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.
Urine cultures are the most frequently ordered microbiologic test, with the majority of specimens submitted from asymptomatic patients. Urine cultures should only be ordered if patients have symptoms localizing to the urinary tract such as acute dysuria, urgency, frequency, suprapubic or flank pain or fever without an obvious alternate source. Outside of these specific symptoms, positive cultures indicate asymptomatic bacteriuria and frequently result in antimicrobial therapy that is of no benefit and is potentially harmful. Cloudy or malodorous urine are not specific findings of urinary tract infection and should not prompt culture unless acute urinary tract symptoms are present. Delirium is not considered a symptom of cystitis in non-catheterized patients. In catheterized patients with fever or delirium, a positive urine culture may still represent asymptomatic bacteriuria unless alternate sources have been excluded. Laboratories should consider supplementing educational efforts to reduce collection of urine cultures from asymptomatic patients with analytical interventions that reduce processing of low-value specimens.
Hartley S, et al. Inappropriate testing for urinary tract infection in hospitalized patients: an opportunity for improvement. Infect Control Hosp Epidemiol. 2013 Nov;34(11):1204-7. PMID: 24113606.
Leis JA, et al. Reducing antimicrobial therapy for asymptomatic bacteriuria among noncatheterized inpatients: a proof-of-concept study. Clin Infect Dis. 2014 Apr;58(7):980-3. PMID: 24577290.
McKenzie R, et al. Bacteriuria in individuals who become delirious. Am J Med. 2014 Apr;127(4):255-7. PMID: 24439075.
Nicolle LE, et al. Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 May 2; pii: ciy1121. doi: 10.1093/cid/ciy1121. [Epub ahead of print] PMID: 30895288.
Toolkit: Give the Test a Rest: A toolkit for decreasing unnecessary emergency department laboratory testing
Only liquid stool specimens should be collected or processed for C. difficile detection, as a positive test in the absence of diarrhea likely represents C. difficile colonization. Diagnostic gains are minimal with repeat C. difficile nucleic acid amplification testing within 7 days of a negative test. Repeat C. difficile toxin testing by enzyme immunoassay within 7 days of a prior negative test is also of little incremental diagnostic yield but may be warranted in select cases. Test of cure in patients with recent C. difficile infection is also not recommended. Prior investigations have shown that the use of hospital information systems to restrict ordering of repeat tests for these reasons resulted in a 91% reduction in repeat testing.
Aichinger E, et al. Nonutility of repeat laboratory testing for detection of Clostridium difficile by use of PCR or enzyme immunoassay. J Clin Microbiol. 2008 Nov;46(11):3795-7. PMID: 18784320.
Luo RF, et al. Is repeat PCR needed for diagnosis of Clostridium difficile infection? J Clin Microbiol. 2010 Oct;48(10):3738-41. PMID: 20686078.
Luo RF, et al. Alerting physicians during electronic order entry effectively reduces unnecessary repeat PCR testing for Clostridium difficile. J Clin Microbiol. 2013 Nov;51(11):3872-4. PMID: 23985918.
All wounds are colonized with microorganisms. Cultures should not be obtained from wounds that are not clinically infected (i.e., absence of classical signs of inflammation or purulence or increasing pain). For wounds that are clinically infected, the ideal specimens for culture are deep specimens that are obtained through biopsy or deep curettage following cleansing/debridement of the wound. Laboratories should consider use of screening criteria to reject such swabs without proceeding to culture. For superficial swab specimens that are processed/cultured, interpretation of the results should be correlated with the Gram stain.
Chakraborti C, et al. Sensitivity of superficial cultures in lower extremity wounds. J Hosp Med. 2010 Sep;5(7):415-20. PMID: 20845440.
Gardner SE, et al. Cultures of diabetic foot ulcers without clinical signs of infection do not predict outcomes. Diabetes Care. 2014 Oct;37(10):2693-701. PMID: 25011945.
Lipsky BA, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012 Jun;54(12):e132-73. PMID: 22619242.
Marchand-Senécal X, Brasg I, Kozak R et al. Impact of Rejection of Low-Quality Wound Swabs on Antimicrobial Prescribing: A Controlled Before-After Study. Open Forum Infect Dis 2020 Dec 13; 8(1):ofaa609. PMID: 33511234.
Matkoski C, et al. Evaluation of the Q score and Q234 systems for cost-effective and clinically relevant interpretation of wound cultures. J Clin Microbiol. 2006 May;44(5):1869-72. PMID: 16672426.
Although nucleic acid amplification testing is the modality of choice for determining the viral etiology of meningitis/encephalitis, it should not be requested routinely on all cerebrospinal fluid specimens. The routine use of these tests in patients without compatible clinical syndromes can result in unnecessary empiric antiviral treatment, additional care, and prolonged length of hospitalization for patients awaiting testing results. Additionally, routine testing may result in depletion of cerebrospinal fluid needed for other diagnostic purposes. In cases where nucleic acid testing is requested for adults, laboratories should have policies for when testing will be performed if the cerebrospinal fluid cell count and protein are normal.
Hanson KE, et al. Validation of laboratory screening criteria for herpes simplex virus testing of cerebrospinal fluid. J Clin Microbiol. 2007 Mar;45(3):721-4. PMID: 17202281.
López Roa P, et al. PCR for detection of herpes simplex virus in cerebrospinal fluid: alternative acceptance criteria for diagnostic workup. J Clin Microbiol. 2013 Sep;51(9):2880-3. PMID: 23804382.
Saraya AW, et al. Normocellular CSF in herpes simplex encephalitis. BMC Res Notes. 2016 Feb 15;9:95. PMID: 26879928.
Fluids and tissue specimens can usually be obtained in the controlled setting of the operating room and represent higher quality specimens than swabs. Culture of swab specimens is associated with increased false negative results, as they are inferior in recovering anaerobic bacteria, mycobacteria and fungi, and provide inadequate volumes to perform all necessary diagnostic tests. To encourage collection of fluid and/or tissue samples, consideration should be given to making swabs unavailable in the operating room without specific request.
Baron EJ, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clin Infect Dis. 2013 Aug;57(4):e22-e121. PMID: 23845951.
Koneman EW. Koneman’s Color Atlas and Textbook of Diagnostic Microbiology. Lippincott Williams & Wilkins, 2006.