Recommendations

RACP Paediatrics & Child Health Division

1.
Do not routinely prescribe oral antibiotics to children with fever without an identified bacterial infection

The vast majority of children presenting with fever do not have a bacterial infection and therefore will not benefit from being prescribed oral antibiotics. For instance, one study of febrile infants found overall bacteraemia frequency of well below one per cent. Sometimes, in exception to this, oral antibiotics are prescribed to treat an unapparent bacterial infection or prevent development of severe bacterial infection and appear to have beneficial effects, though even the significance of these effects is disputed. Given that inappropriate prescribing of antibiotics is a major cause of antibiotic resistance and antibiotics have adverse effects, it is not considered good clinical practice to prescribe antibiotics in children without a specific bacterial infection.

Supporting evidence
  • Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2016: first Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC 2016.
  • Hahné SJM, Charlett A, Purcell B, et al. Effectiveness of antibiotics given before admission in reducing mortality from meningococcal disease: systematic review. British Medical Journal 2006; 332(7553):1299-303.
  • Rothrock SG, Harper MB, Green SM, et al. Do oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia? A meta-analysis. Pediatrics 1997; 99(3):438.
  • Rudinsky SL, Carstairs KL, Reardon JM, et al. Serious bacterial infections in febrile infants in the post-pneumococcal conjugate vaccine era. Academic Emergency Medicine 2009; 16(7):585-90.
How this list was made How this list was made

The Paediatrics & Child Health Division (PCHD) formed a group of interested Fellows to comprise a General Paediatrics EVOLVE Working Group. A review of low-value practices relevant to general paediatrics was conducted drawing on lists published by Choosing Wisely US and Canada, contributions to Choosing Wisely Australia by other medical colleges and published EVOLVE lists developed by other specialties in order to identify low-value practices of relevance while avoiding duplicating the mention of practices already identified in other EVOLVE lists. Based on this review, the Working Group shortlisted 15 items for further consideration. 

These 15 items were then reviewed and discussed by participants at a workshop held at the RACP Annual Congress 2016. Following these deliberations, the list was further narrowed down to 10 items. These 10 items were incorporated into an online survey which also summarised the recent evidence on each of these items. A link to the survey was distributed to all Fellows and advanced trainees of the RACP Paediatrics & Child Health Division. 

Survey respondents were asked whether they agreed, disagreed or were unsure about whether each item was undertaken in a significant number of paediatric patients, whether there was good evidence that the item should be undertaken less often and whether reducing use of the item was important in terms of reducing harm and/or costs to the healthcare system. Each item was assigned a score based on respondents’ answers to these three questions on each item. There were 269 respondents representing a survey response rate of approximately 22 per cent. The five highest scoring items were selected to be on this ‘top-five’ list.