Guideline-Recommended Antibiotics Suffice to Treat CAP in Children Under Five

September 25, 2018

By Marilynn Larkin

NEW YORK (Reuters Health) - Young children with community-acquired pneumonia (CAP) can be managed with guideline-recommended antibiotics, without additional diagnostics such as chest X-rays (CXRs) or complete blood counts (CBCs), researchers say.

"The passive adoption of a guideline is inefficient and often leads to incomplete adoption," note Dr. Lilliam Abroggio of Cincinnati Children's Hospital Medical Center in Ohio and colleagues. Therefore, the team sought to proactively implement and evaluate a national guideline for managing CAP in outpatient settings.

Guideline recommendations include prescribing narrow-spectrum antibiotics; increasing reliance on vital sign measurements, including pulse oximetry, for clinical decision-making; and decreasing routine use of laboratory testing and radiography.

Since the guideline is based on "sparse data," according to the authors, they also assessed any unintended consequences of following the recommendations, such as an increase in unscheduled follow-up visits.

"The key take-home message is that quality-improvement methods can be an efficient way to rapidly implement national guidelines at community pediatric practices," Dr. Abroggio told Reuters Health by email. "In addition, when managing CAP in otherwise healthy children, additional diagnostics such as CXR or CBCs, are not necessary."

Dr. Abroggio and colleagues studied children over three months of age who were diagnosed with CAP and their providers in five community-based pediatric primary care practices (PPCPs). Baseline data were collected retrospectively from 2010-2012 and data for the intervention period were collected from July 2013 through March 2015.

Four processes were measured: receiving recommended antibiotic therapy; performing pulse oximetry; ordering a chest X-ray; and not performing a CBC.

Four provider interventions were implemented: an educational, in-person meeting; peer chart review; electronic medical record reminder; and identification and mitigation. Providers had flexibility regarding the best way to implement an intervention in their particular practice.

As reported online September 25 in Pediatrics, 1,906 children were diagnosed with CAP. Over the study period, the rate of guideline- recommended therapy increased from a median baseline of 24.9% to 68.0%, and pulse oximetry use increased from a mean of 4.3% to 85.0%.

Further, the proportion of CXRs decreased from 9.7% to 5.0% and the proportion of CBCs decreased from 6.4% to 1.5% between the preintervention and intervention periods.

Overall, there was no statistical difference between unscheduled follow-up visits across the cohort in the preintervention (10.5%) and intervention (10.7%) periods, although children who presented to the PPCP with fever, asthma, or who had a CXR performed, were more likely to have an unscheduled follow-up visit.


Receipt of guideline-recommended antibiotics (e.g., amoxicillin monotherapy or amoxicillin plus macrolide combination therapy), as compared with nonguideline therapy, was associated with an increased likelihood of unscheduled follow-up in children over age five, but not in younger children.


"Recommendations for limited use of chest radiographs and complete blood cell counts and standardized antibiotic therapy in children (are) supported at PPCPs," the authors conclude. "However, the guideline may need to include macrolide monotherapy as appropriate antibiotic therapy for older children."


Dr. Karen Acker, assistant attending pediatrician at NewYork-Presbyterian Komansky Children's Hospital and Weill Cornell Medicine, told Reuters Health, "One cannot conclude from this study how adherence to the guidelines affects clinical outcome, given the variability in interventions and follow-up practices at each outpatient practice."

"Because the specific intervention, timing of the intervention, and follow-up differed among the outpatient practices, the findings may not be generalizable to other outpatient populations - a limitation addressed by the authors," she said by email.

"The outpatient realm should be a continued focus of education interventions to help increase guideline adherence, although further studies are needed to determine whether adherence to the CAP guidelines improves clinical outcome," Dr. Acker concluded.


Pediatrics 2018.

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