Latvian Primary Care Management of Children with Acute Infections : Antibiotic-Prescribing Habits and Diagnostic Process Prior to Treatment

Publisher Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland.Background and Objectives: Primary care physicians frequently prescribe antibiotics for acutely ill children, even though they usually have self-limiting diseases of viral etiology. The aim of this research was to evaluate the routine antibiotic-prescribing habits of primary care in Latvia, in response to children presenting with infections. Materials and Methods: This cross-sectional study included acutely ill children who consulted eighty family physicians (FP) in Latvia, between November 2019 and May 2020. The data regarding patient demographics, diagnoses treated with antibiotics, the choice of antibiotics and the use of diagnostic tests were collected. Results: The study population comprised 2383 patients aged between one month and 17 years, presenting an acute infection episode, who had a face-to-face consultation with an FP. Overall, 29.2% of these patients received an antibiotic prescription. The diagnoses most often treated with antibiotics were otitis (45.8% of all antibiotic prescriptions), acute bronchitis (25.0%) and the common cold (14.8%). The most commonly prescribed antibiotics were amoxicillin (55.9% of prescriptions), amoxicillin/clavulanate (18.1%) and clarithromycin (11.8%). Diagnostic tests were carried out for 59.6% of children presenting with acute infections and preceded 66.4% of antibiotic prescriptions. Conclusion: Our data revealed that a high level of antibiotic prescribing for self-limiting viral infections in children continues to occur. The underuse of narrow-spectrum antibiotics and suboptimal use of diagnostic tests before treatment decision-making were also identified. To achieve a more rational use of antibiotics in primary care for children with a fever, professionals and parents need to be better educated on this subject, and diagnostic tests should be used more extensively, including the implementation of daily point-of-care testing.publishersversionPeer reviewe

Clinical features of pediatric post-acute COVID-19 : a descriptive retrospective follow-up study

Funding Information: This study was supported by the National Research Program to Mitigate Consequences of COVID-19 (VPP-COVID-2020/1–0011). Publisher Copyright: © 2021, The Author(s).To date, information on COVID-19 long-term post-recovery sequelae in children and adolescents remains scarce. A retrospective descriptive cohort study was performed by collecting data on 92 patients (age ≤ 18 years). All were evaluated during a face-to-face visit following a specially designed post-COVID-19 symptom assessment protocol at the following stage: 1–3 months after COVID-19 onset. Among the 92 children, 45 (49%) were completely free of any COVID-19-related symptoms, while 47 (51%) reported persistence of at least one symptom, in particular tiredness, loss of taste and/or smell and headaches. The most common post-acute COVID-19 clinical features were noted in children aged between 10 and 18 years. A detailed multidisciplinary follow-up of patients with COVID-19 seems relevant, whatever the severity of the symptoms.publishersversionPeer reviewe

Diagnostic markers for early sepsis diagnosis in children with systemic inflammatory response syndrome

Sepsis caused by infection remains a major cause of mortality among children. One of the main reasons for high sepsis mortality rates is the inability to obtain early diagnosis. Sensitive and specific biomarkers are greatly needed in rapid diagnosis of sepsis. The main aim of study was to investigate the ability of high-mobility group box-1 protein (HMGB1), lipopolysaccharide-binding protein (LBP), Interleukin-6 (IL-6), procalcitonin (PCT) and C reactive protein (CRP) to differentiate sepsis patients. Eighty-four children with Systemic Inflammatory Response Syndrome (SIRS) were included in the prospective study. Sepsis was recognised in 23% (n = 19) of them. LBP, IL-6, CRP and PCT levels were significantly higher among the sepsis group (P < 0.05). HMGB1 levels in the sepsis patients did not significantly differ from SIRS patients. In ROC analysis in sepsis patients, identification markers LBP, IL6 and CRP performed quite similarly (P < 0.001), with the best result being for IL6. Our data suggest that in early sepsis diagnosis in children, LBP, IL-6, PCT and CRP are probably the superior diagnostic markers, with the best performance by IL6. LBP and IL-6 are superior markers for sepsis patients' disease process monitoring. HMGB1 does not have a diagnostic value for sepsis patient identification.publishersversionPeer reviewe

Value of parental concern and clinician's gut feeling in recognition of serious bacterial infections : A prospective observational study

Funding Information: Authors are thankful to State Research programme “BIOMEDICINE”, Project No. 5.6.2. “Research on acute and chronic diseases in children of wide age range to develop diagnostic and therapeutic algorithms to reduce mortality, prolong survival and improve quality of life”. This manuscript was drafted as a part of the project. We thank all the participating clinicians and research team of data collectors. Funding Information: This research was funded by State Research programme “BIOMEDICINE”, Project No. 5.6.2. “Research on acute and chronic diseases in children of wide age range to develop diagnostic and therapeutic algorithms to reduce mortality, prolong survival and improve quality of life”. This manuscript was drafted as a part of the project. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. Publisher Copyright: © 2019 The Author(s).Background: Serious bacterial infections (SBI) are a significant cause of mortality worldwide. Parental concern and clinician's gut feeling that there is something wrong has been associated with increased likelihood of developing SBI in primary care studies. The aim of this study is to assess the diagnostic value of parental concern and gut feeling at the emergency department of a tertiary hospital. Methods: This prospective observational study included children with fever attending the emergency department of Children's Clinical University hospital in Riga between October 2017 and July 2018. Data were collected via parental and clinician questionnaires. "Gut feeling" was defined as intuitive feeling that the child may have a serious illness, and "Sense of reassurance" as a feeling that the child has a self-limiting illness. "Parental concern" was defined as impression that this illness is different from previous illnesses. SBI included bacterial meningitis, sepsis, bacteraemia, pneumonia, urinary tract infection, appendicitis, bacterial gastroenteritis, and osteomyelitis. Pearson's Chi-Squared test or Fisher's exact test were used to compare the variables between children with and without SBI. Positive likelihood ratio was calculated for "gut feeling", "sense of reassurance", and parental concern. Results: The study included 162 patients aged 2 months to 17.8 years. Forty-six patients were diagnosed with SBI. "Sense of reassurance" expressed by all clinicians was associated with lower likelihood of SBI (positive likelihood ratio 8.8, 95% confidence interval 2.2-34.8). "Gut feeling" was not significantly predictive of the patient being diagnosed with SBI (positive likelihood ratio 3.1, 95% confidence interval 1.9-5.1), The prognostic rule-in value of parental concern was insignificant (positive likelihood ratio 1.4, 95% confidence interval 1.1-1.7). Conclusion: Sense of reassurance was useful in ruling out SBI. Parental concern was not significantly predictive of SBI.publishersversionPeer reviewe

A comparison of the epidemiology, clinical features, and treatment of acute osteomyelitis in hospitalized children in Latvia and Norway

Publisher Copyright: © 2020 by the authors. Licensee MDPI, Basel, Switzerland.Background and objectives: Paediatric acute osteomyelitis (AO) may result in major lifethreatening and limb-threatening complications if not recognized and treated early. The management of AO may depend on local microbial prevalence and virulence factors. This study compares the approach to paediatric AO in hospitals in two countries-Latvia and Norway. Materials and Methods: The study includes patients with AO hospitalized in the paediatric department in the Norwegian hospital Sørlandet Sykehus Kristiansand (SSK), in the period between the 1st of January 2012 and the 31st of December 2019. The results from SSK are compared to the results of a published study of AO in patients hospitalized at the Children’s Clinical University Hospital (CCUH) in Riga, Latvia. Results: The most isolated pathogen from cultures in both hospitals was S. aureus (methicillinsensitive). The lower extremity was the most affected body part (75% in CCUH, 95% in SSK), the main clinical symptom was pain (CCUH 92%, SSK 96.6%). Deep culture aspiration was most often taken intraoperatively in CCUH (76.6%) and percutaneously in SSK (44.8%). Oxacillin was the most applied antibiotic in CCUH (89.4%), and Cloxacillin in SSK (84.6%). Combined treatment with anti-Staphylococcal penicillins and Clindamycin was administered in 25.5% and 33.8% of CCUH and SSK patients, respectively. The median duration of the intravenous antibacterial treatment in CCUH and SSK was 15 and 10 days, respectively, and a switch to oral therapy was mainly made at discharge in both hospitals. The median total duration of antibiotic treatment was 25 days in CCUH and 35 days in SSK. 75% of CCUH and 10.3% of SSK patients were treated surgically. Complications were seen in 47% of patients in CCUH and in 38% in SSK. Conclusions: The transition to oral antibacterial treatment in both hospitals was delayed, which suggests a lack of criteria for discontinuation of intravenous therapy and could potentially contribute to longer hospitalization, higher cost of treatment and risk of complications. The use of more invasive techniques for deep culturing and significantly more common surgical interventions could possibly be linked to a higher complication rate in AO patients treated at the Latvian hospital.publishersversionPeer reviewe

Integrating Clinical Signs at Presentation and Clinician's Non-analytical Reasoning in Prediction Models for Serious Bacterial Infection in Febrile Children Presenting to Emergency Department

Funding Information: The study was partially derived from the PERFORM (Personalised Risk Assessment in Febrile Illness to Optimise Real-Life Management Across the European Union) project, which has been supported by funding received from the European Union's Horizon 2020 research and innovation program (PERFORM) under Grant Agreement No. 668303. Publisher Copyright: Copyright © 2022 Urbane, Petrosina, Zavadska and Pavare.Objective: Development and validation of clinical prediction model (CPM) for serious bacterial infections (SBIs) in children presenting to the emergency department (ED) with febrile illness, based on clinical variables, clinician's “gut feeling,” and “sense of reassurance. Materials and Methods: Febrile children presenting to the ED of Children's Clinical University Hospital (CCUH) between April 1, 2017 and December 31, 2018 were enrolled in a prospective observational study. Data on clinical signs and symptoms at presentation, together with clinician's “gut feeling” of something wrong and “sense of reassurance” were collected as candidate variables for CPM. Variable selection for the CPM was performed using stepwise logistic regression (forward, backward, and bidirectional); Akaike information criterion was used to limit the number of parameters and simplify the model. Bootstrapping was applied for internal validation. For external validation, the model was tested in a separate dataset of patients presenting to six regional hospitals between January 1 and March 31, 2019. Results: The derivation cohort consisted of 517; 54% (n = 279) were boys, and the median age was 58 months. SBI was diagnosed in 26.7% (n = 138). Validation cohort included 188 patients; the median age was 28 months, and 26.6% (n = 50) developed SBI. Two CPMs were created, namely, CPM1 consisting of six clinical variables and CPM2 with four clinical variables plus “gut feeling” and “sense of reassurance.” The area under the curve (AUC) for receiver operating characteristics (ROC) curve of CPM1 was 0.744 (95% CI, 0.683–0.805) in the derivation cohort and 0.692 (95% CI, 0.604–0.780) in the validation cohort. AUC for CPM2 was 0.783 (0.727–0.839) and 0.752 (0.674–0.830) in derivation and validation cohorts, respectively. AUC of CPM2 in validation population was significantly higher than that of CPM1 [p = 0.037, 95% CI (−0.129; −0.004)]. A clinical evaluation score was derived from CPM2 to stratify patients in “low risk,” “gray area,” and “high risk” for SBI. Conclusion: Both CPMs had moderate ability to predict SBI and acceptable performance in the validation cohort. Adding variables “gut feeling” and “sense of reassurance” in CPM2 improved its ability to predict SBI. More validation studies are needed for the assessment of applicability to all febrile patients presenting to ED.publishersversionPeer reviewe

Impact of educational training and C-reactive protein point-of-care testing on antibiotic prescribing in rural and urban family physician practices in Latvia : a randomised controlled intervention study

Funding Information: This work was supported by the Joint Funds for the innovation of science and Technology of Fujian province (2019Y9031) and Startup Fund for scientific research, Fujian Medical University (2021QH2046). Publisher Copyright: © 2022, The Author(s).BACKGROUND: Although self-limiting viral infections are predominant, children with acute infections are often prescribed antibiotics by family physicians. The aim of the study is to evaluate the impact of two interventions, namely C-reactive protein point-of-care testing and educational training, on antibiotic prescribing by family physicians. METHODS: This randomised controlled intervention study included acutely ill children consulted by 80 family physicians from urban and rural practices in Latvia. The family physicians were divided into two groups of 40. The family physicians in the intervention group received both interventions, i.e. C-reactive protein point-of-care testing and educational training, whereas the family physicians in the control group continued to dispense their standard care. The primary outcome measure was the antibiotic prescribing at the index consultation (delayed or immediate prescription) in both study groups. The secondary outcome was CRP testing per study group. Patient- and family physician- related predictors of antibiotic prescribing were analysed as associated independent variables. Practice location effect on the outcomes was specially addressed, similar to other scientific literature. RESULTS: In total, 2039 children with acute infections were enrolled in the study. The most common infections observed were upper and lower respiratory tract infections. Overall, 29.8% (n = 607) of the study population received antibiotic prescription. Our binary logistic regression analysis did not find a statistically significant association between antibiotic prescriptions and the implemented interventions. In the control group of family physicians, a rural location was associated with more frequent antibiotic prescribing and minimal use of CRP testing of venous blood samples. However, in the intervention group of family physicians, a rural location was associated with a higher level of C-reactive protein point-of-care testing. Furthermore, in rural areas, a significant reduction in antibiotic prescribing was observed in the intervention group compared with the control group (29.0% (n = 118) and 37.8% (n = 128), respectively, p = 0.01). CONCLUSION: Our results show that the availabilty of C-reactive protein point-of-care testing and educational training for family physicians did not reduce antibiotic prescribing. Nevertheless, our data indicate that regional variations in antibiotic-prescribing habits exist and the implemented interventions had an effect on family physicians practices in rural areas.publishersversionPeer reviewe

Beliefs, practices and health care seeking behavior of parents regarding fever in children

Funding Information: Acknowledgments: The authors thank all the data collectors, clinicians and parents who participated in the study. This research project was coordinated by State Research programme “BIOMEDICINE”, Project No. 5.6.2. “Research on acute and chronic diseases in children of wide age range to develop diagnostic and therapeutic algorithms to reduce mortality, prolong survival and improve quality of life”. Publisher Copyright: © 2019 by the authors. Licensee MDPI, Basel, Switzerland.Background and objectives: Fever in children is one of the most common reasons for seeking medical attention. Parents often have misconceptions about the effects to fever, which leads to inappropriate use of medication and nonurgent visits to emergency departments (ED). The aim of this study was to clarify the beliefs on the effects and management of fever and to identify healthcare seeking patterns among parents of febrile children in Latvia. Materials and Methods: Parents and legal guardians of children attending ED with febrile illness were included in the study. Participants were recruited in Children’s Clinical University Hospital (CCUH) in Riga, and in six regional hospitals in Latvia. Data on beliefs about fever, administration of antipyretics, healthcare-seeking behavior, and experience in communication with health care workers were collected via questionnaire. Results: In total, 355 participants were enrolled: 199 in CCUH and 156 in regional hospitals; 59.2% of participants considered fever itself as indicative of serious illness and 92.8% believed it could raise the child’s body temperature up to a dangerous level. Antipyretics were usually administered at median temperature of 38.0 °C, and the median temperature believed to be dangerous was 39.7 °C; 56.7% of parents usually contacted a doctor within the first 24 h of the illness. Parents who believed that lower temperatures are dangerous to a child were more likely to contact a doctor earlier and out-of-hours; 60.1% of participants had contacted their family doctor prior their visit to ED. Parental evaluation of satisfaction with the information and reassurance provided by the doctors at the hospital was higher than of that provided by their family doctor; 68.2% of participants felt safer when their febrile children were treated at the hospital. Conclusions: Fever itself was regarded as indicative of serious illness and potentially dangerous to the child’s life. These misconceptions lead to inappropriate administration of antipyretics and early-seeking of medical attention, even out-of-hours. Hospital environment was viewed as safer and more reassuring when dealing with febrile illness in children. More emphasis must be placed on parental education on proper management of fever, especially in primary care.publishersversionPeer reviewe

Coping with febrile illness in children : A qualitative interview study of parents

Funding Information: This study was part of the State Research Programme “Biomedicine”, Project No. 5.6.2. “Research on acute and chronic diseases in children of wide age range to develop diagnostic and therapeutic algorithms to reduce mortality, prolong survival and improve quality of life”. Publisher Copyright: © 2019 Urzula Nora Urbane et al., published by Sciendo 2019.The aim of this study was to investigate parental perception of febrile illness in their children, the most commonly applied management practices, as well as the expectations from clinicians when coping with fever in children. The study included parents of patients admitted to the Emergency and Observation Department of Children's Clinical University Hospital in Ria, Latvia. Data were collected via semi-structured interviews. All interviews were transcribed, and the transcripts analysed by inductive thematic analysis. Thirty-four parental interviews were analysed. Six themes emerged from the study, which were: signs causing concern; beliefs regarding fever; assessment and monitoring of fever; fever management practices; help-seeking behaviour; and expectations from the healthcare personnel. Many parents believed that fever could potentially cause injuries to the nervous system, kidneys, the brain, other internal organs, and even cause death. The perceived threat of fever resulted in frequent temperature measurements and administration of antipyretics. Meeting the emotional and information needs of the parents were considered as equally important to meeting the child's medical needs. The study found that fever phobia exists among parents. Parental misconceptions of fever lead to overly zealous management practices. Parental education initiatives must be organised in order to improve parental knowledge of fever and its management in children.publishersversionPeer reviewe

Levels of Inflammatory Cytokines and Chemokines in Hospitalized Children with Sepsis and Pneumonia

Introduction. Pneumonia is a common childhood lower respiratory tract infection, which accounts for large number of hospitalization and death among children; its diagnosis is based mainly on clinical signs.Aim of the study was to measure inflammatory cytokine panels in children with pneumonia, and their correlation with clinically used inflammatory markers. Materials and methods. We included 20 patients, hospitalized in Children’s Clinical University hospital, with systemic inflammatory response syndrome (SIRS) and radiologically confirmed pneumonia from October 2011 to January 2013. In all patients cytokine and chemokine panels and clinical inflammatory markers were measured at the time of admission, after 24 hours and on the time of discharge.Results. 12 different inflammatory cytokines were measured. sFAS, sVCAM1, IL-8, IL-10, TNF alpha, Eotaxin, G-CSF, IL1ra, IP10 and MCP1 showed statistically significant changes between levels of inclusion in the study and levels after 24 hours. G-CSF, IL-8, IFN gamma, TNF alpha and IL-10 showed also medium strong correlation with clinically used inflammatory markers (PCT, CRO, and IL-6).Conclusions. Inflammatory cytokines show statistically significant changes during course of treatment, thus they could be used in diagnostics in septic patients with pneumonia, and also could show patients response to therapy.publishersversionPeer reviewe