Clinical practice guidelines for acute otitis media in children: A systematic review and appraisal of European national guidelines

Objectives: To appraise European guidelines for acute otitis media (AOM) in children, including methodological quality, level of evidence and strength of recommendations (SoR), and consideration of antibiotic stewardship. Design: Systematic review of the literature Data sources: Three-pronged search of 1) Databases: Medline, Embase, Cochrane library, Guidelines International Network, and Trip Medical Database; 2) websites of European national paediatric associations and 3) contact of European experts. Data was collected between January 2017-February 2018. Eligibility criteria: National guidelines of European countries for the clinical management of AOM in children aged <16 years. Data extraction and synthesis: Data was extracted using tables constructed by the research team. Guidelines were graded using AGREE II criteria. Level of Evidence (LoE) and Strength of Recommendations (SoR) were compared. Guidelines were assessed for principles of antibiotic stewardship. Results: AOM guidelines were obtained from 17 of the 32 EU/EFTA countries. The mean AGREE II score was ≤41% across most domains. Diagnosis of AOM was based upon similar signs and symptoms. The most common indication for antibiotics was tympanic membrane perforation/otorrhoea (14/15,93%). The majority (15/17;88%) recommended a watchful waiting approach to antibiotics. Amoxicillin was the most common first-line antibiotic (14/17;82%). Recommended treatment duration varied from five to ten days. Seven countries advocated high dose (75-90mg/kg/day) and five low dose (30-60mg/kg/day) amoxicillin. Less than 60% of guidelines used a national or international scale system to rate level of evidence to support recommendations. Under half of the guidelines (7/17; 41%) referred to country-specific microbiological and antibiotic resistance data. Conclusions: Guidelines for managing AOM were similar across European countries. Guideline quality was mostly weak, and often did not refer to country-specific antibiotic resistance patterns. Co-ordinating efforts to produce a core guideline which can then be adapted by each country may help improve overall quality and contribute to tackling antibiotic resistance. Strengths and limitations of this study: • Strengths: The methodology includes the use of a comprehensive three-pronged search strategy with no language restrictions to identify guidelines from across Europe, the use of a standardized and internationally recognised guideline appraisal tool (AGREE II), the assessment of Leveles of Evidence and Strength of Recommendations, and the assessment of whether antibiotic stewardship, a key measure to reduce antimicrobial resistance (AMR), was considered. • Limitations: The review focused only on AOM without complications; guidelines for complex otitis media requiring specialist (Ear Nose Throat) input were not included. Another limitation is the consideration of whether guidelines developers used country-specific AMR patterns to assess if the recommendations of antibiotics were based on AMR data. However, there is often wide heterogeneity in terms of AMR patterns within each country

Role of point-of-care tests in the management of febrile children: a qualitative study of hospital-based doctors and nurses in England

Objectives The use of rapid point-of-care tests (POCTs) has been advocated for improving patient management and outcomes and for optimising antibiotic prescribing. However, few studies have explored healthcare workers’ views about their use in febrile children. The aim of this study was to explore the perceptions of hospital-based doctors and nurses regarding the use of POCTs in England. Study design Qualitative in-depth interviews with purposively selected hospital doctors and nurses. Data were analysed thematically. Setting Two university teaching hospitals in London and Newcastle. Participants 24 participants (paediatricians, emergency department doctors, trainee paediatricians and nurses). Results There were diverse views about the use of POCTs in febrile children. The reported advantages included their ease of use and the rapid availability of results. They were seen to contribute to faster clinical decision-making; the targeting of antibiotic use; improvements in patient care, flow and monitoring; cohorting (ie, the physical clustering of hospitalised patients with the same infection to limit spread) and enhancing communication with parents. These advantages were less evident when the turnaround for results of laboratory tests was 1–2 hours. Factors such as clinical experience and specialty, as well as the availability of guidelines recommending POCT use, were also perceived as influential. However, in addition to their perceived inaccuracy, participants were concerned about POCTs not resolving diagnostic uncertainty or altering clinical management, leading to a commonly expressed preference for relying on clinical skills rather than test results solely. Conclusion In this study conducted at two university teaching hospitals in England, participants expressed mixed opinions about the utility of current POCTs in the management of febrile children. Understanding the current clinical decision-making process and the specific needs and preferences of clinicians in different settings will be critical in ensuring the optimal design and deployment of current and future tests. Data availability statement Data are available upon reasonable request. The datasets generated and/or analysed during the current study will be made available upon reasonable request through the London School of Hygiene and Tropical Medicine data depository (LSHTM Data COMPASS)

Characteristics and management of adolescents attending the ED with fever: a prospective multicentre study

Objective Most studies on febrile children have focused on infants and young children with serious bacterial infection (SBI). Although population studies have described an increased risk of sepsis in adolescents, little is known about febrile adolescents attending the emergency department (ED). We aimed to describe patient characteristics and management of febrile adolescents attending the ED. Design and setting The MOFICHE/PERFORM study (Management and Outcome of Febrile Children in Europe/Personalised Risk assessment in Febrile illness to Optimise Real-life Management across the European Union), a prospective multicentre study, took place at 12 European EDs. Descriptive and multivariable regression analyses were performed, comparing febrile adolescents (12–18 years) with younger children in terms of patient characteristics, markers of disease severity (vital signs, clinical alarming signs), management (diagnostic tests, therapy, admission) and diagnosis (focus, viral/bacterial infection). Results 37 420 encounters were included, of which 2577 (6.9%) were adolescents. Adolescents were more often triaged as highly urgent (38.9% vs 34.5%) and described as ill appearing (23.1% vs 15.6%) than younger children. Increased work of breathing and a non-blanching rash were present less often in adolescents, while neurological signs were present more often (1% vs 0%). C reactive protein tests were performed more frequently in adolescents and were more often abnormal (adjusted OR (aOR) 1.7, 95% CI 1.5 to 1.9). Adolescents were more often diagnosed with SBI (OR 1.8, 95% CI 1.6 to 2.0) and sepsis/meningitis (OR 2.3, 95% CI 1.1 to 5.0) and were more frequently admitted (aOR 1.3, 95% CI 1.2 to 1.4) and treated with intravenous antibiotics (aOR 1.7, 95% CI 1.5 to 2.0). Conclusions Although younger children presented to the ED more frequently, adolescents were more often diagnosed with SBI and sepsis/meningitis. Our data emphasise the importance of awareness of severe infections in adolescents

Variation in hospital admission in febrile children evaluated at the Emergency Department (ED) in Europe: PERFORM, a multicentre prospective observational study

Objectives Hospitalisation is frequently used as a marker of disease severity in observational Emergency Department (ED) studies. The comparison of ED admission rates is complex in potentially being influenced by the characteristics of the region, ED, physician and patient. We aimed to study variation in ED admission rates of febrile children, to assess whether variation could be explained by disease severity and to identify patient groups with large variation, in order to use this to reduce unnecessary health care utilization that is often due to practice variation. Design MOFICHE (Management and Outcome of Fever in children in Europe, part of the PERFORM study, www.perform2020.org), is a prospective cohort study using routinely collected data on febrile children regarding patient characteristics (age, referral, vital signs and clinical alarming signs), diagnostic tests, therapy, diagnosis and hospital admission. Setting and participants Data were collected on febrile children aged 0–18 years presenting to 12 European EDs (2017–2018). Main outcome measures We compared admission rates between EDs by using standardised admission rates after adjusting for patient characteristics and initiated tests at the ED, where standardised rates >1 demonstrate higher admission rates than expected and rates <1 indicate lower rates than expected based on the ED patient population. Results We included 38,120 children. Of those, 9.695 (25.4%) were admitted to a general ward (range EDs 5.1–54.5%). Adjusted standardised admission rates ranged between 0.6 and 1.5. The largest variation was seen in short admission rates (0.1–5.0), PICU admission rates (0.2–2.2), upper respiratory tract infections (0.4–1.7) and fever without focus (0.5–2.7). Variation was small in sepsis/meningitis (0.9–1.1). Conclusions Large variation exists in admission rates of febrile children evaluated at European EDs, however, this variation is largely reduced after correcting for patient characteristics and therefore overall admission rates seem to adequately reflect disease severity or a potential for a severe disease course. However, for certain patient groups variation remains high even after adjusting for patient characteristics