How long is a piece of string? – antibiotic treatment duration in paediatrics

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It’s 2am on your fourth night shift in a row. Johnny is 2 years old and has osteomyelitis of his toe. He looks pretty well and doesn’t like sitting still for cannulas. Poor Johnny has marks on both hands and both elbows from recent IVs that have not gone the distance and now you have just been paged to say he has managed to remove another one. He has been being treated for 5 days and you are wondering if he really needs this IV re-siting.

 

How do we know how long to prescribe IV antibiotics for?

As it turns out, often we don’t. Recognising this gap in the literature a leading group of Australasian paediatric infectious disease experts have conducted a systematic review of treatment duration in 36 infectious diseases. They have used this review to create recommendations on the duration of both IV and total (IV and oral) antimicrobial treatment for each of these 36 diseases.

What are the highlights?

This will depend on your practice setting as with 36 diseases covered there really is something for everyone. For me, working in an emergency department, I am looking forward to wielding the recommendations that a minimum of 0 days IV treatment (i.e orals only) are required for pharyngitis, mild cases of both cellulitis and cervical lymphadenitis as well as UTIs in patients over 3 months old. The paper also adds weight to the idea that most kids with otitis media should get 48 hours to fix themselves before being hit with antibiotics. The usual cautions around immunocompromised and otherwise medically complex children apply. The paper also includes a nice box on the general principles guiding IV to oral switching of antibiotics – namely clinical stability, ability to absorb orals and the availability of an appropriate oral preparation.

Who wrote this guideline and why should I believe them?

The guideline was written by the Australian and New Zealand Paediatric Infectious Diseases Australasian Stewardship of Antimicrobials in Paediatrics (ANZPID-ASAP) group of the Australasian Society for Infectious Diseases (ASID). This group is formed of paediatric ID specialists from all over Australia and New Zealand. The guideline is very clear about the strength of each recommendation, with some Grade A evidence in ENT, orthopaedic and urinary tract infections as well as appendicitis. Although the majority of the 36 recommendations are based on grade C and D evidence, the author list includes at least one person you would phone for an ID consult if you work at any major paediatric centre in Australia.

 

Where can I find out more?

The full and abbreviated forms of the guideline can be found here.

The paper is currently in the ‘publish ahead of print’ section of the Lancet Infectious Diseases. It is also linked from the ASID page above and the full text is available for free on the Lancet ID’s webpage.

ASID have even created a handy image that you can print on to a lanyard (below).  If you want to order some of these for your friends you can register interest at the link above and if enough people are keen ASID will get some printed.

asid Lanyard Front

asid Lanyard Back

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