Trial finds stewardship intervention neither helped nor harmed kids with respiratory tract infections

Coughing girl in bed

Jane Rubtsova / iStock

A randomized controlled trial in England found that a multifaceted antibiotic stewardship intervention for children with respiratory tract infections did not reduce overall antibiotic dispensing or increase respiratory tract infection–related hospitalizations in children, researchers reported yesterday in The BMJ.

The trial enrolled 294 general practices in England and randomly assigned them to two arms. One arm (144 practices) implemented an intervention that consisted of eliciting parental concerns during consultation, using a clinician-focused algorithm to predict the risk of hospital admission within 30 days for children with respiratory tract infection along with antibiotic-prescribing guidance, and giving parents a leaflet with information on caring for children with coughs. The practices in the control arm (150) were asked to treat children presenting with cough or respiratory tract infection as they normally would.

No difference in antibiotic dispensing

The primary outcomes of the trial, which was conducted from November 2018 through September 2021, were the rate of dispensed amoxicillin and macrolide antibiotics and the rate of hospital admission for respiratory infections in children ages 0 to 9 years over a 12-month stretch.

No evidence was found that antibiotic dispensing differed between the intervention practices (155 items dispensed per year per 1,000 children; 95% confidence interval [CI], 138 to 174) and the control practices (157 items dispensed/year/1,000 children) (rate ratio, 1.011; 95% CI, 0.992 to 1.029). The rate of hospital admission in the intervention practices (13/1,000 children; 95% CI, 10 to 18) was non-inferior compared with control practices (15/1,000 children; 95% CI, 12 to 20).

Evidence suggested that prescribing rates were slightly reduced in certain subgroups of intervention practices, such as single-site practices, practices with fewer nurses, and practices in deprived areas. In addition, a post-hoc analysis found reduced dispensing in some intervention clinics prior to the COVID-19 pandemic. But the reductions weren't clinically relevant.

More research needed in subgroups

"More research is needed to confirm potential effects seen in practices with fewer prescribing nurses, restricted to a single site, or located in areas of lower deprivation and in younger children and post-pandemic conditions," the authors wrote.

Given the significant external factors that blindsided this trial at the start of the pandemic, a post hoc analysis of this kind is justified.

In a related commentary, Jerome Leis, MD, an infectious disease specialist at the University of Toronto, wrote, "This trial should not be written off as yet another unsuccessful attempt at improving antibiotic prescribing for respiratory tract infections in primary care.

"Importantly, a sensitivity analysis found significantly lower antibiotic dispensing in the practices in the intervention arm before March 2020. Given the significant external factors that blindsided this trial at the start of the pandemic, a post hoc analysis of this kind is justified. This finding suggests that when deployed as designed, this intervention can reduce antibiotic dispensing for respiratory tract infections in primary care, although the full magnitude of this effect remains unknown."

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