Gijs Elshout

Alarm signs and antibiotic prescription in febrile children in primary care: an observational cohort study

BACKGROUND Although fever in children is often self-limiting, antibiotics are frequently prescribed for febrile illnesses. GPs may consider treating serious infections by prescribing antibiotics. AIM To examine whether alarm signs and/or symptoms for serious infections are related to antibiotic prescription in febrile children in primary care. DESIGN AND SETTING Observational cohort study involving five GP out-of-hours services. METHOD Clinical information was registered and manually recoded. Children (<16 years) with fever having a face-to-face contact with a GP were included. Children who were already using antibiotics or referred to secondary care were excluded. The relation between alarm signs and/or symptoms for serious infections and antibiotic prescription was tested using multivariate logistic regression. RESULTS Of the 8676 included patients (median age 2.4 years), antibiotics were prescribed in 3167 contacts (36.5%). Patient characteristics and alarm signs and/or symptoms positively related to antibiotic prescription were: increasing age (odds ratio [OR] = 1.03; 95% confidence interval [95% CI] = 1.02 to 1.05), temperature measured by GP (OR = 1.72; 95% CI = 1.59 to 1.86), ill appearance (OR = 3.93; 95% CI = 2.85 to 5.42), being inconsolable (OR = 2.27; 95% CI = 1.58 to 3.22), shortness of breath (OR = 2.58; 95% CI = 1.88 to 3.56), duration of fever (OR = 1.31; 95% CI = 1.26 to 1.35). Negative associations were found for neurological signs (OR = 0.45; 95% CI = 0.27 to 0.76), signs of urinary tract infection (OR = 0.63; 95% CI = 0.49 to 0.82), and vomiting and diarrhoea (OR = 0.65; 95% CI = 0.57 to 0.74). These variables explained 19% of the antibiotic prescriptions. CONCLUSION Antibiotics are often prescribed for febrile children. These data suggest that treatment of a supposed serious bacterial infection is a consideration of GPs. However, the relatively low explained variation indicates that other considerations are also involved.

Duration of fever and course of symptoms in young febrile children presenting with uncomplicated illness

Purpose: It is important to advise parents when to consult a doctor when their child has fever. To provide evidence-based, safety-net advice for young febrile children, we studied the risk of complications, the occurrence of alarm symptoms, the duration of fever. Methods: In a 7-day prospective follow-up study, we included 463 consecutive children aged 3 months to 6 years who presented with fever at a general practitioner out-of-hours service. We excluded 43 children with complicated illnesses at presentation. In a structured assessment, the duration of fever before presentation was noted and a physical examination was performed. Parents reported alarming symptoms and rectal temperature in a diary for 1 week. The total duration of fever included its duration before presentation. Median duration of fever was estimated using the Kaplan-Meier test. Results: During follow-up, 3.2% of the children with uncomplicated illness at presentation developed a complicated illness. The presence of alarming symptoms dropped from 79.3% at day 2 of the fever episode to 36.7% at day 9. The estimated median duration of the total fever episode was 4.0 days (95% confidence interval, 3.6–4.4). Conclusions: In children with uncomplicated illnesses, the daily occurrence of alarming symptoms reported by parents was high. The median duration of fever was 4 days. The predictive value of alarming symptoms reported by parents for complicated illness should be reconsidered.

Duration of fever and serious bacterial infections in children: a systematic review

BackgroundParents of febrile children frequently contact primary care. Longer duration of fever has been related to increased risk for serious bacterial infections (SBI). However, the evidence for this association remains controversial. We assessed the predictive value of duration of fever for SBI.MethodsStudies from MEDLINE, Embase and Cochrane databases (from January 1991 to December 2009) were retrieved. We included studies describing children aged 2 months to 6 years in countries with high Haemophilus influenzae type b vaccination coverage. Duration of fever had to be studied as a predictor for serious bacterial infections.ResultsSeven studies assessed the association between duration of fever and serious bacterial infections; three of these found a relationship.ConclusionThe predictive value of duration of fever for identifying serious bacterial infections in children remains inconclusive. None of these seven studies was performed in primary care. Studies evaluating the duration of fever and its predictive value in children in primary care are required.

C-Reactive Protein Level as Diagnostic Marker in Young Febrile Children Presenting in a General Practice Out-of-Hours Service

Background: It is unclear how well a C-reactive protein (CRP) value predicts a serious infection (SI) in young febrile children in general practice. Methods: This prospective cohort study with 1-week follow-up included children, aged 3 months to 6 years, presenting with fever to a general practitioner out-of-hours service. We evaluate whether CRP level has predictive value for diagnosing a child at risk for an SI either at presentation or during follow-up. The index test was CRP ≤20 mg/L (rule out an SI) and >80 mg/L (rule in an SI). The reference standard was referral to a pediatric emergency department or diagnosis of an SI. The main outcome measure was CRP value. Results: CRP level was available for 440 children. To rule out an SI, CRP ≤20 mg/L did not change the probability of having no SI (87.5%). CRP >80 mg/L increased the probability of having an SI from 11.4% (pretest probability) to 21.2% (posttest probability). In children without a diagnosis of SI at presentation, CRP could not predict an SI during follow-up (CRP >80 mg/L: positive likelihood ratio, 2.1, 95% confidence interval, 1.3–3.5; CRP ≤20 mg/L: negative likelihood ratio, 0.9, 95% confidence interval, 0.7–1.2). Conclusions: In general practice CRP has little clinically relevant value in discriminating febrile children in need of medical care from those who are not.

Current problems associated with the microbiological point-of-care testing of respiratory tract infections in primary care

Department of Medical Microbiology & Infectious Diseases, Erasmus University Medical Center Rotterdam (Erasmus MC), Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands Department of General Practice, Erasmus University Medical Center Rotterdam (Erasmus MC), Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany Laboratory for MEMS Applications, IMTEK – Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany *Author for correspondence: j.hays@erasmusmc.nl

Challenges in identifying antibiotic resistance targets for point-of-care diagnostics in general practice

General practitioners stand at the front line of healthcare provision and have a pivotal role in the fight against increasing antibiotic resistance. In this respect, targeted antibiotic prescribing by general practitioners would help reduce the unnecessary use of antibiotics, leading to reduced treatment failures, fewer side-effects for patients and a reduction in the (global) spread of antibiotic resistances. Current ‘gold standard’ antibiotic resistance detection strategies tend to be slow, taking up to 48 h to obtain a result, although the implementation of point-of-care testing by general practitioners could help achieve the goal of targeted antibiotic prescribing practices. However, deciding on which antibiotic resistances to include in a point-of-care diagnostic is not a trivial task, as outlined in this publication.

Booklet for Childhood Fever in Out-of-Hours Primary Care: A Cluster-Randomized Controlled Trial

PURPOSE Fever is the most common reason for a child to be taken to a physician, yet the level of unwarranted antibiotic prescribing remains high. We aimed to determine the effect on antibiotic prescribing of providing an illness-focused interactive booklet on fever in children to out-of-hours primary care clinicians. METHODS We conducted a cluster-randomized controlled trial in 20 out-of-hours general practice centers in the Netherlands. Children aged younger than 12 years with fever were included. Family physicians at the 10 intervention sites had access to an illness-focused interactive booklet between November 2015 and June 2016. The primary outcome was antibiotic prescribing during the index consultation. Analysis was performed by fitting 2-level random intercept logistic regression models. RESULTS The trial took place among 3,518 family physicians and 25,355 children. The booklet was used in 28.5% of 11,945 consultations in the intervention group. Compared with usual care, access to the booklet did not significantly alter antibiotic prescribing during the index consultation (odds ratio = 0.90; 95% CI, 0.79-1.02; prescription rate, 23.5% vs 25.2%; intracluster correlation coefficient = 0.005). In contrast, use of the booklet significantly reduced antibiotic prescribing (odds ratio = 0.83; 95% CI, 0.74-0.94; prescription rate, 21.9% vs 25.2%; intracluster correlation coefficient = 0.002). Children managed by family physicians with access to the booklet were less likely to receive any drug prescription, and parents in the booklet group showed a reduced intention to consult again for similar illnesses. CONCLUSIONS Benefit of an illness-focused interactive booklet in improving outcomes of childhood fever in out-of-hours primary care was largely restricted to the cases in which family physicians actually used the booklet. Insight into reasons for use and nonuse may inform future interventions of this type.

Vaccinaties zorgen voor minder kindersterfte

SamenvattingNederlandse onderzoekers maakten een historische tijdreeksanalyse van 1903 tot 2012. Deze analyse laat een sterke associatie zien tussen een toenemende vaccinatiegraad en een afnemende sterfte voor bepaalde infectieziektes.

Betere zorg voor kinderen met koorts op de huisartsenpost

SamenvattingKool M, Elshout G, Bohnen AM, Koes BW, Berger MY. Betere zorg voor kinderen met koorts op de huisartsenpost. Huisarts Wet 2016;59(11):474-7. Ouders nemen relatief vaak ’s avonds of ’s nachts contact op met de huisartsenpost omdat hun kind koorts heeft; ze melden dan veelal één of meer alarmsymptomen. Het overgrote deel van deze kinderen heeft een onschuldige infectie en heeft geen verdere behandeling nodig. Lijkt een kind ernstig ziek, dan moet het verwezen worden naar de tweede lijn. De NHG-Standaard Kinderen met koorts adviseert dat al te doen bij één alarmsymptoom, maar de grote meerderheid van de verwijzingen is loos alarm. Huisartsen zijn relatief terughoudend met verwijzen en scoren daarmee beter dan de predictieregels, dus alarmsymptomen zijn waarschijnlijk niet hun enige overweging.Moeilijker ligt het wanneer de arts op de huisartsenpost twijfelt over de ernst van de ziekte. Vaak schrijft deze dan een antibioticum voor om zichzelf of de ouders gerust te stellen, maar dat zou moeten worden vermeden, want het biedt slechts schijnzekerheid. Het is verstandiger de ouders goed te instrueren wanneer en waar ze opnieuw contact moeten opnemen en ervoor te zorgen dat het medisch dossier altijd ondubbelzinnig en volledig is, zodat in een eventueel vervolgconsult het beloop van het ziektebeeld gevolgd kan worden.AbstractKool M, Elshout G, Bohnen AM, Koes BW, Berger MY. Better care for febrile children seen at out-of-hours services. Huisarts Wet 2016;59(11):474-7. Parents contact out-of-hours services relatively often because their child has a temperature and mention one or more alarm symptoms. The vast majority of these children have a non-serious infection and do not require further treatment. Children that appear to be seriously ill should be referred to secondary care. The Dutch Association of General Practitioners’ guideline ‘Children with fever’ recommends that children with only one alarm symptom be referred, but the majority of these referrals turn out to be a false alarm. General practitioners are relatively conservative in their referrals and score better in this respect than diagnostic algorithms, so it seems that they are guided by more than the alarm symptoms alone.It is more complex if GPs are uncertain about the seriousness of the illness. They often prescribe an antibiotic to reassure themselves and the parents, but this should be avoided because it gives a false sense of security. It would be better to clearly tell the parents when and where they should contact the service again. If the medical record is complete and unambiguous, the course of the disorder can be reviewed in the follow-up consultation, even if this occurs with a different GP.

Antibiotica bij kinderen met koorts

SamenvattingElshout G, Kool M, Van der Wouden JC, Moll HA, Koes BW, Berger MY. Antibiotica bij kinderen met koorts. Huisarts Wet 2013;56(2):58-61.InleidingHuisartsen schrijven vaak antibiotica voor aan kinderen met koorts. Patiëntkenmerken en symptomen die gerelateerd zijn aan antibioticavoorschriften geven zicht op de overwegingen van de huisarts. Wij onderzochten de hoeveelheid antibioticavoorschriften bij kinderen die de huisartsenpost bezochten met koorts en bekeken welke patiëntkenmerken en symptomen hieraan gerelateerd zijn.MethodeKinderen (3 maanden tot 6 jaar) kwamen in aanmerking voor inclusie wanneer de ouders contact opnamen met de huisartsenpost met koorts als belangrijkste reden. Symptomen en antibioticavoorschriften werden op gestandaardiseerde wijze genoteerd.ResultatenVan de 443 geïncludeerde kinderen kregen er 121 telefonisch advies en 322 een consult op de huisartsenpost. Bij deze laatste groep schreef de huisarts 117 kinderen (36,3%) antibiotica voor; dit was 26,5% (117/443) van de totale onderzoekspopulatie. In de multivariate analyse waren de volgende kenmerken en symptomen positief gerelateerd aan een antibioticavoorschrift: ongeruste ouders (OR 2,02; 95%-BI 1,06-3,58), zieke indruk (OR 3,26; 95%-BI 1,30-8,20), oorpijn resulterend in veranderd gedrag of slaappatroon (OR 2,59; 95%-BI 1,06-6,30), tekenen van een keelontsteking (OR 2,37; 95%-BI 1,35-4,15) en verminderde urineproductie (OR 2,00; 95%-BI 1,17-3,41). Voor de leeftijd van 3 tot 6 maanden en de hoogte van de rectale temperatuur vonden we een negatieve associatie (respectievelijk OR 0,17; 95%-BI 0,03-0,74 en OR 0,52; 95%-BI 0,37-0,71).ConclusieEen op de vier kinderen met koorts kreeg op de huisartsenpost antibiotica voorgeschreven. De patiëntkenmerken en symptomen geassocieerd met een antibioticavoorschrift verklaren slechts voor een klein deel de afwegingen van de huisarts.