Raising AWaRe-ness of Antimicrobial Stewardship Challenges in Pediatric Emergency Care: Results from the PERFORM Study Assessing Consistency and Appropriateness of Antibiotic Prescribing Across Europe
Authors: Kolberg Laura , Khanijau Aakash , van der Velden Fabian J S , Herberg Jethro , De Tisham , Galassini Rachel , Cunnington Aubrey J , Wright Victoria J , Shah Priyen , Kaforou Myrsini , Wilson Clare , Kuijpers Taco , Martinón-Torres Federico , Rivero-Calle Irene , Moll Henriette , Vermont Clementien , Pokorn Marko , Kolnik Mojca , Pollard Andrew J , Agyeman Philipp K A , Schlapbach Luregn J , Tsolia Maria N , Yeung Shunmay , Zavadska Dace , Zenz Werner , Schweintzger Nina A , van der Flier Michiel , de Groot Ronald , Usuf Effua , Voice Marie , Calvo-Bado Leonides , Mallet François , Fidler Katy , Levin Michael , Carrol Enitan D , Emonts Marieke , von Both Ulrich ,   The PERFORM Consortium, Levin Michael , Cunnington Aubrey , De Tisham , Herberg Jethro A , Kaforou Myrsini , Wright Victoria J , Baumard Lucas , Bellos Evangelos , D'Souza Giselle , Galassini Rachel , Habgood-Coote Dominic , Hamilton Shea , Hoggart Clive , Hourmat Sara , Jackson Heather , Lin Naomi , Maconochie Ian , Menikou Stephanie , Nichols Samuel , Nijman Ruud , Paz Ivonne Pena , Powell Oliver , Shah Priyen , Vito Ortensia , Wilson Clare , Stevens Molly , Kim Eunjung , Kim Nayoung , Abdulla Amina , Ali Ladan , Darnell Sarah , Jorgensen Rikke , Mustafa Sobia , Persand Salina , Fidler Katy , Dudley Julia , Richmond Vivien , Tavliavini Emma , Carrol Enitan D , Cocklin Elizabeth , Jennings Rebecca , Johnston Joanne , Khanijau Aakash , Leigh Simon , Lewis-Burke Nadia , Newall Karen , Romaine Sam , Pollard Andrew J , Kandasamy Rama , Paulus Stéphane , Carter Michael J , O'Connor Daniel , Bibi Sagida , Kelly Dominic F , Gurung Meeru , Thorson Stephen , Ansari Imran , Murdoch David R , Shrestha Shrijana , Oliver Zoe , Emonts Marieke , Lim Emma , Valentine Lucille , Allen Karen , Bell Kathryn , Chan Adora , Crulley Stephen , Devine Kirsty , Fabian Daniel , King Sharon , McAlinden Paul , McDonald Sam , McDonnell Anne , Pickering Ailsa , Thomson Evelyn , Wood Amanda , Wallia Diane , Woodsford Phil , Baxter Frances , Bell Ashley , Rhodes Mathew , Agbeko Rachel , Mackerness Christine , Baas Bryan , Kloosterhuis Lieke , Oosthoek Wilma , Arif Tasnim , Bennet Joshua , Collings Kalvin , van der Giessen Ilona , Martin Alex , Rashid Aqeela , Rowlands Emily , de Vries Gabriella , van der Velden Fabian , Soon Joshua , Valentine Lucille , Martin Mike , Mistry Ravi , Valentine Lucille , Yeung Shunmay , Dewez Juan Emmanuel , Hibberd Martin , Bath David , Miners Alec , Nijman Ruud , Fitchett Elizabeth , Fink Colin , Voice Marie , Calvo-Bado Leo , Martinón-Torres Federico , Salas Antonio , ález Fernando Álvez Gonz , Farto Cristina Balo , Barral-Arca Ruth , Castro Marií Barreiro , Bello Xabier , García Mirian Ben , Carnota Sandra , Cebey-López Miriam , Curras-Tuala María José , árez Carlos Dur án Su , Vicente Luisa García , Gómez-Carballa Alberto , Rial Jose Gómez , Iglesias Pilar Lebor áns , Martinón-Torres Federico , Martinón-Torres Nazareth , ánchez José María Martinón S , Pérez Belén Mosquera , Pardo-Seco Jacobo , Rodríguez Lidia Piñeiro , Pischedda Sara , ázquez Sara Rey V , Calle Irene Rivero , Rodríguez-Tenreiro Carmen , Redondo-Collazo Lorenzo , Ora Miguel Sadiki , Salas Antonio , ández Sonia Serén Fern , Trasorras Cristina Serén , Iglesias Marisol Vilas , Moll Henriëtte A , Vermont Clementien L , Borensztajn Dorine M , Hagedoorn Nienke N , Tan Chantal , Zachariasse Joany , Dik W , de Groot Ronald , van der Flier Michiel , de Jonge Marien I , van Aerde Koen , Alkema Wynand , van den Broek Bryan , Gloerich Jolein , van Gool Alain J , Henriet Stefanie , Huijnen Martijn , Philipsen Ria , Willems Esther , Gerrits G P J M , van Leur M , Heidema J , de Haan L , Miedema C J , Neeleman C , Obihara C C , Tramper-Stranders G A , Kuijpers Taco , Jongerius Ilse , van den Berg J M , Schonenberg D , Barendregt A M , Pajkrt D , van der Kuip M , van Furth A M , Sprenkeler Evelien , Zandstra Judith , van Mierlo G , Geissler J , Zavadska Dace , Balode Anda , Bārzdiņa Arta , Deksne Dārta , Gardovska Dace , Grāvele Dagne , Grope Ilze , Meiere Anija , Nokalna Ieva , Pavāre Jana , Pučuka Zanda , Selecka Katrīna , Rudzāte Aleksandra , Svile Dace , Urbāne Urzula Nora , Zenz Werner , Kohlmaier Benno , Schweintzger Nina A , Sagmeister Manfred G , Kohlfürst Daniela S , Zurl Christoph , Binder Alexander , Høsele Susanne , Leitner Manuel , Pølz Lena , Rajic Glorija , Bauchinger Sebastian , Baumgart Hinrich , Benesch Martin , Ceolotto Astrid , Eber Ernst , Gallistl Siegfried , Gores Gunther , Haidl Harald , Hauer Almuthe , Hude Christa , Keldorfer Markus , Krenn Larissa , Pilch Heidemarie , Pfleger Andreas , Pfurtscheller Klaus , Nordberg Gudrun , Niedrist Tobias , Rødl Siegfried , Skrabl-Baumgartner Andrea , Sperl Matthias , Stampfer Laura , Strenger Volker , Till Holger , Trobisch Andreas , Løffler Sabine , von Both Ulrich , Kolberg Laura , Zwerenz Manuela , Buschbeck Judith , Bidlingmaier Christoph , Binder Vera , Danhauser Katharina , Haas Nikolaus , Griese Matthias , Feuchtinger Tobias , Keil Julia , Kappler Matthias , Lurz Eberhard , Muench Georg , Reiter Karl , Schoen Carola , Tsolia Maria , Eleftheriou Irini , Tambouratzi Maria , Marmarinos Antonis , Xagorari Marietta , Syggelou Kelly , Agyeman Philipp , Schlapbach Luregn J , Aebi Christoph , Wyss Verena , Usman Mariama , Giannoni Eric , Stocker Martin , Posfay-Barbe Klara M , Heininger Ulrich , Bernhard-Stirnemann Sara , Niederer-Loher Anita , Kahlert Christian , Natalucci Giancarlo , Relly Christa , Riedel Thomas , Aebi Christoph , Berger Christoph , Pokorn Marko , Kolnik Mojca , Vincek Katarina , Srovin Tina Plankar , Bahovec Natalija , Prunk Petra , Osterman Veronika , Avramoska Tanja , Mallet François , Brengel-Pesce Karen , Pachot Alexandre , Mommert Marine , Usuf Effua , Bojang Kalifa , Zaman Syed M A , Secka Fatou , Anderson Suzanne , Sarr Anna RocaIsatou , Saidykhan Momodou , Darboe Saffiatou , Ceesay Samba , D'alessandro Umberto , Shen Ching-Fen , Liu Ching-Chuan , Wang Shih-Min 
Published: October 2023

Abstract

Background
Optimization of antimicrobial stewardship is key to tackling antimicrobial resistance, which is exacerbated by overprescription of antibiotics in pediatric emergency departments (EDs). We described patterns of empiric antibiotic use in European EDs and characterized appropriateness and consistency of prescribing.

Methods
Between August 2016 and December 2019, febrile children attending EDs in 9 European countries with suspected infection were recruited into the PERFORM (Personalised Risk Assessment in Febrile Illness to Optimise Real-Life Management) study. Empiric systemic antibiotic use was determined in view of assigned final “bacterial” or “viral” phenotype. Antibiotics were classified according to the World Health Organization (WHO) AWaRe classification.

Results
Of 2130 febrile episodes (excluding children with nonbacterial/nonviral phenotypes), 1549 (72.7%) were assigned a bacterial and 581 (27.3%) a viral phenotype. A total of 1318 of 1549 episodes (85.1%) with a bacterial and 269 of 581 (46.3%) with a viral phenotype received empiric systemic antibiotics (in the first 2 days of admission). Of those, the majority (87.8% in the bacterial and 87.0% in the viral group) received parenteral antibiotics. The top 3 antibiotics prescribed were third-generation cephalosporins, penicillins, and penicillin/β-lactamase inhibitor combinations. Of those treated with empiric systemic antibiotics in the viral group, 216 of 269 (80.3%) received ≥1 antibiotic in the “Watch” category.

Conclusions
Differentiating bacterial from viral etiology in febrile illness on initial ED presentation remains challenging, resulting in a substantial overprescription of antibiotics. A significant proportion of patients with a viral phenotype received systemic antibiotics, predominantly classified as WHO Watch. Rapid and accurate point-of-care tests in the ED differentiating between bacterial and viral etiology could significantly improve antimicrobial stewardship.