 |
|
Use of Simple Heuristics to Target Macrolide Prescription in Children With Community-Acquired Pneumonia
Joachim E. Fischer, MD, MSc;
Felicitas Steiner, MD;
Franziska Zucol, MD;
Christoph Berger, MD;
Laura Martignon, PhD;
Walter Bossart, PhD;
Martin Altwegg, PhD;
David Nadal, MD
Arch Pediatr Adolesc Med. 2002;156:1005-1008.
Background Macrolides are the first-line antibiotic treatment of community-acquired
pneumonia (CAP). Owing to alarming resistance rates among invasive Streptococcus pneumoniae isolates, particularly in young children,
macrolide use should be restricted to patients infected with susceptible pathogens,
eg, Mycoplasma pneumoniae.
Objective To develop a simple clinical prediction rule for identifying M pneumoniae as the cause of CAP in children.
Design and Setting Prospective cohort study in 253 children with radiologically confirmed
CAP in a walk-in clinic of a tertiary care hospital.
Main Outcome Measures Mycoplasma infection, proven by results of antibody testing of paired
serum samples (gold standard). We compared the area under the receiver operating
characteristic curve (c statistic) of the following 2 prediction models: a
scoring system derived from logistic regression analysis and a fast-and-frugal
decision tree.
Results Mycoplasma pneumoniae infection was confirmed
in 32 (13%) of 253 children. A scoring system based on duration of fever and
patient age yielded a c statistic of 0.84 (95% confidence interval [CI], 0.77-0.91),
compared with that of the decision tree (c = 0.76 [95% CI, 0.70-0.83]). The
scoring system identified 75% of all cases as being at high or very high risk
for M pneumoniae infection; the decision tree, 72%
at high risk. The scoring system would curtail macrolide prescriptions by
75%; the decision tree, by 68%.
Conclusions In children with CAP, simple clinical decision rules identify patients
at risk for M pneumoniae infection. At present US
macrolide resistance rates among invasive S pneumoniae
isolates, both rules increase the chance of prescribing effective first-line
antibiotics compared with general macrolide administration.
From the Horten-Zentrum (Dr Fischer), the Institute of Medical Virology
(Dr Bossart), and the Department of Medical Microbiology (Dr Altwegg), University
of Zurich, and the Division of Infectious Diseases, University Children's
Hospital of Zurich (Drs Steiner, Zucol, Berger, and Nadal), Zurich, Switzerland;
and the Max Planck Institute for Human Development, Berlin, Germany (Dr Martignon).
|
