Point-of-care decision rule for antibiotic prescriptions in young children with fever without source: an open cluster
David Malorey1,2, Elsa Tavernier3,4, Anne Drouard2
1Pediatric Emergency Department, University Hospital Centre Nantes, F-44000 Nantes, France david.malorey@chu-nantes.fr.
Insights
A new decision rule safely reduced antibiotic prescriptions for children with fever without source in emergency departments. This approach lowered antibiotic use by 32% without increasing serious infections or mortality.
Area of Science:
- Pediatric Emergency Medicine
- Infectious Disease Management
- Clinical Decision Support
Background:
- Fever without source is a common pediatric emergency department presentation.
- Unnecessary antibiotic prescribing contributes to antimicrobial resistance.
- Point-of-care decision rules aim to optimize antibiotic use.
Purpose of the Study:
- To evaluate a point-of-care decision rule for reducing antibiotic prescriptions in children with fever without source.
- To assess the safety and efficacy of the decision rule in a multi-center trial.
Main Methods:
- Open cluster randomized clinical trial across 25 European pediatric emergency departments.
- Intervention involved a decision rule based on age, symptoms, urine analysis, and procalcitonin.
- Primary outcome was antibiotic exposure within 15 days; secondary outcomes included morbidity and mortality.
Main Results:
- The decision rule group had significantly lower antibiotic use (26.2%) compared to usual care (38.0%).
- No significant difference in morbidity or mortality rates between the groups.
- Serious bacterial infections occurred in 15.7% and invasive bacterial infections in 1.4% of children.
Conclusions:
- The point-of-care decision rule safely and effectively reduced antibiotic prescriptions in children with fever without source.
- Implementation of this rule can help combat antimicrobial resistance in pediatric populations.
Objective:
To evaluate whether a point-of-care decision rule could safely reduce antibiotic prescriptions in children presenting with fever without source in emergency departments.
Design:
Open cluster randomised clinical trial (registered on ClinicalTrials.gov).
Setting:
Twenty-five European paediatric emergency departments participated from November 2018 to October 2021.
Patients:
Children aged 6 days to 36 months presenting with acute fever without source.
Interventions:
During the first year, all centres (or clusters) followed their usual care protocols. In the second year, centres were randomised 1:1 to either continue usual care or to adopt the decision rule based on age, clinical symptoms, urine analysis and point-of-care procalcitonin measurements. In the third year, all centres applied the decision rule.
Main Outcomes And Measures:
The primary outcome was antibiotic exposure within 15 days. Secondary outcomes included morbidity and mortality assessed at day 15.
Results:
Among 4882 children (median age: 3 months, IQR 1-14), 2440 were in the usual care group and 2442 in the decision rule group. Serious bacterial infections occurred in 766 (15.7%) children, and invasive bacterial infections in 67 (1.4%). In the intention-to-treat analysis, 927 children (38.0%) received antibiotics within 15 days in the usual care group, compared with 641 (26.2%) in the decision rule group (OR 0.57; 95% CI 0.43 to 0.75; p<0.001). Morbidity and mortality rates were similar between groups (OR 0.83; 95% CI 0.57 to 1.22; p=0.34).
Conclusions:
The decision rule safely reduced unnecessary antibiotic use in young children with fever without source in emergency departments.
Trial Registration Number:
NCT03607162.
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