Abstract
The aim of this study is to evaluate the influence of chest X-ray (CXR) results on antibiotic prescription in children suspected of lower respiratory tract infections (RTI) in the emergency department (ED). We performed a secondary analysis of a stepped-wedge, cluster randomized trial of children aged 1 month to 5 years with fever and cough/dyspnoea in 8 EDs in the Netherlands (2016–2018), including a 1-week follow-up. We analysed the observational data of the pre-intervention period, using multivariable logistic regression to evaluate the influence of CXR result on antibiotic prescription. We included 597 children (median age 17 months [IQR 9–30, 61% male). CXR was performed in 109/597 (18%) of children (range across hospitals 9 to 50%); 52/109 (48%) showed focal infiltrates. Children who underwent CXR were more likely to receive antibiotics, also when adjusted for clinical signs and symptoms, hospital and CXR result (OR 7.25 [95% CI 2.48–21.2]). Abnormalities on CXR were not significantly associated with antibiotic prescription.Conclusion: Performance of CXR was independently associated with more antibiotic prescription, regardless of its results. The limited influence of CXR results on antibiotic prescription highlights the inferior role of CXR on treatment decisions for suspected lower RTI in the ED.What is Known:• Chest X-ray (CXR) has a high inter-observer variability and cannot distinguish between bacterial or viral pneumonia.• Current guidelines recommend against routine use of CXR in children with uncomplicated respiratory tract infections (RTIs) in the outpatient setting.What is New:• CXR is still frequently performed in non-complex children suspected of lower RTIs in the emergency department• CXR performance was independently associated with more antibiotic prescriptions, regardless of its results, highlighting the inferior role of chest X-rays in treatment decisions.
Highlights
Community-acquired pneumonia (CAP) is one of the leading causes of childhood morbidity and mortality worldwide
The limited influence of chest X-ray (CXR) results on antibiotic prescription highlights the inferior role of CXR on treatment decisions for suspected lower respiratory tract infections (RTI) in the emergency department (ED)
Current guidelines recommend against routine use of CXR in children with uncomplicated respiratory tract infections (RTIs) in the outpatient setting
Summary
Community-acquired pneumonia (CAP) is one of the leading causes of childhood morbidity and mortality worldwide. More recent evidence shows the limitations of CXR in guiding the management of these children, like the high inter-observer variability, inability to distinguish viral from bacterial pneumonia and radiation exposure [4,5,6,7]. Inter-observer variability of CXR reading for paediatric pneumonia has shown to be present between radiologists as well as between various other specialists [8,9,10]. Reported reasons for this are lack of radiological training of treating physicians, lack of clinical information available for radiologists and human error. In 2011, guidelines for the management of childhood CAP were published in Europe and the USA [5, 6], recommending against routine use of CXR in most children in the outpatient setting, and restricting the use of CXR to children with moderate to severe signs and symptoms of CAP at risk of developing complications
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