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Predicting illness progression for children with lower respiratory infections in primary care: a prospective cohort
Paul Little1, Taeko Becque1, Alastair D Hay2
1Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK.
Insights
A new three-item prognostic score effectively identifies children with lower respiratory tract infections (LRTIs) at low risk of adverse outcomes, aiding clinical decisions and reducing antibiotic overuse.
Area of Science:
- Pediatrics
- Infectious Diseases
- Clinical Prognostics
Background:
- Antibiotic overuse for pediatric lower respiratory tract infections (LRTIs) contributes to antibiotic resistance.
- Limited availability of prognostic tools hinders effective management of pediatric LRTIs.
Purpose of the Study:
- To externally validate the STARWAVe prognostic model for identifying children with LRTIs at low risk of illness progression.
- To develop and internally validate a new prognostic model if STARWAVe performance was insufficient.
Main Methods:
- Prospective cohort study with a nested randomized controlled trial in primary care.
- Included children aged 6 months to 12 years with uncomplicated LRTIs.
- Clinical data collected at baseline to predict adverse outcomes (illness progression).
Main Results:
- The STARWAVe model showed moderate performance (AUROC 0.66).
- A new seven-item model demonstrated good discrimination (AUROC 0.83).
- A simplified three-item model (respiratory rate, oxygen saturation, chest findings) performed well (AUROC 0.81) and a derived score (<70) identified 89% of children with low progression risk.
Conclusions:
- A simple, three-item prognostic score can reliably identify children with LRTIs at low risk of adverse outcomes.
- This score can guide clinical management and potentially reduce unnecessary antibiotic prescriptions.
- The findings support the use of this tool to improve pediatric LRTI care.
Background:
Antibiotics are commonly prescribed for children with lower respiratory tract infections (LRTIs), fuelling antibiotic resistance, and there are few prognostic tools available to inform management.
Aim:
To externally validate an existing prognostic model (STARWAVe) to identify children at low risk of illness progression, and if model performance was limited to develop a new internally validated prognostic model.
Design And Setting:
Prospective cohort study with a nested trial in a primary care setting.
Method:
Children aged 6 months to 12 years presenting with uncomplicated LRTI were included in the cohort. Children were randomised to receive amoxicillin 50 mg/kg per day for 7 days or placebo, or if not randomised they participated in a parallel observational study to maximise generalisability. Baseline clinical data were used to predict adverse outcome (illness progression requiring hospital assessment).
Results:
A total of 758 children participated (n = 432 trial, n = 326 observational). For predicting illness progression the STARWAVe prognostic model had moderate performance (area under the receiver operating characteristic [AUROC] 0.66, 95% confidence interval [CI] = 0.50 to 0.77), but a new, internally validated model (seven items: baseline severity; respiratory rate; duration of prior illness; oxygen saturation; sputum or a rattly chest; passing urine less often; and diarrhoea) had good discrimination (bootstrapped AUROC 0.83, 95% CI = 0.74 to 0.92) and calibration. A three-item model (respiratory rate; oxygen saturation; and sputum or a rattly chest) also performed well (AUROC 0.81, 95% CI = 0.70 to 0.91), as did a score (ranging from 19 to 102) derived from coefficients of the model (AUROC 0.78, 95% CI = 0.67 to 0.88): a score of <70 classified 89% (n = 600/674) of children having a low risk (<5%) of progression of illness.
Conclusion:
A simple three-item prognostic score could be useful as a tool to identify children with LRTI who are at low risk of an adverse outcome and to guide clinical management.
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