Wednesday, February 29, 2012

Pediatric Pneumonia n antibiotics use

From Archives of Disease in Childhood

Why Do Children Hospitalised With Pneumonia Not Receive Antibiotics in Primary Care?

CC Grant; A Harnden; D Mant; D Emery; G Coster
Posted: 02/17/2012; Arch Dis Child. 2012;97(1):21-27. © 2012 BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health

Abstract and Introduction


Background Although antibiotics are recommended for the primary care management of community-acquired pneumonia, a recent UK study reported that most children admitted to hospital had not received antibiotics.
Objective To describe primary care antibiotic use for children subsequently hospitalised with community-acquired pneumonia.
Design/methods A case series of 280 children <5 years old hospitalised with pneumonia in Auckland, New Zealand. Pneumonia was defined as an acute illness with cough or respiratory distress, the presence of tachypnoea or indrawing and an abnormal chest radiograph. Receipt of antibiotics was determined by parental report and medical record review.
Results Fewer than half (108, 39%) of the children had received an antibiotic before hospital admission. For 60 children (21%) there had been no opportunity to prescribe because the illness evolved rapidly, resulting in early hospital admission. For the remaining 112 children (40%) an opportunity to receive antibiotics was missed. The parent failed to obtain the antibiotic prescribed for 23 children (21% of 112), but in 24 children (21%) pneumonia was diagnosed but no antibiotic prescribed and in a further 28 children (25%) the diagnosis was not made despite parental report of symptoms suggesting pneumonia. Missed opportunities to prescribe were not associated with increased overall severity of symptoms at hospital presentation but were associated with an increased risk of: focal chest radiological abnormalities (rate ratio (RR)=2.14; 95% CI 1.49 to 2.83), peripheral leucocytosis >15×109/l (RR=2.29; 95% CI 1.61 to 2.98) and bacteraemia (RR=6.68, 95% CI 1.08 to 58.44).
Conclusions Young children with community-acquired pneumonia may not receive an antibiotic before hospital admission because the illness evolves rapidly or the prescribed medicine is not given by parents. However, missed opportunities for appropriate antibiotic prescribing by health professionals in primary care appear to be common.


Antibiotics are recommended as first-line treatment for community-acquired pneumonia and are almost always prescribed to preschool aged children on hospital admission with pneumonia. For example, the British Thoracic Society recommends amoxicillin as first-line treatment for children <5 years old with community-acquired pneumonia. However, the same guideline also says that children with 'mild' symptoms of lower respiratory tract infection (LRTI) do not require antibiotics. This creates a diagnostic challenge for primary care doctors. Not treating serious disease can result in death. Antibiotic overprescribing for lower respiratory infections increases the risk of antimicrobial resistance.
A case series of children hospitalised with community-acquired pneumonia in England called into doubt whether primary care doctors are meeting the diagnostic challenge effectively. It reported that only 22% of infants and 31% of children 1–15 years old had received antibiotics before admission.[1] Moreover, the children not prescribed antibiotics had more severe disease on hospital admission.[1] However, the report was not based on a consecutive series of cases from a defined population and no information was reported about the primary care given or the reasons for non-prescribing.
We therefore analysed a consecutive series of admissions of children from a defined catchment population in New Zealand (NZ) to confirm, in a country with a similar health system to the UK, the low rate of preadmission antibiotic prescribing for community-acquired pneumonia. We also sought to go further by consulting parents and reviewing primary care records to explore why this might happen.

No comments: