Recommendations in line with the current national guidelines for childhood community-acquired pneumonia (CAP), including limited use of chest radiographs, complete blood cell counts, and standardized antibiotic therapy in children, were found to be supported at pediatric primary care practices, according to data published in Pediatrics.
A total of 1906 immunocompetent children aged >3 months diagnosed with CAP with no history of complex chronic conditions at 5 pediatric primary care practices were included in this stepped wedged study. The interventions aimed at increasing adherence to guidelines were focused on education, knowledge of colleagues’ prescribing practices, and feedback sessions. The association between adherence and unscheduled follow-up visits was evaluated using changes in recommendations and antibiotic treatments assessed using statistical process control charts compared with unscheduled follow up visits across time.
Increases in guideline-recommended therapy and pulse oximetry, to a mean of 68.0% from a mean baseline of 24.9%, was observed, from 4.3% to 85.0%, respectively, over the study period. An increased likelihood of an unscheduled follow-up was associated with the receipt of guideline-recommended antibiotics, compared with non–guideline-recommended therapy in children older than 5 years (adjusted odds ratio 2.12; 95% CI 1.31-3.43). Complete blood cell counts and chest radiographs were rarely performed at baseline.
The study had several limitations, including that investigators were not blinded to which patients were prescribed antibiotic and causative agents of CAP were not identified meaning the appropriateness of a given antibiotic could not be evaluated. Processes for initial evaluation and follow-up for patients differed across the pediatric primary care practices included in the study. It was difficult to report on the sustainability of the interventions because access to electronic medical records was different.
Investigators recommended that “macrolide monotherapy may need to be considered as empiric antibiotic therapy for children [aged] >5 years.” They further stated their support for the recommendations of a decrease in the use of chest radiographs and complete blood cell counts in the outpatient setting.
Ambroggio L, Mangeot C, Murtagh Kurowski E, et al. Guideline adoption for community-acquired pneumonia in the outpatient setting. Pediatrics. 2018; 142: e20180331.