182 Journal of Research in Medical Sciences | February 2012 |
Assessment of a new algorithm in the management
of acute respiratory tract infections in children
Seyed Ahmad Tabatabaei1, Seyed Alireza Fahimzad2, Ahmad Reza Shamshiri3, Farideh Shiva4, Shadab Salehpor5, Shirin
Sayyahfar6, Ghamartag Khanbabaei1, Shahnaz Armin7, Sedigheh Rafii Tabatabaei4, Alireza Khatami8, Maryam Kadivar9
1Assistant Professor, Department of Pediatrics, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences. 2Assistant
Professor, Department of Pediatrics, Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences. 3PhD Candidate,
Department of Epidemiology and Biostatistics, School of Health and Institute of Health Research, Tehran University of Medical Sciences.
4Assistant Professor, Pediatric Infections Research Center, Department of Pediatrics, Shahid Beheshti University of Medical Sciences.
5Assistant Professor, Department of Pediatrics, Shahid Beheshti University of Medical Sciences. 6Assistant Professor, Department of
Pediatrics, Shool of Medicine, Tehran University of Medical Sciences. 7Associate Professor, Pediatric Infections Research Center,
Department of Pediatrics, Shahid Beheshti University of Medical Sciences. 8Associate Professor, Department of Radiology, Shool of
Medicine, Shahid Beheshti University of Medical Sciences. 9Assistant Professor, Department of Pathology, School of Medicine, Tehran
University of Medical Sciences, Tehran, Iran
Objectives: To assess the practicability of a new algorithm in decreasing the rate of incorrect diagnoses and inappropriate antibiotic
usage in pediatric Acute Respiratory Tract Infection (ARTI). Materials and Methods: Children between 1 month to15 years brought
to outpatient clinics of a children’s hospital with acute respiratory symptoms were managed according to the steps recommended in
the algorithm. Results: Upper Respiratory Tract Infection, Lower Respiratory Tract Infection, and undifferentiated ARTI accounted
for 82%, 14.5%, and 3.5% of 1 209 cases, respectively. Antibiotics were prescribed in 33%; for: Common cold, 4.1%; Sinusitis, 85.7%;
Otitis media, 96.9%; Pharyngotonsillitis, 63.3%; Croup, 6.5%; Bronchitis, 15.6%; Pertussis-like syndrome, 82.1%; Bronchiolitis, 4.1%;
and Pneumonia, 50%. Conclusion: Implementation of the ARTIs algorithm is practicable and can help to reduce diagnostic errors
and rate of antibiotic prescription in children with ARTIs.
Key words: Acute respiratory tract infection, algorithm, children
Acute Respiratory Tract Infections (ARTIs) are the
most common reasons for children visiting a physician,
leading to increased utilization of health services
including hospital admissions. Furthermore, Lower
Respiratory Tract Infections (LRTI) are major cause
of morbidity and mortality (25%-50%) in developing
countries.[2-4] Incidence rates of ARI in children of
developing and developed countries are comparable,
but cause-specific mortality rates from ARTIs are 10 to
50 times higher in underdeveloped countries.[5,6]
However, most childhood ARTIs have a viral etiology.[7,8]
They are the principal reason for antibiotic prescriptions
in the pediatric population (e.g., 46% in a Dutch study)
resulting in increasing bacterial resistance, adverse drug
effects, and increased financial burden.
Facilities for identifying various organisms are
totally lacking in underdeveloped societies, and
limited in transitional countries. WHO has initiated
a program for clinical management and control of
ARTIs which has resulted in the reduction of ARTI
mortality rates by 25% to 67%.[4,10,11] Some countries
approach to ARITs.[12-14] We developed an
algorithm for the diagnosis of ARTIs in children
solely based on clinical manifestations, with minimal
use of laboratory facilities and the main objective of
this study was to assess the practicability of this
algorithm, how much the ARITs and antibiotics usage
are common and in comparison with other studies could
it reduce the rate of incorrect diagnoses and
inappropriate antibiotic usage.
MATERIALS AND METHODS
This prospective cross-sectional study was conducted
from October 2007 to September 2008, on children aged
between one month and 15 years with acute respiratory
symptoms, cough, fever, hoarseness, and nasal discharge
with or without tachypnea, in the outpatients clinics of a
university-affiliated children’s hospital in Tehran.
ARTI was defined as respiratory symptoms lasting < 3
weeks.All consecutive patients above the age of one
month and below the age of 15 years with ARTIs
symptoms brought to the outpatients clinics were
included and patients with more than 3 weeks’ signs
programmed to recommend guidelines
Address for correspondence: Dr. Alireza Fahimzad, Pediatric Infections Research Center, Mofid Children’s Hospital, Shariati St., Tehran, Iran.
Received: 05.04.2011; Revised: 12.10.2011; Accepted: 01.01.2012
Tabatabaei, et al.: New algorithm in the management of acute respiratory tract infections in children
| February 2012 | Journal of Research in Medical Sciences 183
and symptoms, chronic lung or heart diseases, and
primary or secondary immunodeficiency were excluded.
Informed consent was obtained from the parents before
inclusion in the study.
Demographic and clinical data were collected from the
visit notes. Algorithm designed for this study was derived
from clinical manifestations of ARTIs described in the
Nelson Textbook of Pediatrics. In this algorithm, the
physician categorizes the patients into lower and upper
ARTI according to respiratory rate and lung findings on
auscultation [Figure 1].
Tachypnea was defined according to the standard reference
charts set by the WHO for different age groups and fever
as an axillary temperature of >38°C.
Trained physicians examined the patients and classified
them according to the algorithm into nine primary
Upper Respiratory Tract Infections (URTIs): Common Cold,
Sinusitis, Otitis media, and Pharyngotonsillitis.
Lower Respiratory Tract Infections (LRTIs): Croup,
Bronchitis, Pertussis-like syndrome, Bronchiolitis, and
All data were fed into the computer and analyzed by
SSPS 11.5 software (Chicago, USA). The study variables
were categorical and were summarized as frequency and
The algorithm was used for management of 1 209 patients,
Figure 1: Acute Respiratory Tract Infection Algorithm; Ψ presence of ≥2 following criteria: a) otic pain or irritability, b) redness of tympanic membrane, c) absence of
tympanic membrane landmarks like incus, promontory, cone of light, d) bulging of tympanic membrane or perforated membrane; €presence of ≥2 following criteria:
a) recent family history of cough ≥2 weeks, b) paroxysmal cough attacks with no sigh between them, c) post cough emesis, d) presence of whooping or apnea after
cough attacks; ¥presence of ≥2 following criteria: age between 5 to 15 years old, b) exudative pharyngitis, c) tenderness of anterior neck adenitis, d) high-grade
fever (tem ≥39°C)
184 Journal of Research in Medical Sciences | February 2012 |
Tabatabaei, et al.: New algorithm in the management of acute respiratory tract infections in children
Male: female = 1.2: 1; and 44.8% were <2 years. URTI, LRTI,
and Undifferentiated ARTI accounted for 996 (82%), 176
(14.5%), and 42 (3.5%) cases, respectively. Specific diagnoses
are presented in [Figure 2].
Antibiotics were prescribed in 33% of all visits; rates of
antibiotic prescription in URTI were: Common cold, 4.1%;
Sinusitis, 85.7%; Otitis
Pharyngotonsillitis, 63.3%. For LRTIs: Croup, 6.5%;
Bronchitis, 15.6%; Pertussis- like syndrome, 82.1%;
Bronchiolitis, 4.1%; and Pneumonia, 50% [Table 1].
Clinicians prescribed antibiotics in 33% of all visits. Most
commonly used antibiotics were amoxicillin/ clavulanate
(34.5%), amoxicillin (20.8%), azithromycin (17.5%),
erythromycin (8.7%), and penicillin (8.5%).
media, 96.9%; and
By using the recommended algorithm, physicians prescribed
antibiotics for approximately one-third of children with
ARTI. These figures are in sharp contrast to another study
in our center, which reported antibiotic prescription rate
of >80% in children with ARTI. ARTIs are the number
one reason for antibiotic prescribing in the United States
accounting for about 50% of all antibiotic prescription.
As reported from Scandinavia, prescribing patterns for
ARTIs vary widely between physicians. Antibiotic
therapy in ARTIs is often guided by clinical manifestations
as etiological pathogens may remain undiscovered in most
cases even if all invasive diagnostic steps were taken.[19,20]
Also, cultural factors such as prescribing practices, parents’
Pertussis like syndrome
Figure 2: Acute Respiratory tract infection frequency
Table 1: Frequency of antibiotic usage in acute
respiratory tract infections
Common cold 4.1
Otitis Media 96.9
Pertussis-like syndrome 82.1
expectations, and structure of the healthcare system may
result in differences in clinical practice and antibiotic
consumption between countries.[21,22]
Some physicians prescribe antimicrobials for bronchitis
if the child complains of productive cough, although
controlled trials have failed to demonstrate the benefit of
antibiotic treatment for acute bronchitis. The belief that
purulent nasal discharge is an indication for antibiotics
seems to be common, despite evidence that purulence of
nasal discharge does not indicate bacterial infection.[24,25]
Our research team had attempted to reduce antibiotic
prescribing for respiratory tract infections by an educational
intervention similar to some other studies.[26,27] Studies have
shown the importance of parental demands for antibiotic
treatment, and trials that included educational interventions
for both parents and physicians had promising results, with
Smabrekke et al. demonstrating a reduction in antibiotic
prescriptions for acute otitis media, from 90% to 74%, and
also a reduction in broad-spectrum antibiotic use.[28-30]
Our findings reveal that using the suggested algorithm
is practicable, and may be effective in defining various
forms of ARI more clearly, thereby improving antibiotic
prescription patterns for these infections in children. The
main limitation of our study is the lack of a control group
that was managed without using the algorithm; however,
as stated above, a previous study done in the same hospital,
which investigated antibiotic usage in outpatients with
acute respiratory infections, does show a very high rate of
antibiotic prescription, prior to the use of the algorithm.
Further multi-central researches and control group are
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How to cite this article: Tabatabaei SA, Fahimzad SA, Shamshiri AR, Shiva
F, Salehpor Sh, Sayyahfar Sh, et al. Assessment of a new algorithm in the
management of acute respiratory tract infections in children. J Res Med Sci
2012; 17(2): 182-5.
Source of Support: Nil, Conflict of Interest: None declared.