Treatment of chest infections

How are GPs meeting the challenge of whether to prescribe antibiotics for a young child with a fever and a cough?

The dilemma of whether to prescribe antibiotics for the common presentation of a young child with a fever and a cough is commonplace in the community setting.

It is something that is guided perhaps by the mantra that most common infections in young children are viral and will not respond to antibiotics.

However, the challenge remains to make the diagnosis of more serious bacterial illnesses, such as bacterial pneumonia following a viral infection, in young children.

Grant et al from New Zealand have recently reported that missed opportunities for appropriate antibiotic prescribing by health professionals appear to be common.1

They reported a case series of 280 children aged less than five years who were hospitalised with pneumonia, defined as an acute febrile illness with cough, respiratory distress, rapid breathing or chest wall in-drawing and an abnormal chest radiograph.

Approximately 20% had progressed in their illness so quickly that there was not time to give them an oral antibiotic and approximately 40% had received an antibiotic before presentation to hospital. For the remainder, the diagnosis was missed, antibiotics were not prescribed despite the correct diagnosis being made, or the parent failed to obtain the antibiotic that had been prescribed.

Missed opportunities to prescribe were not associated with illness severity at the time of hospital presentation but were associated with focal chest radiograph changes, a raised peripheral white cell count (>15 x 109/l) and bacteraemia (positive blood culture).

There are some pitfalls in proving the aetiology of pneumonia in young children. There are seasonal peaks in common viral infections such as respiratory syncytial virus, influenza viruses and adenoviruses which may commonly give significant changes on the chest radiograph in symptomatic children.

In the majority of these cases there will be widespread adventitious sounds on auscultation of the lung fields rather than focal signs suggesting a lobar pneumonia.

However, RSV commonly gives rise to partial right upper lobe collapse in young infants when chest radiographs are performed. So a subset of children, the sickest ones, will routinely and appropriately be given antibiotic treatment for the diagnosis of pneumonia when hospitalised, even if on testing it is shown that the only pathogen isolated was a virus.

In truth, the ability to exclude a bacterial cause for pneumonia is difficult. Older children and adults may provide a sputum sample for culture which young children cannot. Additionally, many emergency departments will not perform nasopharyngeal aspirates for viral immunofluorescence studies and culture because of cost pressures or the erroneous belief that it is unhelpful in the management of these children.

Clearly there needs to be a balanced approach to the rational prescribing of antibiotics and the risk of bacterial pneumonia in young children.

The most likely pathogen remains Streptococcus pneumoniae, and it is susceptible in the overwhelming majority of cases to amoxycillin (20mg/kg/dose three times daily for a week).

Therefore, in a febrile young child with a moist or rattly cough (without wheeze), localised signs on chest auscultation (crackles or decreased air entry) one should order a chest radiograph and a full blood count and review the results promptly.

The importance of filling the script for cases of presumed bacterial pneumonia should be emphasised to the parents of the child and instructions to return for review if the child is not improving should be clear.        

1. Archives of Disease in Childhood
doi:10.1136/archdischild-2011-300604