reliance on antibiotics and x-rays, according to Florin.

“Using rigorous QI methods, hospitals have decreased testing and broad-spectrum antibiotics substantially in pediatric pneumonia,” Florin told Contagion®. “Strategies used in these initiatives have included broad based educational initiatives (e.g., grand rounds, divisional seminars), point-of-care reminders (e.g., badge cards with recommendations, posters near computers where orders are entered), and use of the electronic health record (e.g., note templates, order sets and clinical decision support).”