Effectiveness of safety netting approaches for acutely ill children: a network meta-analysis.

BACKGROUND: Safety netting advice (SNA) can help in the management of acutely ill children. AIM: Assess the effectiveness of different SNA methods for acutely ill children on antibiotic prescription and consumption. DESIGN AND SETTING: Systematic review and network meta-analysis of randomised controlled trials, non-randomised trials of interventions, and controlled before-after studies in ambulatory care. METHOD: We searched MEDLINE, Embase, Web-Of-Science Core Collection, and Cochrane Central Register of Controlled Trials (22 January 2024). We assessed the risk of bias (RoB) with the Cochrane Tool 2, Revised Cochrane Tool for Cluster-Randomised Trials, and ROBINS-I tool. Certainty of evidence was assessed using the CINeMA approach. We performed sensitivity analyses and network meta-regression. RESULTS: We included 30 studies (20 interventions). Compared to usual care, paper SNA may reduce antibiotic prescribing (OR=0.66 (95%CI: 0.53-0.85), I²=92%, very low certainty; 3 studies, 35,988 participants), especially when combined with oral SNA (OR=0.40 (95%CI: 0.08-2.00), P-score: 0.86), antibiotic consumption (OR=0.39 (95%CI: 0.27-0.58), low RoB; 1 study, 509 participants), and return visits (OR=0.74 , 95%CI 0.63-0.87). Paper SNA without antibiotics may reduce antibiotic consumption compared to paper SNA and delayed antibiotics (OR=0.27 (95%CI: 0.15-0.51, some RoB; 1 study, 206 participants). Video SNA, oral SNA, read-only websites, and web-based modules may increase parental knowledge (ORs 2.23-4.52). Video SNA and web-based modules may improve parental satisfaction (ORs 1.64-4.08). CONCLUSION: Paper SNA (with oral SNA) may reduce antibiotic use and return visits. Video, oral, and online SNA, may improve parental knowledge while video SNA and web-based modules may increase parental satisfaction.

Temporal trends in antibiotic prescribing and serious and nonserious infections in children presenting to general practice: a registry-based longitudinal cohort study of 162 507 individuals.

BACKGROUND: It is crucial to understand the trends in paediatric antibiotic prescribing and serious and nonserious infections to improve antibiotic prescribing practices for children in ambulatory care. OBJECTIVES: Assessing trends in paediatric antibiotic prescribing and infection incidence in general practice from 2002 to 2022. METHODS: In this retrospective cohort study using INTEGO network data from 162 507 patients in Flanders (Belgium), we calculated antibiotic prescribing rates and proportions alongside incidence rates of serious and nonserious infections, stratified by age (0-1, 2-6, 7-12 years) and municipality. We performed autoregressive moving average time-series analyses and seasonality analyses. RESULTS: From 2002 to 2022, antibiotic prescribing rate decreased significantly: 584/1000 person-years (PY) (95% CI 571-597) to 484/1000PY (95% CI 478-491); so did antibiotic overall prescribing proportion: 46.3% (95% CI 45.1-47.6) to 23.3% (95% CI 22.9-23.7) (59.3% amoxicillin and 17.8% broad spectrum). Prescribing proportions dropped significantly for nonserious (45.6% to 20.9%) and increased for serious infections (64.1% to 69.8%). Proportions significantly dropped for acute suppurative otitis media (74.7% to 64.1%), upper respiratory tract infections (44.9% to 16.6%), bronchitis/bronchiolitis (73.6% to 44.1%) and acute tonsillopharyngitis (59.5% to 21.7%), while significantly increasing for pneumonia (65.2% to 80.2%). Nonserious and serious infection incidence rates increased from 785/1000PY and 34.2/1000PY to 1223/1000PY and 64.1/1000PY, respectively. Blood and CRP testing proportions increased significantly. CONCLUSIONS: Antibiotic prescribing in general practice for children declined from 2002 to 2022. Further targeted antibiotic stewardship initiatives are needed to reduce the use of broad-spectrum antibiotics and antibiotic prescribing for conditions such as otitis media and bronchitis/bronchiolitis.

Towards an international consensus on safety netting advice for acutely ill children presenting to ambulatory care: a modified e-Delphi procedure.

OBJECTIVE: Develop a consensus on the content and form of safety netting advice (SNA) for parents of acutely ill children. DESIGN: Four-round modified e-Delphi using online questionnaires and feedback among clinical and research experts. SETTING: Ambulatory care in high-income countries. PARTICIPANTS: Forty-one experts from 13 countries: 3 emergency physicians, 15 general practitioners, 4 nurses and 19 paediatricians. RESULTS: The experts defined the content of SNA as advice on the normal, expected disease course of the provisional diagnosis, diagnostic uncertainty, alarm signs that indicate the need for medical help and information on where and how to find such help. Regarding the form of the SNA, the experts agree that a reliable source should give SNA verbally with paper or digital written or video/image resources at every appropriate healthcare encounter in a short and simple empowering fashion, specific to the child's situation and seek confirmatory feedback from parents. CONCLUSIONS: SNA needs to contain advice on the expected disease course, alarm signs and where and how to find help. It should be given verbally with written resources by a reliable healthcare professional or digital platform. Short, simple and specific, SNA needs to empower the parent whose understanding of the advice should be checked. The effectiveness of SNA resources coproduced by parents and experts should be assessed in different settings and those providing SNA require up-to-date and reliable training.

Antibiotic use in ambulatory care for acutely ill children in high-income countries: a systematic review and meta-analysis.

OBJECTIVE: To determine the rate and appropriateness of antibiotic prescribing for acutely ill children in ambulatory care in high-income countries. DESIGN: On 10 February 2021, we systematically searched articles published since 2000 in MEDLINE, Embase, CENTRAL, Web Of Science and grey literature databases. We included cross-sectional and longitudinal studies, time-series analyses, randomised controlled trials and non-randomised studies of interventions with acutely ill children up to and including 12 years of age in ambulatory care settings in high-income countries. Pooled antibiotic prescribing and appropriateness rates were calculated using random-effects models. Meta-regression was performed to describe the relationship between the antibiotic prescribing rate and study-level covariates. RESULTS: We included 86 studies comprising 11 114 863 children. We found a pooled antibiotic prescribing rate of 45.4% (95% CI 38.2% to 52.8%) for all acutely ill children, and 85.6% (95% CI 73.3% to 92.9%) for acute otitis media, 37.4% (95% CI 30.9% to 44.3%) for respiratory tract infections, and 40.4% (95% CI 29.9% to 51.9%) for other diagnoses. Considerable heterogeneity can only partly be explained by differences in diagnoses. The overall pooled appropriateness rate is 68.5% (95% CI 55.8% to 78.9%, I²=99.8%; 19 studies, 119 995 participants). 38.3% of all prescribed antibiotics were aminopenicillins. CONCLUSIONS: Antibiotic prescribing rates for acutely ill children in ambulatory care in high-income countries remain high. Large differences in prescription rates between studies can only partly be explained by differences in diagnoses. Better registration and further research are needed to investigate patient-level data on diagnosis and appropriateness.

Using Belgian pharmacy dispensing data to assess antibiotic use for children in ambulatory care.

BACKGROUND: The desired effect of antibiotics is compromised by the rapid escalation of antimicrobial resistance. Children are particularly at high-risk for unnecessary antibiotic prescribing, which is owing to clinicians' diagnostic uncertainty combined with parents' concerns and expectations. Recent Belgian data on ambulatory antibiotic prescribing practices for children are currently lacking. Therefore, we aim to analyse different aspects of antibiotic prescriptions for children in ambulatory care. METHODS: Pharmacy dispensing data on antibiotics for systematic use referring from 2010 to 2019 were retrieved from Farmanet, a database of pharmaceutical dispensations in community pharmacies. Population data were obtained from the Belgian statistical office (Statbel). Descriptive statistics were performed in Microsoft Excel. The Mann-Kendall test for trend analysis and the seasplot function for seasonality testing were conducted in R. RESULTS: The past decade, paediatric antibiotic use and expenditures have relatively decreased in Belgian ambulatory care with 35.5% and 44.3%, respectively. The highest volumes of antibiotics for children are prescribed by GPs working in Walloon region and rural areas, to younger children, and during winter. The most prescribed class of antibiotics for children are the penicillins and the biggest relative reduction in number of packages is seen for the sulfonamides and trimethoprim and quinolone antibacterials. CONCLUSIONS: Paediatric antibiotic use has decreased in Belgian ambulatory care. Further initiatives are needed to promote prudent antibiotic prescribing in ambulatory care.