White Blood Cell Count Can Aid Judicious Antibiotic Prescribing in Acute Upper Respiratory Infections in Children

Abstract

Fifty percent or more of children with upper respiratory infections (URIs) and nonspecific febrile illnesses (e.g., children febrile, anorexic, decreased activity, irritable) receive unnecessary antibiotics from community-based physicians. This study was undertaken to show that white blood cell (WBC) count testing can aid physicians in avoiding antibiotic prescribing when managing children with URIs, and nonspecific febrile illnesses. A prospective, 3-year study was conducted in a community-based pediatric practice. A weekly convenience sample (Tuesdays) of acute URI and febrile patients ages 3 months to 21 years was studied. Data collected on enrollment included: age, gender, duration of illness, recent/current antibiotic use, temperature, symptoms, signs, laboratory testing (WBC count, cultures), diagnosis and treatment. Similar data on any illness visits in the previous 2 weeks and the subsequent 2 weeks after enrollment were collected. Viral culture specimens were obtained on a subset. The use of the WBC count was assessed, including obviating antibiotic prescription, frequency of related follow-up visits, and the occurrence of subsequent bacterial infections. Of 1,956 patients with respiratory or febrile illness enrolled, 1,219 (62%) had a diagnosis established by history and examination (e.g., acute otitis media) and 737 (38%) did not. Of the 737 patients without an established diagnosis, 386 (52%) did not receive an antibiotic because they did not appear particularly ill, their temperature was less than 101 °F, and parents were not demanding antibiotics, leaving 351 (48%) patients who appeared ill, had a temperature greater than 101 °F, and parents were demanding an antibiotic or physicians were inclined to give an antibiotic. A WBC count was performed on these 351 children; 337 children (96%) had a WBC count less than 15,000/mm3, and 14 (4%) had a W1BC 15,000/mm3 or greater. An antibiotic was prescribed for 13 of the 14 children with a WBC count greater than 15,000/mm3. With this approach, return office visits in the following 2 weeks were infrequent (13% of 737 patients), and no child had significant bacterial illness that was missed. With selective use of WBC count testing near-complete avoidance of unnecessary antibiotic use can be achieved in caring for children with URI and nonspecific febrile illness without adverse outcomes.