The Pediatric Infectious Disease Journal, Год журнала: 2024, Номер 43(7), С. e235 - e239

Опубликована: Апрель 2, 2024

Intravenous (IV) antibiotic therapy is a mainstay of treatment for numerous bacterial infections, but associated with longer duration inpatient hospitalization, greater healthcare costs, opportunities line infection and other complications, potentially reduced patient quality-of-life, compared oral therapy.1 In children, establishing maintaining IV access can be particularly challenging traumatic. Transition to therefore important unwarranted delays occur frequently. Prescribed durations therapy, both adults are often based on historical dogma rather than high-quality evidence. However, substantial body clinical trials has now established that at least as effective IV-only in various types limited research also been conducted the common neonatal pediatric diseases, alongside shorter total therapy. The Australian New Zealand Paediatric Infectious Diseases group published systematic review guidelines this topic 2016,2 while similar efforts underway adult medicine.3 we consider recent developments area, studies challenge longstanding practices respect IV-to-oral switch immunocompetent children neonates. Urinary Tract Infections tract (UTI) antibiotics generally recommended infants aged <90 days old febrile UTI. Although 7–10 commonly recommended, practice challenged. A found no difference recurrence between bacteremic UTI switched <7 days, those who received ≥7 therapy.4 Similarly, there was among nonbacteremic treated ≤3 versus >3 antibiotics.4 Previous studies, largely observational, support entirely or rapid UTI, even pyelonephritis.2 contrast, randomized controlled trial (RCT) investigated efficacy "standard"-course (10 days) short-course (5 United States 2 months 10 years UTI.5 Among 664 patients randomized, largest such date, receiving were significantly more likely have symptomatic asymptomatic bacteriuria 6 11–14 day follow-up visit, after starting treatment. outcome failure occurred infrequently (4.2%), however standard care, measurement primary took place immediately cessation authors acknowledge introduced bias favoring course. Furthermore, placebo period ended. concluded could "considered reasonable option exhibiting improvement 5 antimicrobial treatment." More recently, smaller RCT comparing management 142 well-appearing either amoxicillin-clavulanate.6 outcome, rate recurrence, lower 5-day (14.3% vs. 2.8%), strengthening evidence clinically stable children. clinicians may cautious about bacteremia anatomical variations genitourinary tract, including vesicoureteral reflux, lack all-IV notable should not dissuade consideration future guidelines. Bone Joint osteomyelitis septic arthritis all ages conventionally included prolonged administration antibiotics, weeks Historically, treatment, although courses common: short 3 followed by therapy.2 present bone joint infections absence sepsis, it possible noninferior currently underway.7 Pediatric Bacteremia Meningitis For bloodstream however, does typically include context UTIs pneumococcal where early recommended.2 Again, routes conventional wisdom, Reliance endocarditis challenged, large retrospective available outcomes selected patients, hospitalization fewer adverse events.8 It noted emerging from undertaken adults, data date. Traditional meningitis open-label over many years, predominantly resource-constrained settings, using 4 finding comparable 7 >7 14 days.2 These resulted widespread change practice, due concerns selection bias, low mortality relative expected outcomes, identified causative organisms, high prevalence Haemophilus influenzae B meningitis, which precipitously declined areas infant immunization available. Further undertaken, accounting organisms.2 Appendicitis most surgical diagnosis. While uncomplicated appendicitis managed operatively single-dose prophylaxis, nonoperative increasingly common. Current trends controversies recently reviewed detail, did detail route duration.9 One cohort study that, 67.1% initial minimum 24 hours effectively without need subsequent appendectomy, statistically disability 1 year urgent management.10 Not cases suitable management, risk perforation overall cure considerations.11 Management complicated appendicitis, perforated appendix peritonitis, includes several hospital. recommend once afebrile normal bowel function.2 Recently regarding ≥8 demonstrated 2-day undergoing laparoscopic rates reintervention complication.12 Community-acquired Pneumonia pneumonia (CAP) leading cause globally organism CAP difficult identify, given empirically, uncertainty efficacy. already, guidance developed Recent attempted address gap. 2023 meta-analysis 16 12,774 total, middle-income countries high-income countries, differences longer-duration terms cure, serious events.13 Notable listed Table 1. caveat these mild-moderate CAP, optimal timing severe remains an area requiring further research. Children had viral pneumonia, biased results favor noninferiority, better tests distinguish illnesses needed. TABLE - Summary Studies Evaluating Intravenous-to-oral Antibiotic Switch Shorter Oral Therapy Neonates Reference Diagnosis Study Type Setting (Country, Level Care) Measure Patient Population No. Patients Results investigating (including management) (bacteremic) Systematic Multiple, multilevel ≤7 Infants ≤90 Total 468 describing 30-day significant association all-cause (nonbacteremic) 12 15,826 complications States, tertiary months—10 showing 6–14 (4.2% 0.6%, 1-sided 95% CI: 5.5; P < 0.01) No number within 9 product discontinuation (2.7% 4.2%, 4.2; = 0.32) (febrile) Italy, months—5 episodes recurrence. (Difference −11.51%; −20.54 −2.47) Uncomplicated Nonrandomized intervention Nonoperative appendectomy 7–17 1068 Success 67.1%(96% 61.5–72.3; 0.86) Disability group. (6.6 10.9 days; 99% −6.17 −2.43; 0.001) Authors defined success 11 5–18 acute 404 successful 90.5% ratio 8.92. (M-H fixed-effects 2.67–29.79, heterogeneity, 0.99; I 0%) resolution symptoms surgery 48 month initiation Complex Netherlands, postoperative complex Note: Total: 1066 Aged 8–17 years: 111 (10.4%) infectious mortality. (aRD 2.0%, −1.6–5.6) Readmission hospital frequent (12% 6%; OR: 2.135; 1.342–3.396) provide pediatric-specific high-dose amoxicillin presenting ED, admitted 281 (85.7% 84.1%, RD 0.023, 97.5% −0.061) Median caregiver work absenteeism (2 3, IRR: 0.76, 0.66–0.87; 15 6–71 outpatient setting 380 response persistent assessment 69% (95% 63–75) probability desirable adjusted Kingdom Ireland, 7days ≥6 discharged 814 retreatment 28 (12.5% 12.5%, 3.9%) 13 ≤5 >5 outpatients (OR: 1.01; 0.87–1.17) relapse (RR: 1.12; 0.92–1.35) (RD: −0.2%; −0.9–0.5) 17 Neonatal 31 described 0.95; 0.79–1.16; 2: 1.11; 0.72–1.72; 18 (probable) Term neonates probable 510 reinfection (Absolute 0%; −1.9–1.9; 0.0001) median length-of-stay (3.4 6.8 19 Probable proven (early-onset) PCS Denmark, multicenter signs 0–72 birth 531 readmitted. (0/478) [3.0 (IQR: 2.5–3.5) 7.4 (IQR 7.0–7.5)] All presented reported study.CAP indicates community-acquired pneumonia; CI, confidence interval; CL, level; emergency department; IQR, interquartile range; IV, intravenous; OR, odds ration; PCS, prospective study; RCT, trial; RD, difference; RR, risk; urinary infection. Antibiotics frequently nonspecific deterioration. only minority apparent sepsis culture-confirmed infection, entire Uncertainty drug absorption first life 2019 adequate serum levels achieved neonates.17 Analysis involving preterm term infants, suggest worse suspected sepsis. reach maximum concentration later, bioavailability parenteral dosing, majority achieve killing. 2022, same multicenter, open-label, noninferiority Netherlands postmenstrual age ≥35 weeks, postnatal 0–28 bodyweight ≥2 kg unproven Investigators 504 receive amoxicillin-clavulanic acid 3.18 observed nor frequency effects. population-based readmission 30 therapy.19 2023, Denmark whether early-onset readmission.19 analysis, 90% underwent switch. considerably remained (3.0 respectively). evident considered routine care. required, growing well pharmacological supporting use young performed Resources devoted extended reallocated expanding programs facilitate safer, discharge antibiotics. Adult Medicine—What Can We Learn From Each Other? Evidence previously deemed require strong adults. There multiple RCTs transitional osteomyelitis, Gram-negative Gram-positive infective endocarditis.20–22 clear reluctance adopt much do tradition inertia data.23 literature yet robust population, fact safe concordant date superiority demonstrates somehow magically "more powerful" Indeed, microbes way knowing administered. Rather, salient issue sufficient foci they unable replicate function. Framed manner, bolstered proving question is, under what conditions will true administered orally site concentrations? Many parallels extensive This provides reassurance—bidirectionally—that if capable taking absorbing orally, agents against target pathogens. all-oral required long immunocompromised host priority Research directed toward implementation existing earlier needed, impacts discharge, costs quality-of-life conclusion, supports contention courses. Clinicians reluctant apply despite cultural imaginative shift treat infections—for benefit

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