The influence of chest X-ray results on antibiotic prescription for childhood pneumonia in the emergency department

AbstractThe 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.

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Chest Ultrasound versus Chest X-Ray in Children with Lower Respiratory Tract Infections

Open Journal of Pediatrics ◽

10.4236/ojped.2021.114055 ◽

2021 ◽

Vol 11 (04) ◽

pp. 597-607

Author(s):

Elham Saad Ellithey Elkhazragy ◽

Saneya Abdel Halim Fahmy ◽

Mona Sayed Mohammad Attaya ◽

Ashraf Mohammad Abd Elrahman

Keyword(s):

Respiratory Tract ◽

Lower Respiratory Tract ◽

Respiratory Tract Infections ◽

Lower Respiratory Tract Infections ◽

X Ray ◽

Chest Ultrasound ◽

Chest X Ray ◽

Tract Infections

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Inter-observer agreement in interpreting chest X-rays on children with acute lower respiratory tract infections and concurrent wheezing

Sao Paulo Medical Journal ◽

10.1590/s1516-31802007000300005 ◽

2007 ◽

Vol 125 (3) ◽

pp. 150-154 ◽

Cited By ~ 18

Author(s):

Carlos Bada ◽

Nilton Yhuri Carreazo ◽

Juan Pablo Chalco ◽

Luis Huicho

Keyword(s):

Respiratory Tract Infections ◽

Observer Variation ◽

Observer Agreement ◽

X Rays ◽

Lower Respiratory Tract Infections ◽

Emergency Ward ◽

X Ray ◽

Alveolar Infiltrate ◽

Chest X Ray ◽

Tract Infections

CONTEXT AND OBJECTIVE: Many children with acute lower respiratory tract infections (ALRI) present to the emergency ward with concurrent wheezing. A chest x-ray is often requested to rule out pneumonia. We assessed inter-observer agreement in interpreting x-rays on such children. DESIGNS AND SETTING: Prospective consecutive case study at Instituto de Salud del Niño, Lima, Peru. METHODS: Chest x-rays were obtained from eligible children younger than two years old with ALRI and concurrent wheezing who were seen in the emergency ward of a nationwide pediatric referral hospital. The x-rays were read independently by three different pediatric residents who were aware only that the children had a respiratory infection. All the children had received inhaled beta-adrenergic agonists before undergoing chest x-rays. Lobar and complicated pneumonia cases were excluded from the study. RESULTS: Two hundred x-rays were read. The overall kappa index was 0.2. The highest individual kappa values for specific x-ray findings ranged from 0.26 to 0.34 for rib horizontalization and from 0.14 to 0.31 for alveolar infiltrate. Inter-observer variation was intermediate for alveolar infiltrate (kappa 0.14 to 0.21) and for air bronchogram (kappa 0.13 to 0.23). Reinforcement of the bronchovascular network (kappa 0.10 to 0.16) and air trapping (kappa 0.05 to 0.20) had the lowest agreement. CONCLUSIONS: There was poor inter-observer agreement for chest x-ray interpretation on children with ALRI and concurrent wheezing seen at the emergency ward. This may preclude reliable diagnosing of pneumonia in settings where residents make management decisions regarding sick children. The effects of training on inter-observer variation need further studies.

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How good are the examination findings in predicting the chest radiographic abnormalities amongst children with LRTI?

International Journal of Contemporary Pediatrics ◽

10.18203/2349-3291.ijcp20164599 ◽

2016 ◽

Vol 4 (1) ◽

pp. 167

Author(s):

Ishank Goel ◽

Anjali Kher ◽

Jayant Vagha

Keyword(s):

Respiratory Tract ◽

Lower Respiratory Tract ◽

Daily Practice ◽

X Rays ◽

Mortality And Morbidity ◽

X Ray ◽

Plain Chest Radiograph ◽

Breath Sounds ◽

Chest X Ray ◽

Tract Infections

Background: Acute lower respiratory tract infections are an important cause of mortality and morbidity in children below five years of age. Plain chest radiograph remains the most accessible and commonly used radiological tool. The present study is thus designed to clinically evaluate children with pneumonia, to identify the risk factors and correlate them with the X-ray findings.Methods: Our study was an observational and Analytical study. A total of 250 patients from the age group of 2 months to 5 years, admitted in paediatrics wards with respiratory complaints suggestive of involvement of lower respiratory tract whose X-rays were done were included in our study. All the patients were examined by the clinical experts every day and the findings were being confirmed by at least two experts. Radiologists/residents in the department made the first assessment during their daily practice through online database. The radiologist, who was not informed about the results of the first assessment, re-examined the radiographs. X-ray findings were then compared with clinical features.Results: Out of 250 children, 137 patients had normal radiographs and 113 had abnormal radiographs. Pallor, intercostal retractions, subcostal retractions, grunt, nasal flaring, decreased breath sounds and crepts had a sensitivity of 80.53%, 84.07%, 76.99%, 70.80%, 76.99%, 73.45%, 62.83% and specificity of 30.66%, 35.77%, 67.88%, 82.48%, 36.50%, 88.32%, 49.64% respectively, in predicting the chest X-ray abnormalities in LRTI.Conclusions: Tachypnea, pallor, retractions, grunt, nasal flaring, decreased breath sounds and crepitations were the main indicators of ALRI confirmed by X-ray. Inspection and Auscultation were two more important pillars of Respiratory system examination in children, where we could predict abnormal X-ray findings.

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Clinical, Microbiological and Radiological Characterises of Lower Respiratory tract Infection in Children with Established Congenital Heart Diseases.

Pediatric Review International Journal of Pediatric Research ◽

10.17511/ijpr.2021.i04.03 ◽

2021 ◽

Vol 8 (4) ◽

pp. 182-188

Author(s):

Dr. Sandeep Bhaskar ◽

◽

Dr. Afzal K M ◽

Dr. Manjunatha Babu R ◽

Dr. Subramanya NK ◽

...

Keyword(s):

Respiratory Tract ◽

Lower Respiratory Tract ◽

Congenital Heart ◽

Respiratory Tract Infections ◽

Heart Diseases ◽

Congenital Heart Diseases ◽

Lower Respiratory Tract Infections ◽

X Ray ◽

Chest X Ray ◽

Tract Infections

Introduction: Acute Lower Respiratory Tract Infection (ALRTI) is the most common cause of deathin children under five. Various demographic, socio-economic and environmental factors have beenassociated with ALRTI, with conflicting results. Children with congenital heart diseases are morevulnerable to lower respiratory tract infections following the fact that they had an anatomical defectthat causes hemodynamic disturbance of lung circulation and mucosal oedema finally leads todecreased lung compliance and recurrent lower respiratory tract infections. Methods: Children agedbetween1 month and 18 years with clinically established congenital heart disease confirmed byechocardiography and presenting with signs and symptoms suggestive of lower respiratory tractinfection were enrolled in the study. A detailed history was taken and routine blood investigationswere done in all cases. Chest X-Ray was done to confirm the clinical diagnosis. Results: Mean ageof the study subjects was 2 years. VSD was seen in 64.9% of cases while 10.5% of cases had VSDand ASD. The most common presenting symptoms were: cough (98.2%), reduced feeding (97.4%),fever (89.5%), running nose (67.5%) and wheeze (49.1%). Leucocytosis and raised ESR were seenin 66.7% and 64.9% cases respectively. In Throat swab Commensals were seen in 36% of caseswhile gram-positive cocci were seen in 3.5% cases respectively. In blood culture Streptococcuspneumoniae being the commonest organism isolated. Bilateral and unilateral opacities on chest x-ray were seen in 16.7% and 12.3% cases respectively. Conclusion: Bronchopneumonia was thecommonest LRTI in children with the predominance of VSD.

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Role of peak expiratory flow rate and chest radiography in children above 5 years of age with acute asthma

International Journal of Contemporary Pediatrics ◽

10.18203/2349-3291.ijcp20200112 ◽

2020 ◽

Vol 7 (2) ◽

pp. 372

Author(s):

Sankeerthana Shankarnarayana ◽

Jaidev M. Devdas ◽

Sujonitha John ◽

Habeeb Ullah Khan ◽

Pavan Hegde

Keyword(s):

Emergency Department ◽

Oxygen Saturation ◽

Standard Treatment ◽

Acute Asthma ◽

X Rays ◽

Bronchodilator Therapy ◽

X Ray ◽

Before And After ◽

Chest X Ray

Background: Asthma is a heterogeneous disease characterized by cough, wheeze and shortness of breath that vary in intensity and time with variable expiratory airflow limitation, associated with chronic airway inflammation. Aim of the study was to assess the usefulness of Peak Expiratory Flow Rate [PEFR] and oxygen saturation in determining severity of acute asthma, to measure objective change in PEFR and oxygen saturation following bronchodilator therapy and the role of chest X-rays in acute asthma.Methods: A prospective study of 50 children above 5 years with acute asthma who presented to the emergency department in a tertiary care hospital were included. PEFR and oxygen saturation before and after bronchodilator therapy was measured. Indication for chest X-rays, its clinical correlation and change in standard treatment of acute asthma based on X-ray reports was noted.Results: The mean PEFR and PEFR % of expected was lower in severe asthma when compared to moderate asthma and was statistically significant (p<0.001). The % of expected PEFR before salbutamol therapy was 48.78±14.36, which improved significantly to 67.13±14.22 after treatment (p<0.001). Oxygen saturation before and after salbutamol therapy was 94.96 ± 4.11 and 96.96±2.87 respectively with the change being significant (p value <0.001). Chest X-rays were performed in 12 (24%) children as per standard guidelines, of which 1(9%) was abnormal showing right basal consolidation. Chest X-ray correlated with clinical findings in 1 child and the findings on chest X-ray altered the ongoing treatment by addition of antibiotic.Conclusions: PEFR and oxygen saturation is useful in the emergency department to objectively assess the severity of acute asthma and the response to initial bronchodilator therapy. Chest X-rays are not routinely indicated in the standard treatment of acute asthma.

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Are Patient Decision Aids Effective in Decreasing Antibiotic Prescription for Acute Upper Respiratory Tract Infections During General Practice and Emergency Department Encounters: A Systematic Review Protocol (Preprint)

10.2196/preprints.11020 ◽

2018 ◽

Author(s):

Shiva Ramasamy ◽

Ali Gilani ◽

Mohamad Alshurafa ◽

Leesa Phillip ◽

Janath De Silva

Keyword(s):

Emergency Department ◽

Respiratory Tract ◽

Respiratory Tract Infections ◽

Antibiotic Prescription ◽

Decision Aids ◽

Upper Respiratory Tract Infections ◽

Upper Respiratory Tract ◽

Patient Decision ◽

Upper Respiratory ◽

Tract Infections

UNSTRUCTURED ABSTRACT Background Antibiotic resistance is a global issue that has a significant impact on patient morbidity and mortality. Evidence exists within the general practice and the emergency department setting to suggest that antimicrobial overuse is a significant contributor to resistance. Upper respiratory tract infections are a group of conditions for which antibiotics may be inappropriately prescribed. Patient decision aids are tools allowing for shared decision making between clinician and patient, incorporating patient values and the latest evidence into the decision of whether to prescribe antibiotics or not. Objectives To determine if patient decision aids are effective in decreasing antibiotic prescription for acute upper respiratory tract infections during general practice and emergency department encounters, and to comment on the depth of literature available in this field. Methods and Analysis We have established a protocol for a systematic review to assess the efficacy of patient decision aids in reducing antibiotic prescription for upper respiratory tract infections in general practices and emergency departments. A set of inclusion criteria has been established. We will include systematic reviews and randomised controlled trials only. A search strategy was formed and will be used in the Medline, Embase, ScienceDirect and Cochrane databases as well as sources of unpublished literature. Primary and secondary outcomes will focus on immediate and longer-term antibiotic prescription rate and patient decision aid efficacy. We have established a literature screening process and criteria for quantitative synthesis. Literature screening and study quality assessment will be carried out by two independent and blinded reviewers. We will use a single data extraction protocol. Results We are yet to start any formal data collection or analysis but have secured funding from Mackay Institute of Research and Innovation. Ethics and Dissemination It was decided that this systematic review protocol did not require ethical approval. Study sponsors will be communicated with regularly regarding the study, which will be published in a journal in the relevant field. Any updates to the protocol will be published as required. Registration Prospero registration number: CRD42017069598 Keywords Patient decision aid; Shared decision making; Upper respiratory tract infection; Antibiotic prescription; General practice; Emergency department

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