[New guidelines to decrease x-ray use may increase unnecessary antibiotic use]

The newly reLeased guidelines of infectious disease societies suggest abstaining from performing routine chest radiographs in the diagnosis of community acquired pneumonia in clinically stable children, based upon studies where the measured outcome is time to resolution of the disease not antibiotic use. However, the impact of possible over-treatment with antibiotics that might result from this clinical approach is not discussed.

The goal of this study was to quantify how many children with clinicaL signs suggestive of pneumonia would have been given unnecessary antibiotic treatment had the chest radiograph not been performed.

In a system of urgent care centers, we reviewed the medical records of patients > 2 months and <10 years with the chief complaint of fever, cough or dyspnea who had a chest X-ray performed upon their evaluation. Demographic and cLinical data were obtained with the final reports of X-rays interpreted by senior radiologists. An X-ray was considered positive if an infiltrate or pneumonia was noted in the report.

There were 3343 children over a one year period who met the inclusion criteria. A total of 877 had findings suggestive of pneumonia on the basis of physical examination. Of these, 433 (48.6%) had normal chest radiographs. Among those with negative X-rays, 305 (68.8%) had rates or crepitus on auscultation.

Reliance on physical examination alone in the diagnosis of community-acquired pneumonia (CAP) in children may over-diagnose cases of pneumonia in a clinically significant manner. Further consideration of this possibility is needed before widely disseminating guidelines that advocate antibiotic treatment based on clinical diagnosis alone.