Paediatric Common Infections Pathways: improving antimicrobial stewardship and promoting ambulation for children presenting with common infections to hospitals in the UK and Ireland

Decision Challenges for Managing Acute Paediatric Infections: Implications for Antimicrobial Resistance

Overprescribing of antibiotics in paediatrics accounts for a significant proportion of inappropriate antibiotic use in human healthcare, thereby contributing to the global health emergency of antimicrobial resistance. Antimicrobial stewardship efforts are complicated by the unique social dynamics in paediatric healthcare, with a specific challenge being the prominent role of parents and carers who act as intermediaries between prescribers and paediatric patients. In this Perspective article concentrating on healthcare of the United Kingdom, we describe this complicated interplay of different decision stakeholders (patients, parents and prescribers), outline four dimensions of decision challenges (social, psychological, systemic and specific diagnostic and treatment challenges) and provide a number of theory-based strategies for supporting different stakeholders during the decision process, ultimately with the aim of improving antimicrobial stewardship. Key decision challenges for patients and carers include limited knowledge and experience of managing infections, which were exacerbated during the COVID-19 pandemic and frequently result in health anxiety and inappropriate health-seeking behaviours. Challenges for medical prescribers span societal pressures from prominent patient litigation cases, cognitive biases, and system pressures to specific diagnostic problems (e.g., age limitations of current clinical scoring systems). Strategies for mitigating decision challenges in paediatric infection management will need to include a range of context- and stakeholder-specific actions, including improvements of integrated care and public health education as well as better clinical decision tools and access to evidence-based guidelines.

Antibiotic Prescribing Patterns for Outpatient Pediatrics at a Private Hospital in Abu Dhabi: A Clinical Audit Study

BACKGROUND

Antibiotics are commonly used in pediatrics. The aim and objectives were to evaluate the antibiotic prescribing patterns of pediatric outpatients at a private hospital in Abu Dhabi, UAE.

METHODS

A retrospective drug utilization review was conducted for pediatric patients aged 1-18 between June and December 2018. The prescriptions with inclusion criteria were reviewed and evaluated by using the WHO indicators.

RESULTS

419 encounters included were female (50.1%). Most pediatrics were aged 4-6 years (35.3%). The average number of drugs per prescription were 4.9 drugs. The percentage of parenteral medication prescriptions was 16.9%, and with antibiotic prescriptions was 43.0%, where cefaclor was the most prescribed antibiotic (31.1%). The average consultation time was 14 min, while the average dispensing time was 9.6 min. The most common diagnosis where antibiotics were prescribed was acute pharyngitis (33.4%). There were about 60.6% with lab investigation.

CONCLUSION

As per the WHO indicators, the pediatric outpatient department has a high rate of antibiotic use and polypharmacy, but adherence to the drug formulary and prescribing medicines using generic names was appropriate. The average time for consultation and dispensing were suitable. Irrational antibiotic use for inappropriate diagnoses such as acute otitis media and bronchiolitis were found.

Five years of outpatient parenteral antibiotic therapy with ceftriaxone in the paediatric emergency department: what clinical features are associated with need for admission?

BACKGROUND

More children presenting to Emergency Departments (EDs) with acute infections are now directly referred for outpatient parenteral antibiotic therapy (OPAT). Sparse data exist on what clinical features in these children are associated with OPAT failure. We hypothesised that children who were younger or presented with systemic features of infection would be more likely to need admission.

METHODS

We conducted a service evaluation over a 5-year period (12 September 2015-12 September 2020) at a single UK tertiary centre paediatric ED formally known as the Royal Hospital for Sick Children Edinburgh. All children referred from the ED for OPAT with ceftriaxone were included. OPAT failure was defined as a decision by a senior clinician of need for admission. Univariate statistical testing and multivariate logistic regression modelling were performed.

RESULTS

754 children received OPAT in the ED over a 5-year period. 95 children (13%) required admission for inpatient management. Need for admission was independently associated with having a positive blood culture (adjusted OR (aOR) 8.9; 95% CI 1.49 to 47; p=0.01) or an ultrasound performed (aOR 6.8; 95% CI 3.74 to 12.7; p<0.001). We observed no significant association between age and systemic features (fever, white cell count or C reactive protein) with need for admission in our multivariate analysis.

CONCLUSION

In children presenting with acute infections to our paediatric ED who were deemed suitable by senior clinicians to be managed using OPAT with ceftriaxone, younger age (above 3 months) and the presence of systemic features were not independently associated with need for admission. Overall, our service was safe and no child came to harm from early ambulation during this evaluation.