Preschool-aged children with CAP (community acquired pneumonia) frequently do not require antibiotics, as most disease is caused by viral infections. Children with suspected CAP of bacterial origin should usually receive amoxicillin for outpatient treatment, or ampicillin or penicillin G for inpatient treatment. These agents have sufficient activity against the common bacterial pathogens causing CAP without being unnecessarily broad. Third-generation cephalosporins should be reserved for children who are unimmunized or with severe infection, or where there are high rates of penicillin-resistance among invasive pneumococcal isolates. Additional agents may be indicated in cases of suspected staphylococcal pneumonia, atypical pathogens, or influenza.
Bradley JS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011 Oct; 53(7):e25-76. PMID: 21880587.
Le Saux N, et al. Uncomplicated pneumonia in healthy Canadian children and youth: Practice points for management. Paediatr Child Health. 2015 Nov-Dec;20(8):441-50. PMID: 26744558.
Jain S, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med. 2015 Feb 26;372(9):835-45. PMID: 25714161.
Bacterial growth in cultures of bag urine specimens are more likely to be falsely positive in young children with suspected urinary tract infection (UTI) due to contamination with perineal flora. A bag urine culture cannot therefore be used to establish the diagnosis of UTI and may lead to overtreatment. Although a negative bag culture would rule out a UTI, a positive culture requires confirmation by a more specific method, incurring substantial delay. Cultures of urine specimens obtained by catheterization or suprapubic aspiration are more specific and as such are preferred as the routine method of urine collection in non-toilet trained children. Clean-catch, the standard technique of urine collection for toilet-trained children, is a non-invasive method sometimes attempted in infants but is also associated with relatively high rates of contamination.
Subcommittee On Urinary Tract Infection, Steering Committee On Quality Improvement And Management et al. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. Aug 2011, 595-610. PMID: 21873693.
Robinson JL, et al. Urinary tract infections in infants and children: Diagnosis and management. Paediatrics & Child Health. 2014;19(6):315-19. PMCID: PMC4173959.
Labrosse M, et al. Evaluation of a New Strategy for Clean-Catch Urine in Infants. Pediatrics Aug 2016, e20160573. PMID: 27542848.
Tosif S, et al. Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: An observational cohort study. J Paediatr Child Health. 2012 Aug;48(8):659-64. PMID: 22537082.
Infants are commonly asymptomatic carriers of C. difficile (14-63%), but clinical illness is rarely reported before 12-24 months of age. It has been hypothesized that infants lack the cellular machinery for Clostridium toxin internalization. When investigating an infant with diarrhea, alternative diagnoses should be considered even with a positive test for C. difficile. Testing should be limited to immunosuppressed infants or those with underlying intestinal conditions (e.g. Hirschsprung disease, inflammatory bowel disease) when other etiologies have been ruled out. Therefore, it is prudent to avoid routine testing in children less than 12 months, and for children 1-3 years of age, test for other causes of diarrhea first, particularly viral.
Schutze G, et al. Clostridium difficile infection in infants and children. Pediatrics. 2013 Jan;131(1):196-200. PMID: 23277317.
Allen U, et al. Clostridium difficile in paediatric populations. Paediatr Child Health. 2014 Jan;19(1):43-54. PMID: 24627655.
Large retrospective cohort studies have shown no difference in treatment failure rate between children with uncomplicated acute hematogenous osteomyelitis treated with prolonged IV therapy when compared with shorter IV therapy and early transition to oral, to complete the course of therapy. “Prolonged” IV therapy definitions varied and ranged from 7 days or more in one cohort to the entire treatment course of 3 to 6 weeks in another. Of note, complications with PICC lines in the prolonged treatment arms were seen at a rate between 3-15%. Consideration for use of prolonged IV therapy is in complicated disease (significant bone destruction; resistant or unusual pathogen; immunocompromised patient; sepsis or septic shock; venous thrombosis; metastatic foci or important abscess formation). Guidance as to when to consider transition to oral therapy includes a good clinical response and consideration of the following: afebrile for 48-72 hours; normalization of inflammatory markers or decrease in CRP by 50%; absence of complications or metastatic foci; and negative blood culture if culture was initially positive.
Peltola H, et al. Simplified treatment of acute staphylococcal osteomyelitis of childhood. The Finnish Study Group. Pediatrics. 1997 Jun;99(6):846-50. PMID: 9190554.
Le Saux N, et al. Shorter courses of parenteral antibiotic therapy do not appear to influence response rates for children with acute hematogenous osteomyelitis: a systematic review. BMC Infectious Diseases. 2002;2:16. PMC128824.
Ruebner R, et al. Complications of central venous catheters used for the treatment of acute hematogenous osteomyelitis. Pediatrics. 2006 Apr;117(4):1210-5. PMID: 16585317.
Zaoutis T, et al. Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for actue osteomyelitis in children. Pediatrics. 2009 Feb;123(2):636-42. PMID: 19171632.
Keren R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015 Feb;169(2):120-8. PMID: 25506733.
Saavedra-Lozano J, et al. Bone and Joint Infections. Pediatr Infect Dis J. 2017 Aug;36(8):788-799. PMID: 28708801.
Krogstad P. Hematogenous osteomyelitis in children: Management. UpToDate. Updated September 20, 2017.
Antimicrobials such as fluoroquinolones, trimethoprim-sulfamethoxazole, clindamycin, linezolid, metronidazole and fluconazole have excellent bioavailability and only rarely need to be administered intravenously. Use of oral formulations of these medications reduces the need for placement and maintenance of venous access devices and their associated complications.
Centers for Disease Control and Prevention. Core elements of antimicrobial stewardship programs [Internet]. Atlanta, GA: US Department of Health and Human Resources, CDA; 2014 [cited 2015 Jul 10].
Dellit TH, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007 Jan 15;44(2):159-77. PMID: 17173212.
Li HK, et al. Oral versus Intravenous Antibiotics for Bone and Joint Infection. N Engl J Med 2019; 380: 425-36. PMID: 30699315.
Reported penicillin reactions frequently result in the use of alternate second-line agents that may be clinically inferior or may pose increased risks to patients resulting in longer lengths of stay and increased costs of care. Alternate broad-spectrum agents may also result in increased rates of adverse events and selection for antimicrobial resistance. Therefore, it is important to obtain a detailed history of a patient’s reported prior reaction to penicillin to determine whether beta-lactam therapy can be safely administered.
Blumenthal KG, et al. Improving Clinical Outcomes in Patients With Methicillin-Sensitive Staphylococcus aureus Bacteremia and Reported Penicillin Allergy. Clin Infect Dis. 2015 May 19. pii: civ394. PMID: 25991471.
MacFadden DR, et al. Impact of Reported Beta-Lactam Allergy on Inpatient Outcomes: A Multicenter Prospective Cohort Study. Clin Infect Dis. 2016 Oct 1;63(7):904-910. PMID: 27402820.
Picard M, et al. Treatment of patients with a history of penicillin allergy in a large tertiary-care academic hospital. J Allergy Clin Immunol Pract. 2013 May-Jun;1(3):252-7. PMID: 24565481.
Yates AB. Management of patients with a history of allergy to beta-lactam antibiotics. Am J Med. 2008 Jul;121(7):572-6. PMID: 18589051.
The 2014 recommendations of the International Antiviral Society – US Panel state that measurement of CD4 count is optional among patients with suppressed viral loads for >2 years and CD4 counts >500/µL. CD4 measurement in these patients is of low-value and may create unnecessary patient concern in response to normal variation of CD4 counts. In prospective studies of patients who have responded to antiretroviral therapy with HIV-1 RNA suppression and rises in CD4 cell count >200 cells/μL, there was little clinical benefit from continued routine measurement of CD4 counts.
Gale HB, et al. Is frequent CD4+ T-lymphocyte count monitoring necessary for persons with counts ≥300 cells/μL and HIV-1 suppression? Clin Infect Dis. 2013 May;56(9):1340-3. PMID: 23315315.
Günthard HF, et al. Antiretroviral treatment of adult HIV infection: 2014 recommendations of the International Antiviral Society-USA Panel. JAMA. 2014 Jul 23-30;312(4):410-25. PMID: 25038359.
Sax PE. Editorial commentary: can we break the habit of routine CD4 monitoring in HIV care? Clin Infect Dis. 2013 May;56(9):1344-6. PMID: 23315314.
There is poor correlation between clinical response and resolution of findings on magnetic resonance imaging (MRI), computed tomography (CT), and nuclear studies in patients with osteomyelitis. Because radiologic resolution may lag behind clinical improvement, repeat imaging may lead to unnecessary prolongation of antimicrobial therapy. Repeat imaging is indicated in cases where there is a lack of clinical response, progression of clinical findings, or the presence of an undrained abscess on the initial scan.
Euba G, et al. Long-term clinical and radiological magnetic resonance imaging outcome of abscess-associated spontaneous pyogenic vertebral osteomyelitis under conservative management. Semin Arthritis Rheum. 2008 Aug;38(1):28-40. PMID: 18055000.
Zarrouk V, et al. Imaging does not predict the clinical outcome of bacterial vertebral osteomyelitis. Rheumatology (Oxford). 2007 Feb;46(2): 292-5. PMID: 16877464.
Zimmerli W. Clinical practice. Vertebral osteomyelitis. N Engl J Med. 2010 Mar 18;362(11):1022-9. PMID: 20237348.
The addition of an aminoglycoside such as gentamicin to beta-lactam therapy or vancomycin for treatment of bacteremia or native valve infective endocarditis caused by Staphylococcus aureus has not been demonstrated to improve clinical outcomes. This practice may result in adverse effects including acute kidney injury and ototoxicity. The addition of gentamicin is still recommended in cases of prosthetic valve endocarditis caused by Staphylococcus aureus.
Cosgrove SE, et al. Initial low-dose gentamicin for Staphylococcus aureus bacteremia and endocarditis is nephrotoxic. Clin Infect Dis. 2009 Mar 15;48(6):713-21. PMID: 19207079.
Fowler VG Jr, et al. Daptomycin versus standard therapy for bacteremia and endocarditis caused by Staphylococcus aureus. N Engl J Med. 2006 Aug 17;355(7):653-65. PMID: 16914701.
Using Antibiotics Wisely in Primary Care
A campaign to help primary care clinicians use antibiotics wisely in practice.