Study says STARWAVe tool may enhance treatment of respiratory tract infections in children


Emobileclinic Researchers Corner 

A new research published in the Lancet Respiratory Medicine has pinpointed seven key indicators that could assist general medical practitioners and nurses in the primary health care to identity children who might not need antibiotics in the treatment of respiratory tract infections (RTI) with cough.


The team developed a tool known as STARWAVe, which uses seven predictors of future hospitalisation that can be easily identified by doctors and nurses during a patient visit. The seven indicators are: short illness lasting for less than 3 days, high temperature (≥37.8°C on examination or parent reported severe fever in the previous 24 hours), aged under 2 years, respiratory distress, wheeze, asthma, and moderate/severe vomiting in the previous 24 hours.

The authors said that children presenting with no more than one of these items are deemed at very low risk of future complications, however, there is need to externally confirm and validate this in a randomized trial. It is their submission that this could be a useful tool to improve the targeting of antibiotics to reduce the growing threat of antibiotic resistance.

In the view of Prof. Alastair Hay from the University of Bristol, Bristol, UK said that “excessive antibiotic use has contributed to the development of resistance to these drugs”. He revealed the aim of the study to include developing a simple, usable predictive tool based on symptoms and signs to help GPs and nurses identify children presenting in primary care at the lowest and highest risk of future complications and hospitalisation, so that antibiotics can be targeted accordingly.

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In developing the tool, the team analysed data collected between July 2011 and May 2013 from almost 8400 children aged between 3 months and 16 years with acute (less than 28 days) cough and respiratory tract infection symptoms (eg, fever) who were seen at 247 GP practices across England. They used modelling to determine which of the 50 demographic characteristics, parent-reported symptoms and physical examination signs measured might be most useful and accurate in distinguishing good from poor prognosis illnesses, defined as those resulting in hospitalisation for respiratory infection in the month following a visit to primary care.
Modelling showed that seven characteristics were independently linked with hospitalisation – short (≤3 days) illness; temperature; age (

Based on these findings, the authors developed a seven-item scoring system for a child’s risk of future hospitalisation. For example, a child showing 0-1 of these characteristics would be at very low risk of hospitalisation (0.3% risk; 67% of children in the study); a child with 2-3 of these characteristics would be at normal risk, similar to the general population (1.5% risk; 30% of children in the study); whilst a child showing 4 or more would be a high risk candidate for future hospitalisation (11.8% risk; 3% of children in the study).
According to the authors, a ‘no antibiotic’ prescribing strategy would be appropriate for low risk children; whilst a ‘no antibiotic or delayed antibiotic’ treatment strategy would be best for normal risk children – as recommended by NICE; and children deemed at high risk of hospitalisation should be closely monitored for signs of deterioration and followed-up within 24 hours.
In a related comment, Professor David Price, Chair of Primary Care Respiratory Medicine at the University of Aberdeen, Aberdeen, UK and colleagues discuss the need to test the tool in whole study populations and not just those recruiting and consenting to enter a study. They write, “Notwithstanding the inclusion of patients prescribed an antibiotic and the absence of an independent validation cohort, STARWAVe promises to achieve better targeting of antibiotics in primary care. There are few efficacious interventions for respiratory tract infection available to primary care clinicians beyond offering reassurance and self-management advice, so the modest benefit offered by antibiotics can persuade general practitioners to prescribe them. STARWAVe offers primary care clinicians an evidence-based practical tool to help guide antibiotic prescribing decisions and, through shared decision-making, has the potential to reduce prescribing based on prognostic uncertainty or on nonmedical grounds.”

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Alastair D Hay, (2016): Development and internal validation of a clinical rule to improve antibiotic use in children presenting to primary care with acute respiratory tract infection and cough: a prognostic cohort study. The Lancet Respiratory Medicine, doi: 10.1016/ S2213-2600(16)30223-5, published online 1 September 2016.

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