Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia: The CAP-IT Randomized Clinical Trial

Amoxicillin-induced bacterial gut dysbiosis: A critical influence on mice reproduction and their offspring development

The use of antibiotics such as amoxicillin can induce intestinal dysbiosis leading to rupture the essential microbiota role in regulating immune, metabolic, and reproductive functions. This study assessed the effects of amoxicillin-induced intestinal dysbiosis on the female mice reproductive function and its repercussions on their offspring. Female mice were treated with amoxicillin for 15 days (AMOX) showed an increase in Proteobacteria and a decrease in Firmicutes and Bacteroidetes in feces and estrous cycle changes, with a predominance of the metestrus and diestrus phases in the treated mice. During gestation the AMOX group presented reduced number of implantations and decreased embryonic viability, resulting in a higher rate of resorption. Differential gene expression of reproductive hormones in AMOX-treated female mice suggested that intestinal dysbiosis interferes with hormonal regulation during pregnancy. The survival, body development, and intestinal microbiota composition of offspring showed significantly altered patterns in the AMOX mice. These findings indicate that amoxicillin-induced intestinal dysbiosis affects not only the estrous cycle and reproductive hormones but also has lasting impacts on offspring development. The study highlights the need for caution in the use of antibiotics during pregnancy to avoid potential harm to maternal and offspring health.

Antibiotics for Paediatric Community-Acquired Pneumonia: What is the Optimal Course Duration?

Despite significant global reductions in cases of pneumonia during the last 3 decades, pneumonia remains the leading cause of post-neonatal mortality in children aged <5 years. Beyond the immediate disease burden it imposes, pneumonia contributes to long-term morbidity, including lung function deficits and bronchiectasis. Viruses are the most common cause of childhood pneumonia, but bacteria also play a crucial role. However, the optimal duration of antibiotic therapy for bacterial pneumonia remains uncertain in both low- and middle-income countries and in high-income countries. Knowing the optimal duration of antibiotic therapy for pneumonia is crucial for effective antimicrobial stewardship. This is especially important as concerns mount over rising antibiotic resistance in respiratory bacterial pathogens, which increases the risk of treatment failure. Numerous studies have focused on the duration of oral antibiotics and short-term outcomes, such as clinical cure and mortality. In contrast, only one study has examined both intravenous and oral antibiotics and their impact on long-term respiratory outcomes following pneumonia hospitalisation. However, study findings may be influenced by their inclusion criteria when children unlikely to have bacterial pneumonia are included. Efforts to differentiate between bacterial and non-bacterial pneumonia continue, but a validated, accurate, and simple point-of-care diagnostic test remains elusive. Without certainty that a child has bacterial pneumonia, determining the optimal duration of antibiotic treatment is challenging. This review examines the evidence for the recommended duration of antibiotics for treating uncomplicated pneumonia in otherwise healthy children and concludes that the question of duration is unresolved.

Evaluating the desirability of outcome ranking and response adjusted for duration of antibiotic risk for clinical trials of antibiotics in pediatric pneumonia

Objective outcomes for pediatric community-acquired pneumonia (CAP) are lacking. The desirability of outcome ranking (DOOR) and response adjusted for duration of antibiotic risk (RADAR) outcome encompass clinical benefit and adverse effects, while also accounting for antibiotic exposure. We evaluated DOOR and RADAR (DOOR/RADAR) through simulations and compared sample-size considerations to noninferiority designs in a hypothetical trial comparing antibiotics and no antibiotics (ie, placebo) for children with mild CAP. We also evaluated a trial comparing different durations of antibiotic therapy. Three scenarios were considered: 1 with no difference in DOOR between the 2 groups, 1 in which placebo is more efficacious, and another in which amoxicillin is more efficacious than placebo. The power to detect a difference between arms was greater using DOOR/RADAR compared with DOOR alone. Assuming a sample size of 200, DOOR had 2.5%, 50%, and 65% power to detect a statistical difference between arms for scenarios 1-3, respectively, significantly less than DOOR/RADAR. Importantly, DOOR/RADAR incorrectly identified placebo as superior in scenario 3, where amoxicillin was truly efficacious. Sample size requirements for noninferiority designs were larger to achieve similar levels of power as DOOR and DOOR/RADAR. DOOR/RADAR has the potential to lead to an incorrect conclusion declaring placebo superior when amoxicillin is efficacious.

Impact of Clinician Feedback Reports on Antibiotic Use in Children Hospitalized With Community-acquired Pneumonia

BACKGROUND

Feedback reports summarizing clinician performance are effective tools for improving antibiotic use in the ambulatory setting, but the effectiveness of feedback reports in the hospital setting is unknown.

METHODS

Quasi-experimental study conducted between December 2021 and November 2023 within a pediatric health system measuring the impact of clinician feedback reports delivered by email and reviewed in a monthly meeting on appropriate antibiotic use in children hospitalized with community-acquired pneumonia (CAP). We used an interrupted time series analysis (ITSA) to estimate the immediate change and change over time in the proportion of CAP encounters adherent to validated metrics of antibiotic choice and duration, then used Poisson regression to estimate intervention effect as a risk ratio (RR).

RESULTS

Preintervention, 213 of 413 (52%) encounters received the appropriate antibiotic choice and duration, which increased to 308 of 387 (80%) postintervention. The ITSA demonstrated an immediate 18% increase in the proportion of CAP encounters receiving both the appropriate antibiotic choice and duration (95% confidence interval [CI]: 3-33%), with no further change over time (-0.3% per month, 95% CI: -2%-2%). In the Poisson model adjusted for age, sex, race, season, site, and intensive care unit admission, the intervention was associated with a 32% increase in the rate of appropriate antibiotic choice and duration (RR 1.32, 95% CI: 1.12-1.56, P < .01). No difference in length of stay or revisits were detected postintervention.

CONCLUSIONS

The intervention was associated with an increase in clinician adherence to antibiotic choice and duration recommendations for children hospitalized with CAP.

Evidence of Poor Utility of Current Sepsis Screening Tools in an At-Risk Population of Children With Community-Acquired Pneumonia

BACKGROUND

Children (6-24 kg) with lower respiratory tract infections were prospectively recruited in emergency departments to high or low doses of oral amoxicillin. We identified children who met the criteria for medium and high risks of sepsis, as per the UK's National Institute for Health and Care Excellence (NICE). Of those able to be discharged with oral antibiotics; 54% (318/591) had high-risk sepsis criteria. NICE sepsis guidance is poorly specific, with implications for antimicrobial resistance and iatrogenic patient harm.

METHODS

Children (6-24 kg) with lower respiratory tract infections were prospectively recruited in emergency departments to high or low doses of oral amoxicillin.

RESULTS

Of those able to be discharged with oral antibiotics, 54% (318/591) had high-risk sepsis criteria as per the UK's NICE.

CONCLUSIONS

NICE sepsis guidance is poorly specific, with implications for antimicrobial resistance and iatrogenic patient harm.

Evaluating Short-Course Antibiotic Therapy for Pediatric Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis

BACKGROUND

The optimal duration of antibiotic therapy for community-acquired pneumonia (CAP) in children remains uncertain. In this study, we aimed to evaluate whether short-course antibiotic therapy (≤6 days) is associated with poor clinical outcomes compared with long-course antibiotic therapy (>7 days) in children with CAP.

METHODS

A comprehensive search was conducted across databases, including PubMed, Embase, Cochrane Library, and KoreaMed. Studies comparing the efficacy and safety of short-course with long-course antibiotic regimens in children with CAP were eligible. We assessed the risk of bias using the RoB 2 and ROBINS-I tools. Study characteristics such as publication year, country, setting, study design and antibiotic regimens were recorded. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for clinical outcomes, including clinical cure, treatment failure, total adverse events, serious adverse events, relapse and hospitalization. The primary outcomes were clinical cure and treatment failure. Secondary outcomes included total and serious adverse events, relapse and hospitalization rates.

RESULTS

Seventeen studies comprising 155,944 children met the inclusion criteria, with 15 of these studies being randomized controlled trials. There were no significant differences between short-course and long-course treatments in clinical cure [21,156 patients; RR, 1.01 (95% CI, 0.97-1.05); P = 0.73; I² = 81%], treatment failure [28,942 patients; RR, 0.88 (95% CI, 0.51-1.51); P = 0.64; I²= 94%] or total adverse events [24,446 children; RR, 0.94 (95% CI, 0.61-1.44); P = 0.77; I² = 90%]. However, short-course treatment was associated with fewer serious adverse events [4194 patients; RR, 0.89 (95% CI, 0.79-0.99); P = 0.04; I² = 11%]. Relapse rates were nominally lower with short-course treatment compared with long-course treatments (5.5% vs. 6.2%; P = 0.04). This difference was primarily observed in the subgroup analysis comparing 5-day treatments to ≥10-day treatments. Hospitalization rates were similar between the two groups [122,607 patients; RR, 1.20 (95% CI, 0.85-1.68); P = 0.29; I² = 0%].

CONCLUSIONS

Short-course antibiotic treatment is as effective as long-course treatment for pediatric CAP in terms of clinical cure and treatment failure while resulting in fewer serious adverse events.

Antibiotic duration for common bacterial infections-a systematic review

Background

Reducing antibiotic duration is a key stewardship intervention to mitigate antimicrobial resistance (AMR). We examined current evidence informing antibiotic duration for common bacterial infections to identify any gaps in terms of settings, patient populations and infectious conditions. Trial methodologies were assessed to identify areas for improvement.

Methods

MEDLINE and Embase were searched up to July 2024 for randomized trials comparing antibiotic durations in hospital and community settings (PROSPERO 2021, CRD42021276209). A narrative synthesis of the results was performed with a review on the major guidelines published by IDSA, NICE, WHO and other international societies to assess the impact of these trials on practice guidance.

Results

Out of 315 studies, 85% concluded equivalence or non-inferiority of shorter courses. Adult bacterial sinusitis, community-acquired pneumonia, female cystitis/pyelonephritis, uncomplicated cellulitis and intra-abdominal infection with adequate source control and perioperative prophylaxis had robust evidence supporting shorter durations. Few trials studied severe infections, such as bloodstream infections and ventilator-associated pneumonia. Twenty-three (7%) of the trials were conducted in intensive care settings and only 43 trials (14%) enrolled patients from low-to-middle- or low-income countries. Only 15% of studies were at low risk for bias.

Conclusions

Reducing antibiotic duration likely remains an important strategy for antibiotic stewardship, and an area of active research. While shorter antibiotic courses may be suitable for many bacterial infections, more evidence is needed for severe infections and in low- and middle-income settings.

Working group summary of the 2023 full update of the Finnish national guidelines for paediatric lower respiratory tract infections

AIM

The first evidence-based Finnish guidelines for paediatric lower respiratory tract infections (LRTIs) were published in 2014 and completely updated in 2023. This paper, by the interdisciplinary working group that developed the 2023 guidelines, summarises the main recommendations.

METHODS

The 2023 guidelines were produced after a systematic review. Strong evidence was at least two separate, high-quality studies, moderate evidence was at least one high-quality study and weak evidence was at least one satisfactory study. The authors have now summarised the key points.

RESULTS

There was strong evidence that antitussives and beta-sympathomimetics were not effective for bronchitis-related cough and that laryngitis should be treated with oral corticosteroids, with adrenaline inhalations added in severe cases. Also, that amoxicillin for 5 days provided sufficient treatment for paediatric community-acquired pneumonia and that children with apparent viral pneumonia could be observed without antimicrobial therapy. There was moderate evidence that corticosteroids or inhaled agents were not effective for bronchiolitis and that administering salbutamol with a holding chamber could relieve symptoms of wheezing bronchitis. Also, pertussis should be considered for unvaccinated infants with coughs.

CONCLUSION

The 2023 guidelines aim to improve acute evidence-based treatment of LRTIs, through appropriate antibiotics, inhaled drugs, corticosteroids, radiology and laboratory testing.

Penicillin V versus amoxicillin for pneumonia in children-a Swedish nationwide emulated target trial

OBJECTIVES

Although most countries recommend amoxicillin for paediatric pneumonia, there is a long tradition of treatment with penicillin V (PcV) in Sweden, thus not empirically covering Haemophilus influenzae. There are, however, large regional differences in treatment practice. The aim was to compare clinical outcomes (treatment failure and severe complications), in children aged 1-59 months treated with PcV vs. amoxicillin for pneumonia.

METHODS

This population-based emulated target trial included all children born in Sweden between 2001 and 2021, using national health, sociodemographic, and population registers. All pneumonia cases from hospitals and paediatric outpatient clinics in children aged 1-59 months treated as outpatients with PcV or amoxicillin between July 2005 and December 2021, were identified. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for treatment failure (newly dispensed antibiotic prescription or pneumonia-associated hospitalization day 1-14) and severe complications (lung complications, an invasive bacterial disease, admission to intensive care unit or death day 1-28) were calculated with logistic regression analysis.

RESULTS

PcV was prescribed in 14 766 cases and amoxicillin in 10 566. Treatment failure occurred in 7.7% with PcV vs. 4.7% with amoxicillin, aOR 1.76 (95% CI: 1.54-2.00). Severe complications were rare, with no significant difference between PcV and amoxicillin (0.3% vs. 0.2%, aOR 0.96, 95% CI: 0.53-1.73). Sensitivity and interaction analyses showed consistent results.

DISCUSSION

PcV treatment compared with amoxicillin, was associated with an increased risk for treatment failure but not for severe complications. The absolute risks for adverse outcomes were low in both groups suggesting a minor role of H. influenzae in paediatric pneumonia.

Treatment of mild to moderate community-acquired pneumonia in previously healthy children: an Italian intersociety consensus (SIPPS-SIP-SITIP-FIMP-SIAIP-SIMRI-FIMMG-SIMG)

Community-acquired pneumonia (CAP) is an acute infection of the lung parenchyma acquired outside the hospital or other healthcare settings, typically affecting previously healthy individuals. This intersociety consensus aims to provide evidence-based recommendations for the antibiotic treatment of mild to moderate CAP in previously healthy children in Italy.A systematic review was conducted to identify the most recent and relevant evidence. Embase, Scopus, PubMed, and Cochrane databases were systematically screened, with a date restriction from 2012 to April 2024, but without language limitations. The review included studies conducted in high-income countries on antibiotic therapy in children over 3 months of age diagnosed with mild-moderate CAP. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methods. The final recommendations were obtained through a Delphi consensus of an expert panel.Amoxicillin is the first-line treatment if the child is at least immunized against Haemophilus influenzae type b (low/very low quality of evidence, strong recommendations), while amoxicillin-clavulanate or second- or third-generation cephalosporins should be prescribed for those unimmunized or with incomplete immunization coverage for both H. influenzae type b and Streptococcus pneumoniae (low/very low quality of evidence, strong recommendations). Macrolides should be considered in addition to amoxicillin in children over 5 years old, if symptoms persist and the clinical condition remains good after 48 h of therapy (low/very low quality of evidence, strong recommendations). The dosage of amoxicillin is 90 mg/kg/day divided in three doses, although two doses could be considered to improve compliance (moderate quality of evidence, weak recommendations). A five-day duration of therapy is recommended, with clinical monitoring and re-assessment approximately 72 h after the start of antibiotic treatment to evaluate symptom resolution (moderate quality of evidence, strong recommendations).To improve the management of CAP in pediatric patients, we have developed this consensus based on a thorough review of the best available evidence and extensive discussions with an expert panel. However, further efforts are needed. Future research should focus on enhancing diagnostic accuracy, optimizing antibiotic utilization, comparing the efficacy of different antibiotic regimens, and determining the optimal dosage and duration of treatment in different setting.

Optimal Pediatric Outpatient Antibiotic Prescribing

Importance

In the US, 50% of all pediatric outpatient antibiotics prescribed are unnecessary or inappropriate. Less is known about the appropriateness of pediatric outpatient antibiotic prescribing.

Objective

To identify the overall percentage of outpatient antibiotic prescriptions that are optimal according to guideline recommendations for first-line antibiotic choice and duration.

Design, Setting, and Participants

This cross-sectional study obtained data on any clinical encounter for a patient younger than 20 years with at least 1 outpatient oral antibiotic, intramuscular ceftriaxone, or penicillin prescription filled in the state of Tennessee from January 1 to December 31, 2022, from IQVIA's Longitudinal Prescription Claims and Medical Claims databases. Each clinical encounter was assigned a single diagnosis corresponding to the lowest applicable tier in a 3-tier antibiotic tier system. Antibiotics prescribed for tier 1 (nearly always required) or tier 2 (sometimes required) diagnoses were compared with published national guidelines. Antibiotics prescribed for tier 3 (rarely ever required) diagnoses were considered to be suboptimal for both choice and duration.

Main Outcomes and Measures

Primary outcome was the percentage of optimal antibiotic prescriptions consistent with guideline recommendations for first-line antibiotic choice and duration. Secondary outcomes were the associations of optimal prescribing by diagnosis, suboptimal antibiotic choice, and patient- and clinician-level factors (ie, age and Social Vulnerability Index) with optimal antibiotic choice, which were measured by odds ratios (ORs) and 95% CIs calculated using a multivariable logistic regression model.

Results

A total of 506 633 antibiotics were prescribed in 488 818 clinical encounters (for 247 843 females [50.7%]; mean [SD] age, 8.36 [5.5] years). Of these antibiotics, 21 055 (4.2%) were for tier 1 diagnoses, 288 044 (56.9%) for tier 2 diagnoses, and 197 660 (39.0%) for tier 3 diagnoses. Additionally, 194 906 antibiotics (38.5%) were optimal for antibiotic choice, 259 786 (51.3%) for duration, and 159 050 (31.4%) for both choice and duration. Acute otitis media (AOM) and pharyngitis were the most common indications, with 85 635 of 127 312 (67.3%) clinical encounters for AOM and 42 969 of 76 865 (55.9%) clinical encounters for pharyngitis being optimal for antibiotic choice. Only 257 of 4472 (5.7%) antibiotics prescribed for community-acquired pneumonia had a 5-day duration. Optimal antibiotic choice was more likely in patients who were younger (OR, 0.98; 95% CI, 0.98-0.98) and were less socially vulnerable (OR, 0.84; 95% CI, 0.82-0.86).

Conclusions and Relevance

This cross-sectional study found that less than one-third of antibiotics prescribed to pediatric outpatients in Tennessee were optimal for choice and duration. Four stewardship interventions may be targeted: (1) reduce the number of prescriptions for tier 3 diagnoses, (2) increase optimal prescribing for AOM and pharyngitis, (3) provide clinician education on shorter antibiotic treatment courses for community-acquired pneumonia, and (4) promote optimal antibiotic prescribing in resource-limited settings.

Twenty-four Month Outcomes of Extended- Versus Standard-course Antibiotic Therapy in Children Hospitalized With Pneumonia in High-risk Settings: A Randomized Controlled Trial

BACKGROUND

Pediatric community-acquired pneumonia (CAP) can lead to long-term respiratory sequelae, including bronchiectasis. We determined if an extended (13-14 days) versus standard (5-6 days) antibiotic course improves long-term outcomes in children hospitalized with CAP from populations at high risk of chronic respiratory disease.

METHODS

We undertook a multicenter, double-blind, superiority, randomized controlled trial involving 7 Australian, New Zealand, and Malaysian hospitals. Children aged 3 months to ≤5 years hospitalized with radiographic-confirmed CAP who received 1-3 days of intravenous antibiotics, then 3 days of oral amoxicillin-clavulanate, were randomized to either extended-course (8-day oral amoxicillin-clavulanate) or standard-course (8-day oral placebo) arms. Children were reviewed at 12 and 24 months. The primary outcome was children with the composite endpoint of chronic respiratory symptoms/signs (chronic cough at 12 and 24 months; ≥1 subsequent hospitalized acute lower respiratory infection by 24 months; or persistent and/or new chest radiographic signs at 12-months) at 24-months postdischarge, analyzed by intention-to-treat, where children with incomplete follow-up were assumed to have chronic respiratory symptoms/signs ("worst-case" scenario).

RESULTS

A total of 324 children were randomized [extended-course (n = 163), standard-course (n = 161)]. For our primary outcome, chronic respiratory symptoms/signs occurred in 97/163 (60%) and 94/161 (58%) children in the extended-courses and standard-courses, respectively [relative risk (RR) = 1.02, 95% confidence interval (CI): 0.85-1.22]. Among children where all sub-composite outcomes were known, chronic respiratory symptoms/signs between groups, RR = 1.10, 95% CI: 0.69-1.76 [extended-course = 27/93 (29%) and standard-course = 24/91 (26%)]. Additional sensitivity analyses also revealed no between-group differences.

CONCLUSION

Among children from high-risk populations hospitalized with CAP, 13-14 days of antibiotics (versus 5-6 days), did not improve long-term respiratory outcomes.

Long-term effects of ciprofloxacin treatment on the gastrointestinal and oropharyngeal microbiome are more pronounced after longer antibiotic courses

BACKGROUND

Urinary tract infections (UTIs) are one of the main reasons for antibiotic prescriptions in primary care. Recent studies demonstrate similar clinical outcomes with short vs. long antibiotics courses. The aim of this study was to investigate the differential collateral effect of ciprofloxacin treatment duration on the gastrointestinal and oropharyngeal microbiome in patients presenting with uncomplicated UTI to primary care practices in Switzerland, Belgium and Poland.

METHODS

Stool and oropharyngeal samples were obtained from 36 treated patients and 14 controls at the beginning of antibiotic therapy, end of therapy and one month after the end of therapy. Samples underwent shotgun metagenomics.

RESULTS

At the end of therapy, patients treated with both short (≤7 days) and long (>7 days) ciprofloxacin courses showed similar changes in the gastrointestinal microbiome compared to non-treated controls. After one month, most changes in patients receiving short courses were reversed; however, long courses led to increased abundance of the genera Roseburia, Faecalicatena and Escherichia. Changes in the oropharynx were minor and reversed to baseline levels within one month. Ciprofloxacin resistance encoding mutations in gyrA/B and parC/E reads were observed in both short and long treatment groups but decreased to baseline levels after one month. An increased abundance of resistance genes was observed in the gastrointestinal microbiome after longer treatment, and correlated to increased prevalence of aminoglycoside, β-lactam, sulphonamide, and tetracycline resistance genes.

CONCLUSION

Collateral effects on the gastrointestinal community, including an increased prevalence of antimicrobial resistance genes, persists for up to at least one month following longer ciprofloxacin therapy. These data support the use of shorter antimicrobial treatment duration.

Leftover of Amoxicillin Suspension After Use by Children in the Netherlands

PURPOSE

In clinical practice, a discrepancy may exist between the prescribed amount of a drug and the commercially available pack sizes in the pharmacy, potentially contributing to drug waste. This study aimed-as an example of this phenomena-to quantify leftover of amoxicillin suspension prescribed to children, due to discrepancies between physician-prescribed and pharmacy-dispensed amounts.

METHODS

We performed a retrospective cohort study including amoxicillin suspension dispensations for patients aged 0-12 years between 2017 and 2019 utilizing the Dutch PHARMO database. Leftover amount of amoxicillin was estimated by assessing the discrepancy between the prescribed and dispensed amounts. Extrapolated amoxicillin weight and economic spillage estimates for the Netherlands were determined. The impact of two theoretical interventions on leftover amount was assessed: (1) introducing vials with half the volume of the current 100 and 30 mL vials and (2) a combination of the first intervention with a maximum of 10% round-down by the dispensing pharmacy of the prescribed dose.

RESULTS

We included 79 512 amoxicillin suspension dispensations for 62 252 patients. The mean leftover amount of amoxicillin suspension per dispensing was 27%. The yearly amount of amoxicillin leftover was 49.8 kg in the study cohort, equivalent to yearly 633 kg and €621 000 when extrapolated to the Netherlands. Employing the first theoretical intervention reduced the mean leftover per dispensing to 20%, reducing the yearly leftover to 31.6 kg amoxicillin in the study cohort, and to 400 kg and €400 000 extrapolated. The second theoretical intervention further reduced leftover to 17%, reducing the yearly leftover to 24.3 kg amoxicillin in the study cohort, and to 300 kg and €300 000 extrapolated.

CONCLUSION

Approximately a quarter of amoxicillin suspension remains as leftover per dispensing. Applying different theoretical intervention shows the potential for a significant reduction of amoxicillin leftover.

Towards pharmacokinetic boosting of phenoxymethylpenicillin (penicillin-V) using probenecid for the treatment of bacterial infections

In the face of increasing antimicrobial tolerance and resistance there is a global obligation to optimise oral antimicrobial dosing strategies including narrow spectrum penicillins, such as penicillin-V. We conducted a randomised, crossover study in healthy volunteers to characterise the influence of probenecid on penicillin-V pharmacokinetics and estimate the pharmacodynamics against Streptococcus pneumoniae. Twenty participants took six doses of penicillin-V (250 mg, 500 mg or 750 mg four times daily) with and without probenecid. Total and free concentrations of penicillin-V and probenecid were measured at two timepoints. A pharmacokinetic model was developed, and the probability of target attainment (PTA) calculated. The mean difference (95% CI) between penicillin-V alone and in combination with probenecid for serum total and free penicillin-V concentrations was significantly different at both timepoints (total: 45 min 4.32 (3.20-5.32) mg/L p < 0.001, 180 min 2.2 (1.58-3.25) mg/L p < 0.001; free: 45 min 1.15 (0.88-1.42) mg/L p < 0.001, 180 min 0.5 (0.35-0.76) mg/L p < 0.001). There was no difference between the timepoints in probenecid concentrations. PTA analysis shows probenecid allows a fourfold increase in MIC cover. Addition of probenecid was safe and well tolerated. The data support further research into improved dosing structures for complex outpatient therapy and might also be used to address penicillin supply shortages.

Safely Doing Less Antibiotics: Evidence to Guide Duration and Route of Administration in Common Pediatric Infections

The growing evidence detailing the harmful effects of exposure to antibiotics has driven an urgency to evaluate recommendations in common pediatric infections regarding antibiotic course duration and route of administration. The past decade has produced strong evidence in support of many patients with uncomplicated common pediatric infections receiving shortened antibiotic durations and early conversion from intravenous to oral antibiotics. In this review, we offer guidance to providers in selection of duration and route of administration in a subset of common pediatric infections, including community-acquired pneumonia, osteomyelitis, and infections of the head and neck. [Pediatr Ann. 2024;53(6):e229-e233.].

Shortening treatment duration for uncomplicated community acquired pneumonia to align with best practice guidelines in a large academic paediatric emergency department

Recommendations for antibiotic therapy for community acquired pneumonia recently changed from 10-day to 5-day duration. This quality improvement project aimed to change the practice of providers in an urban, free-standing children's hospital paediatric emergency department in the United States to match the updated recommendations. Improvement interventions included educational outreach, data sharing, on-site reminders, and audit-and-feedback. The project included analysis of ED return visits to monitor possible treatment failure. Interventions successfully increased 5-day antibiotic prescription rate from 3% to 85% within 12 months.

Leading Paediatric Infectious Diseases-Current Trends, Gaps, and Future Prospects in Oral Pharmacotherapeutic Interventions

Paediatric infectious diseases contribute significantly to global health challenges. Conventional therapeutic interventions are not always suitable for children, as they are regularly accompanied with long-standing disadvantages that negatively impact efficacy, thus necessitating the need for effective and child-friendly pharmacotherapeutic interventions. Recent advancements in drug delivery technologies, particularly oral formulations, have shown tremendous progress in enhancing the effectiveness of paediatric medicines. Generally, these delivery methods target, and address challenges associated with palatability, dosing accuracy, stability, bioavailability, patient compliance, and caregiver convenience, which are important factors that can influence successful treatment outcomes in children. Some of the emerging trends include moving away from creating liquid delivery systems to developing oral solid formulations, with the most explored being orodispersible tablets, multiparticulate dosage forms using film-coating technologies, and chewable drug products. Other ongoing innovations include gastro-retentive, 3D-printed, nipple-shield, milk-based, and nanoparticulate (e.g., lipid-, polymeric-based templates) drug delivery systems, possessing the potential to improve therapeutic effectiveness, age appropriateness, pharmacokinetics, and safety profiles as they relate to the paediatric population. This manuscript therefore highlights the evolving landscape of oral pharmacotherapeutic interventions for leading paediatric infectious diseases, crediting the role of innovative drug delivery technologies. By focusing on the current trends, pointing out gaps, and identifying future possibilities, this review aims to contribute towards ongoing efforts directed at improving paediatric health outcomes associated with the management of these infectious ailments through accessible and efficacious drug treatments.

High-resolution genomics identifies pneumococcal diversity and persistence of vaccine types in children with community-acquired pneumonia in the UK and Ireland

BACKGROUND

Streptococcus pneumoniae is a global cause of community-acquired pneumonia (CAP) and invasive disease in children. The CAP-IT trial (grant No. 13/88/11; https://www.capitstudy.org.uk/ ) collected nasopharyngeal swabs from children discharged from hospitals with clinically diagnosed CAP, and found no differences in pneumococci susceptibility between higher and lower antibiotic doses and shorter and longer durations of oral amoxicillin treatment. Here, we studied in-depth the genomic epidemiology of pneumococcal (vaccine) serotypes and their antibiotic resistance profiles.

METHODS

Three-hundred and ninety pneumococci cultured from 1132 nasopharyngeal swabs from 718 children were whole-genome sequenced (Illumina) and tested for susceptibility to penicillin and amoxicillin. Genome heterogeneity analysis was performed using long-read sequenced isolates (PacBio, n = 10) and publicly available sequences.

RESULTS

Among 390 unique pneumococcal isolates, serotypes 15B/C, 11 A, 15 A and 23B1 were most prevalent (n = 145, 37.2%). PCV13 serotypes 3, 19A, and 19F were also identified (n = 25, 6.4%). STs associated with 19A and 19F demonstrated high genome variability, in contrast to serotype 3 (n = 13, 3.3%) that remained highly stable over a 20-year period. Non-susceptibility to penicillin (n = 61, 15.6%) and amoxicillin (n = 10, 2.6%) was low among the pneumococci analysed here and was independent of treatment dosage and duration. However, all 23B1 isolates (n = 27, 6.9%) were penicillin non-susceptible. This serotype was also identified in ST177, which is historically associated with the PCV13 serotype 19F and penicillin susceptibility, indicating a potential capsule-switch event.

CONCLUSIONS

Our data suggest that amoxicillin use does not drive pneumococcal serotype prevalence among children in the UK, and prompts consideration of PCVs with additional serotype coverage that are likely to further decrease CAP in this target population. Genotype 23B1 represents the convergence of a non-vaccine genotype with penicillin non-susceptibility and might provide a persistence strategy for ST types historically associated with vaccine serotypes. This highlights the need for continued genomic surveillance.

Community-acquired bacterial pneumonia in children: an update on antibiotic duration and immunization strategies

PURPOSE OF REVIEW

This review is structured to update clinicians on the epidemiology, antibiotic treatment, and prevention of pediatric bacterial pneumonia. The review provides information regarding the current research on antibiotic management for bacterial pneumonia and the newest immunization recommendations to prevent pneumococcal pneumonia and other respiratory infections.

RECENT FINDINGS

The recommended length of antibiotic therapy for bacterial pneumonia has been discrepant between low-income and high-income countries. Recently, randomized controlled trials conducted in high-income countries provided evidence to support a short antibiotic course (3-5 days) for uncomplicated bacterial pneumonia in otherwise healthy children. The negative impact of inaccurate penicillin allergy labels in children with pneumonia has emphasized the importance of prompt allergy de-labeling. Newer pneumococcal vaccines are recommended for children and are expected to have a significant impact on bacterial pneumonia rates.

SUMMARY

Pediatric bacterial pneumonia is an important contributor to childhood morbidity and mortality. A short antibiotic course seems to be sufficient for the outpatient management of uncomplicated bacterial pneumonia; however, more studies are required in the inpatient setting. Future studies will inform the impact of recently introduced pneumococcal and respiratory syncytial virus vaccines on the epidemiology of bacterial pneumonia.

Reducing Antibiotic Duration for Uncomplicated UTI in the Pediatric Emergency Department

BACKGROUND

Short-duration (3-5 days) antibiotic treatment of uncomplicated urinary tract infection (uUTI) in children >24 months of age is equivalent to longer-duration antibiotic treatment, with added benefits of antibiotic stewardship. At our pediatric emergency department (ED), 13% of 5- to 18-year-old patients discharged with uUTI received ≤5 days of antibiotics. We aimed to increase short-duration prescriptions in patients with uUTI from 13% to >50% over 12 months.

METHODS

This quality improvement project was conducted from January 2021 to August 2022. Complicated UTI was excluded. Interventions included education, practice feedback, and electronic health record changes. The outcome measure, the proportion of children treated with a short antibiotic duration, was studied by using p-charts. Antibiotic days saved were calculated. Revisits with UTI within 14 days of confirmed uUTI treated with short-duration antibiotics (balancing measure) were analyzed by using Fisher's exact test.

RESULTS

In 1292 (n = 363 baseline, 929 post-intervention) eligible patients treated for uUTI, shorter antibiotic duration increased from 13% to 91%. We met our 50% aim within 2 months, with continued improvement leading to an additional centerline shift. Consequently, 2619 antibiotic days were saved. Two of 334 (0.6%) patients returned (P = NS) within 14 days of the index visit with a culture-positive uUTI.

CONCLUSIONS

By using education, feedback, and electronic health record changes, we decreased antibiotic duration in children discharged from the ED for uUTI without a significant increase in return visits with UTI. These interventions can be expanded to wider age groups and other outpatient settings.

When should factorial designs be used for late-phase randomised controlled trials?

BACKGROUND

A 2×2 factorial design evaluates two interventions (A versus control and B versus control) by randomising to control, A-only, B-only or both A and B together. Extended factorial designs are also possible (e.g. 3×3 or 2×2×2). Factorial designs often require fewer resources and participants than alternative randomised controlled trials, but they are not widely used. We identified several issues that investigators considering this design need to address, before they use it in a late-phase setting.

METHODS

We surveyed journal articles published in 2000-2022 relating to designing factorial randomised controlled trials. We identified issues to consider based on these and our personal experiences.

RESULTS

We identified clinical, practical, statistical and external issues that make factorial randomised controlled trials more desirable. Clinical issues are (1) interventions can be easily co-administered; (2) risk of safety issues from co-administration above individual risks of the separate interventions is low; (3) safety or efficacy data are wanted on the combination intervention; (4) potential for interaction (e.g. effect of A differing when B administered) is low; (5) it is important to compare interventions with other interventions balanced, rather than allowing randomised interventions to affect the choice of other interventions; (6) eligibility criteria for different interventions are similar. Practical issues are (7) recruitment is not harmed by testing many interventions; (8) each intervention and associated toxicities is unlikely to reduce either adherence to the other intervention or overall follow-up; (9) blinding is easy to implement or not required. Statistical issues are (10) a suitable scale of analysis can be identified; (11) adjustment for multiplicity is not required; (12) early stopping for efficacy or lack of benefit can be done effectively. External issues are (13) adequate funding is available and (14) the trial is not intended for licensing purposes. An overarching issue (15) is that factorial design should give a lower sample size requirement than alternative designs. Across designs with varying non-adherence, retention, intervention effects and interaction effects, 2×2 factorial designs require lower sample size than a three-arm alternative when one intervention effect is reduced by no more than 24%-48% in the presence of the other intervention compared with in the absence of the other intervention.

CONCLUSIONS

Factorial designs are not widely used and should be considered more often using our issues to consider. Low potential for at most small to modest interaction is key, for example, where the interventions have different mechanisms of action or target different aspects of the disease being studied.

Childhood community-acquired pneumonia

Community-acquired pneumonia (CAP) is a common disease in children, and its aetiological and clinical diagnosis are challenging for physicians in both private practice and hospitals. Over the past three decades, conjugate vaccines have successfully reduced the burden of the former main causes of CAP, Streptococcus pneumoniae and Haemophilus influenzae type b. Today, viruses are by far the most commonly detected pathogens in children with CAP.  Conclusion: New insights into the aetiology and treatment of CAP in children in recent years have influenced management and are the focus of this review. In addition to reducing diagnostic uncertainty, there is an urgent need to reduce antibiotic overuse and antimicrobial resistance in children with CAP. What is Known: • Conjugate vaccines against Streptococcus pneumoniae and Haemophilus influenzae type b have shifted the epidemiology of childhood CAP to predominantly viral pathogens and Mycoplasma pneumoniae. • Clinical, laboratory, and radiological criteria cannot reliably distinguish between bacterial and viral aetiology in children with CAP. What is New: • Test results and epidemiological data must be carefully interpreted, as no single diagnostic method applied to non-pulmonary specimens has both high sensitivity and high specificity for determining pneumonia aetiology in childhood CAP. • This review provides a simple and pragmatic management algorithm for children with CAP to aid physicians in providing optimal and safe care and reducing antibiotic prescribing.

Interpretation of Antibiotic Trials in Pediatric Pneumonia

This cohort study assesses radiographic evidence of pneumonia and antibiotic use in children with clinically suspected community-acquired pneumonia.

Significant Publications on Infectious Diseases Pharmacotherapy in 2021

Purpose: To summarize the most noteworthy infectious diseases (ID) pharmacotherapy articles published in peer-reviewed literature in 2021. Summary: Members of the Houston Infectious Diseases Network (HIDN) nominated articles that were deemed to have significant contributions to ID pharmacotherapy in 2021. These nominations included articles pertaining to both general ID, including coronavirus disease 2019 (COVID-19), and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pharmacotherapy. A total of 35 articles were nominated by HIDN: 30 articles pertaining to general ID pharmacotherapy and 5 articles with HIV/AIDS focus. To select the most influential articles of 2021, a survey was created and distributed to members of the Society of Infectious Diseases Pharmacists (SIDP). Of the 239 SIDP members who responded to the survey, there were 192 recorded votes for the top 10 general ID pharmacotherapy articles and 47 recorded votes for the top HIV/AIDS article, respectively. The top publications are summarized. Conclusion: Antimicrobial stewardship and the optimal management of infectious disease states continues to be a priority in the midst of the ongoing coronavirus disease 2019 (COVID-19) global pandemic. In light of the sheer volume of ID-related articles published in the past year, this review aims to aid clinicians in remaining up-to-date on key practice-changing ID pharmacotherapy publications from 2021.

The long and the short of pediatric emergency department antibiotic prescribing: A retrospective observational study

BACKGROUND

Most antibiotics prescribed to children are provided in the outpatient and emergency department (ED) settings, yet these prescribers are seldom engaged by antibiotic stewardship programs. We reviewed ED antibiotic prescriptions for three common infections to describe current prescribing practices.

METHODS

Prescription data between 2018 and 2021 were extracted from the electronic records of children discharged from the Children's Hospital of Eastern Ontario ED with urinary tract infection (UTI), community acquired pneumonia (CAP), and acute otitis media ≥2 years of age (AOM). Antibiotic choice, duration, as well as the provider's time in practice and training background were collected. Antibiotic durations were compared with Canadian guideline recommendations to assess concordance. Provider-level prescribing practices were analyzed using k-means cluster analysis.

RESULTS

10,609 prescriptions were included: 2868 for UTI, 2958 for CAP, and 4783 for AOM. Guideline-concordant durations prescribed was generally high (UTI 84.9%, CAP 94.0%, AOM 52.8%), a large proportion of antibiotic-days prescribed were in excess of the minimally recommended duration for each infection (UTI 16.8%, 19.3%, AOM 25.5%). Cluster analysis yielded two clusters of prescribers, with those in one cluster more commonly prescribing durations at the lower end of recommended interval, and the others more commonly prescribing longer durations for all three infections reviewed. No statistically significant differences were found between clusters by career stage or training background.

CONCLUSIONS

While guideline-concordant antibiotic prescribing was generally high, auditing antibiotic prescriptions identified shifting prescribing towards the minimally recommended duration as a potential opportunity to reduce antibiotic use among children for these infections.

Improving Short Course Treatment of Pediatric Infections: A Randomized Quality Improvement Trial

BACKGROUND AND OBJECTIVES

Short courses of antibiotic treatment are effective for pediatric community-acquired pneumonia (CAP) and skin and soft tissue infections (SSTI). We compared the effectiveness of education with performance feedback, clinical decision support (CDS), and the combination in encouraging appropriately short treatment courses by primary care clinicians.

METHODS

We designed a site-randomized, quality improvement trial within a large pediatric primary care network. Each practice was randomly assigned to 1 of 4 groups: education and feedback; CDS; both interventions ("combined group"); and control. We performed difference-in-differences analysis to compare the proportion of cases with short course treatment before and after intervention among the 4 groups.

RESULTS

For all cases of CAP and SSTI, the proportion in the control group treated with the recommended duration did not change from the baseline period (26.1% [679 of 2603]) to the intervention period (25.8% [196 of 761]; P = .9). For the education and feedback group, the proportion rose from 22.3% (428 of 1925) to 45.0% (239 of 532; P < .001); for the CDS group, from 26.6% (485 of 1824) to 52.3% (228 of 436; P < .001); and for the combined group, from 26.2% (491 of 1875) to 67.8% (314 of 463; P < .001). A difference-in-differences analysis showed that all 3 intervention groups improved performance compared with the control group (P < .001); the combined group had greater improvement than the education and feedback group or the CDS group (P < .001).

CONCLUSIONS

In this quality improvement project to encourage shorter duration treatment of CAP and SSTI, both education with performance feedback and CDS were effective in modifying clinician behavior; however, the combination of the two was substantially more effective than either strategy alone.

Community-Acquired Pneumonia in Children

ABSTRACT

Community-acquired pneumonia (CAP) is the most common cause of childhood mortality globally. In the United States, CAP is a leading cause of pediatric hospitalization and antibiotic use and is associated with substantial morbidity. There has been a dramatic shift in microbiological etiologies for CAP in children over time as pneumococcal pneumonia has become less common and viral etiologies have become predominant. There is no commonly agreed on approach to the diagnosis of CAP in children. When indicated, antimicrobial treatment should consist of narrow-spectrum antibiotics. In this article, we will describe the current understanding of the microbiological etiologies, clinical presentation, diagnostic approach, risk factors, treatment, and future directions in the diagnosis and management of pediatric CAP.

Quality of antibiotic prescribing for pediatric community-acquired Pneumonia in outpatient care

BACKGROUND

Antibiotics remain the primary treatment for community acquired pneumonia (CAP), however rising rates of antimicrobial resistance may jeopardize their future efficacy. With higher rates of disease reported in the youngest populations, effective treatment courses for pediatric pneumonia are of paramount importance. This study is the first to examine the quality of pediatric antibiotic use by agent, dose and duration.

METHODS

A retrospective cohort study included all outpatient/primary care physician visits for pediatric CAP (aged < 19 years) between January 1 2014 to December 31 2018. Relevant practice guidelines were identified, and treatment recommendations extracted. Amoxicillin was the primary first-line agent for pediatric CAP. Categories of prescribing included: guideline adherent, effective but unnecessary (excess dose and/or duration), under treatment (insufficient dose and/or duration), and not recommended. Proportions of attributable-antibiotic use were examined by prescribing category, and then stratified by age and sex.

RESULT(S)

A total of 42,452 episodes of pediatric CAP were identified. Of those, 31,347 (76%) resulted in an antibiotic prescription. Amoxicillin accounted for 51% of all prescriptions. Overall, 27% of prescribing was fully guideline adherent, 19% effective but unnecessary, 10% under treatment, and 44% not recommended by agent. Excessive duration was the hallmark of effective but unnecessary prescribing (97%) Macrolides accounted for the majority on non-first line agent use, with only 32% of not recommended prescribing preceded by a previous course of antibiotics.

CONCLUSION(S)

This study is the first in Canada to examine prescribing quality for pediatric CAP by agent, dose and duration. Utilizing first-line agents, and shorter-course treatments are targets for stewardship.

An Adjudication Protocol for Severe Pneumonia

Background

Clinical end points that constitute successful treatment in severe pneumonia are difficult to ascertain and vulnerable to bias. The utility of a protocolized adjudication procedure to determine meaningful end points in severe pneumonia has not been well described.

Methods

This was a single-center prospective cohort study of patients with severe pneumonia admitted to the medical intensive care unit. The objective was to develop an adjudication protocol for severe bacterial and/or viral pneumonia. Each episode of pneumonia was independently reviewed by 2 pulmonary and critical care physicians. If a discrepancy occurred between the 2 adjudicators, a third adjudicator reviewed the case. If a discrepancy remained after all 3 adjudications, consensus was achieved through committee review.

Results

Evaluation of 784 pneumonia episodes during 593 hospitalizations achieved only 48.1% interobserver agreement between the first 2 adjudicators and 78.8% when agreement was defined as concordance between 2 of 3 adjudicators. Multiple episodes of pneumonia and presence of bacterial/viral coinfection in the initial pneumonia episode were associated with lower interobserver agreement. For an initial episode of bacterial pneumonia, patients with an adjudicated day 7-8 clinical impression of cure (compared with alternative impressions) were more likely to be discharged alive (odds ratio, 6.3; 95% CI, 3.5-11.6).

Conclusions

A comprehensive adjudication protocol to identify clinical end points in severe pneumonia resulted in only moderate interobserver agreement. An adjudicated end point of clinical cure by day 7-8 was associated with more favorable hospital discharge dispositions, suggesting that clinical cure by day 7-8 may be a valid end point to use in adjudication protocols.

Duration of antibiotic therapy among paediatricians: A national survey of current clinical practice in Spain

OBJECTIVES

Appropriate duration of antibiotic treatment is a key principle to reduce the emergence of bacterial resistance and antibiotic harm. The aim of this study was to document current clinical practice among Spanish paediatricians in terms of the duration of antibiotic therapy in both inpatient and outpatient settings, mapping the difference between practice and guidelines, and thus identifying opportunities to improve practice.

METHODS

A national exploratory work survey was distributed in 2020 as a questionnaire about seven main infectious syndromes in children: genitourinary; skin and soft tissue; osteoarticular; ear, nose and throat; pneumonia; central nervous system; and bacteraemia. The answers were contrasted with current recommendations regarding the duration of antibiotic therapy. Demographic analysis was also performed.

RESULTS

The survey was completed by 992 paediatricians in Spain, representing 9.5% of paediatricians working in the Spanish national health system. Hospital care clinicians accounted for 42.7% (6662/15590) of responses. The antibiotic duration used in practice was longer than recommended in 40.8% (6359/15590) of responses, and shorter than recommended in 16% (1705/10654) of responses. Only 25% (249/992) and 23% (229/992) of respondents indicated that they would prescribe antibiotics for the recommended treatment duration for lower urinary tract infection and community-acquired pneumonia (AI evidence). Among severe hospital-managed infections, a tendency towards longer courses of antibiotics was found for non-complicated meningococcal infections and non-complicated pneumococcal, Gram-negative and S. aureus bacteraemia.

CONCLUSIONS

A noteworthy tendency towards prescribing antibiotics for longer than recommended among paediatricians was evidenced in this nationwide study, highlighting a wide range of opportunities for potential improvement.

Harmonization of Amoxicillin Dose, Duration, and Formulation for Acute Childhood Respiratory Infections

Pediatric guidelines vary in their recommended amoxicillin dosing for common respiratory infections. It would help program delivery if there was harmonization of dosing and formulation of amoxicillin across multiple clinical respiratory infections, considering the pharmacokinetics, common targets, drug resistance, availability, cost effectiveness, and ease of administration. The World Health Organization EML AWaRe Book recommends higher dose amoxicillin given twice daily for five days for all uncomplicated respiratory infections where an antibiotic is indicated. The WHO AWaRe Book amoxicillin dosing guidance can be achieved for infants and older children using only scored 250 mg and 500 mg dispersible tablets (DTs), the WHO recommended child formulation. There is a clear need for wider availability of 250 mg/500 mg dispersible tablets of amoxicillin in both public and private health care sectors, to improve access to essential antibiotics.

Individualised versus standard duration of antibiotic therapy in children with acute uncomplicated febrile urinary tract infection: a study protocol and statistical analysis plan for a multicentre randomised clinical trial

INTRODUCTION

Febrile urinary tract infection is one of the most common bacterial infections in children. Currently, recommended antibiotic duration is 10 days. However, recent evidence suggests that 90%-95% of children with febrile urinary tract infections are afebrile and clinically improved 48-72 hours after treatment initiation. Accordingly, individualised duration of antibiotic therapy, according to the recovery time, might be more beneficial than current recommendations, but no evidence exists.

METHODS AND ANALYSIS

An open-label randomised clinical trial equally randomising children aged 3 months to 12 years from eight Danish paediatric departments with uncomplicated febrile (≥38°C) urinary tract infection to either individualised or standard duration of antibiotic therapy. Children allocated to individualised duration of antibiotic therapy will terminate antibiotic therapy 3 days after clinical improvement with no fever, flank pain or dysuria. Children allocated to standard duration will receive 10 days of antibiotic therapy. Co-primary outcomes are non-inferiority for recurrent urinary tract infection or death within 28 days after the end of treatment (non-inferiority margin 7.5 percentage points) and superiority for the number of days with antibiotic therapy within 28 days after treatment initiation. Seven other outcomes will also be assessed. A total of 408 participants are needed to detect non-inferiority (one-sided alpha 2.5%; beta 80%).

ETHICS AND DISSEMINATION

This trial has been approved by the Ethics Committee (H-21057310) and the Data Protection Agency (P-2022-68) in Denmark. Regardless of the trial's findings (whether positive, negative or inconclusive), the results will be compiled into one or more manuscripts for publication in international peer-reviewed scientific journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT05301023.

Short-term antibiotic therapy for the most common bacterial respiratory infections in infants and children

Overuse and misuse of antibiotics have strongly accelerated the progressive increase in bacterial antimicrobial resistance (AMR). The evidence that antimicrobial selective pressure was greater the longer the antibiotic therapy was continued has led some experts to reconsider duration of antibiotic therapy testing the use of short-term drug administration. If as effective as long-term therapy, short-term therapy could have been an easy measure to limit AMR emergence. In the present narrative review, whether present knowledge on short-term therapy of acute streptococcal pharyngitis (ASF), acute otitis media (AOM) and mild to moderate community-acquired pneumonia (CAP) allows systematic use of short-term therapy in infants and children with these diseases is discussed. Literature analysis showed that reducing the duration of antibiotic therapy for some of the most common pediatric respiratory infections could be a valid measure to contain the antibiotic abuse and the consequent impact on the emergence of AMR. Several data seem to indicate that this type of intervention is possible, as short-term therapy has been found as effective as the traditionally recommended long-term therapy in some cases of ASF, AOM and mild to moderate CAP. However, further studies are needed to better characterize infants and children who can have benefit with short-term antibiotic therapy in common bacterial respiratory infections.

Durée d’une antibiothérapie pour une pneumonie acquise dans la communauté chez l’enfant

Question

Un enfant de 4 ans est venu à notre clinique, présentant un tableau clinique conforme à une pneumonie acquise dans la communauté (PAC). On lui a prescrit de l’amoxicilline par voie orale, et un collègue s’est demandé quelle devrait être la durée du traitement. Quelles sont les données probantes actuelles concernant la durée du traitement pour une PAC sans complication en milieu ambulatoire?

Réponse

La durée d’une antibiothérapie auparavant recommandée pour une PAC sans complication était de 10 jours. Des données probantes récentes tirées de quelques essais randomisés contrôlés indiquent qu’une durée de 3 à 5 jours n’est pas inférieure à un régime thérapeutique plus long. Dans un effort pour prescrire la durée efficace la plus courte afin de minimiser le risque d’une résistance antimicrobienne liée à une utilisation prolongée d’antibiotiques, les médecins de famille devraient offrir de 3 à 5 jours d’antibiotiques appropriés et surveiller le rétablissement des enfants souffrant d’une PAC.

Evaluation of a Pediatric Community-Acquired Pneumonia Antimicrobial Stewardship Intervention at an Academic Medical Center

(1) Background: Pneumonia is the leading diagnosis associated with antibiotic use in hospitalized children. The Infectious Diseases Society of America published pediatric community-acquired pneumonia (CAP) guidelines in 2011, but adherence to recommendations varies across institutions. The purpose of this study was to evaluate the impact of an antimicrobial stewardship intervention on antibiotic prescribing in pediatric patients admitted to an academic medical center. (2) Methods: This single-center pre/post-intervention evaluation included children admitted for CAP during three time periods (pre-intervention and post-intervention groups 1 and 2). The primary outcomes were changes in inpatient antibiotic selection and duration following the interventions. Secondary outcomes included discharge antibiotic regimens, length of stay, and 30-day readmission rates. (3) Results: A total of 540 patients were included in this study. Most patients were under five years of age (69%). Antibiotic selection significantly improved, with prescriptions for ceftriaxone decreasing (p < 0.001) and ampicillin increasing (p < 0.001) following the interventions. Antibiotic duration decreased from a median of ten days in the pre-intervention group and post-intervention group 1 to eight days in post-intervention group 2. (4) Conclusions: Our antibiotic stewardship intervention directed at pediatric CAP treatment resulted in improved antibiotic prescriptions and provides data that can be used to further educate providers at our institution.

Children hospitalized with community-acquired pneumonia complicated by effusion: a single-centre retrospective cohort study

OBJECTIVES

To describe children hospitalized with community-acquired pneumonia complicated by effusion (cCAP).

DESIGN

Retrospective cohort study.

SETTING

A Canadian children's hospital.

PARTICIPANTS

Children without significant medical comorbidities aged < 18 years admitted from January 2015-December 2019 to either the Paediatric Medicine or Paediatric General Surgery services with any pneumonia discharge code who were documented to have an effusion/empyaema using ultrasound.

OUTCOME MEASURES

Length of stay; admission to the paediatric intensive care unit; microbiologic diagnosis; antibiotic use.

RESULTS

There were 109 children without significant medical comorbidities hospitalized for confirmed cCAP during the study period. Their median length of stay was 9 days (Q1-Q3 6-11 days) and 35/109 (32%) were admitted to the paediatric intensive care unit. Most (89/109, 74%) underwent procedural drainage. Length of stay was not associated with effusion size but was associated with time to drainage (0.60 days longer stay per day delay in drainage, 95%CI 0.19-1.0 days). Microbiologic diagnosis was more often made via molecular testing of pleural fluids (43/59, 73%) than via blood culture (12/109, 11%); the main aetiologic pathogens were S. pneumoniae (40/109, 37%), S. pyogenes (15/109, 14%), and S. aureus (7/109, 6%). Discharge on a narrow spectrum antibiotic (i.e. amoxicillin) was much more common when the cCAP pathogen was identified as compared to when it was not (68% vs. 24%, p < 0.001).

CONCLUSIONS

Children with cCAP were commonly hospitalized for prolonged periods. Prompt procedural drainage was associated with shorter hospital stays. Pleural fluid testing often facilitated microbiologic diagnosis, which itself was associated with more appropriate antibiotic therapy.

Appropriate Use of Antibiotic and Principles of Antimicrobial Stewardship in Children

Antibiotics account for over 10% of the overall drug expense of the National Health System in Italy in 2021. Their use in children is of particular interest on one side, because acute infections are very common in children, while they build their immunologic library of competence; on the other side, although many acute infections are expected and turn out to be of viral origin, caregivers will often ask the family doctor or primary care attending to reassure them by prescribing antibiotic treatment, although it may often be unnecessary. The inappropriate prescription of antibiotics in children may likely be a source not only of undue economic burden for the public health system but also of increasing development of antimicrobial resistance (AMR). Based on those issues, the inappropriate use of antibiotics in children should be avoided to reduce the risks of unnecessary toxicity, increase in health costs, lifelong effects, and selection of resistant organisms causing undue deaths. Antimicrobial stewardship (AMS) describes a coherent set of actions that ensure an optimal use of antimicrobials to improve patient outcomes while limiting the risk of adverse events including AMR. The aim of this paper is to spread some concept of good use of antibiotics for pediatricians or every other physician involved in the choice to prescribe, or not, antibiotics in children. Several actions could be of help in this process, including the following: (1) identify patients with high probability of bacterial infection; (2) collect samples for culture study before starting antibiotic treatment if invasive bacterial infection is suspected; (3) select the appropriate antibiotic molecule based on local resistance and narrow spectrum for the suspected pathogen(s); avoid multi-antibiotic association; prescribe correct dosage; (4) choose the best route of administration (oral vs. parenteral) and the best schedule of administration for every prescription (i.e., multiple administration for beta lactam); (5) schedule clinical and laboratory re-evaluation with the aim to consider therapeutic de-escalation; (6) stop antibiotic administration as soon as possible, avoiding the application of "antibiotic course".

Commercially available CD4 + and CD8 + IFN-γ release assays combined with an HBHA-induced IGRA improve the characterization of the tuberculosis spectrum and monitoring of treatment in children

Commercially available Interferon-γ release assays (IGRAs), including the last-generation QuantiFERON TB-Plus (QFT-Plus), are effective in aiding the diagnosis of tuberculosis (TB) infection but cannot distinguish latent TB subjects from active TB patients. The aim of this study was to prospectively evaluate the performance of an HBHA-based IGRA, combined with commercially available IGRAs, to assess their usefulness as a prognostic biomarkers and aid in the monitoring of TB treatment in children. Following clinical, microbiological, and radiological assessment, children younger than 18 years of age classified as either LTBI or active TB were tested at baseline and during treatment by the QuantiFERON TB-Plus (QFT) assay and an aliquot of whole-blood was stimulated with HBHA. Among the 655 children evaluated, 559 (85.3%) were classified as "Non TB", 44 patients (6.7%) with active TB, and 52 (7.9%) with LTBI. The median HBHA-IGRA IFN-gamma responses were able to discriminate active TB from LTBI (0.13 IU/ml vs 1.995, (p < 0,0001), those with asymptomatic TB from those with symptomatic TB (1.01 IU/ml vs 0.115 IU/ml, p 0.017), or more severe TB (p 0.022), and significantly raised during successful TB treatment (p < 0.0001). Conversely, CD4 + and CD8 + responses were similar in all groups of patients, although active TB patients had higher CD4 + responses and LTBI higher CD8 + responses.  Conclusion: HBHA-based IGRA, combined with CD4 + and CD8 + responses assessed by commercially available IGRAs, is a useful support in the characterization of the TB spectrum in children and monitoring of TB-therapy. What is Known: • Current immune diagnostics are not able to discriminate active and latent Ttuberculosis, including the recently approved QFT-PLUS.. • New immunological assays with prognostic value are highly needed. What is New: • HBHA-based IGRA, combined with CD4+ and CD8+ responses assessed by commercially available IGRAs, is a useful support for the differentiation of active and latent TB in children.. • HBHA-based IGRA, combined with CD4+ and CD8+ responses assessed by commercially available IGRAs, is a useful support in the monitoring of TBtherapy in children..

Comparison of Short-Term Versus Long-Term Antibiotic Therapy Among Severe Cases of Pneumonia: A Prospective Observational Study Among Children

Introduction Pneumonia continues to be the leading cause of morbidity and mortality in children younger than five years. The World Health Organization (WHO) recommends intravenous antibiotics for five days for severe pneumonia. However, the optimum duration of parenteral antibiotic therapy for pneumonia is not practicable and feasible in poor and resource-constrained settings like India. Given the current Indian scenario wherein childhood pneumonia is extremely prevalent, we attempted to undertake this study to compare the duration of antibiotic therapy in severe cases of community-acquired pneumonia (CAP). Methods A prospective observational study was carried out on 225 cases of severe and very severe CAP patients at a tertiary care center. The study group included children between two months to five years of age. The participants were subjected to antibiotic therapy (parenteral) plus supportive care. The selection of antibiotics was empirical and according to the WHO acute respiratory infection control program. Hematological parameters including blood hemoglobin, C-reactive protein, erythrocyte sedimentation rate (ESR), and total leukocyte count, and radiological evaluation were performed on all the participants. Cases were followed up for the duration of clinical response. Results Out of the 225 cases, 25 patients did not respond to antibiotics and were categorized as the treatment failure group. Of the remaining 200 cases, 104 (52%) showed clinical response within three days (3.0±0.016), and 96 showed a response in four to seven days (4.4±0.064). The mean duration of antibiotic therapy among short-course versus long-course treatment was statistically significant (p<0.0001). The majority of patients developed leukocytosis, neutrophilia, and elevated ESR.  Conclusion Short-course parenteral antibiotics therapy was equally effective as long-course therapy in severe pneumonia. However, very severe pneumonia patients required a longer course of parenteral antibiotics therapy. Very severe pneumonia was significantly associated with high mortality and treatment failure.

Short-course antibiotics for common infections: what do we know and where do we go from here?

BACKGROUND

Over the past 25 years, researchers have performed >120 randomized controlled trials (RCTs) illustrating short courses to be non-inferior to long courses of antibiotics for common bacterial infections.

OBJECTIVE

We sought to determine whether clinical data from RCTs affirm the mantra of 'shorter is better' for antibiotic durations in 7 common infections: pneumonia, urinary tract infection, intra-abdominal infection, bacteraemia, skin and soft tissue infection, bone and joint infections, pharyngitis and sinusitis.

SOURCES

Published RCTs comparing short- versus long-course antibiotic durations were identified through searches of PubMed and clinical guideline documents.

CONTENT

Short-course antibiotic durations consistently result in similar treatment success rates as longer antibiotic courses among patients with community-acquired pneumonia, complicated urinary tract infections in women, gram-negative bacteraemia, and skin and soft tissue infections when the diagnosis is confirmed, appropriate antimicrobials are used, and patients show clinical signs of improvement. For patients with osteomyelitis, 6 weeks of antibiotics is adequate for the treatment of osteomyelitis in the absence of implanted foreign bodies and surgical debridement. Whether durations can be further shortened with debridement is unclear, although small studies are promising.

IMPLICATIONS

With few exceptions, short courses were non-inferior to long courses; future research should focus on appropriately defining the patient population, ensuring the correct choice and dose of antimicrobials and developing meaningful outcomes relevant for frontline clinicians.

Can the Future of ID Escape the Inertial Dogma of Its Past? The Exemplars of Shorter Is Better and Oral Is the New IV

Like all fields of medicine, Infectious Diseases is rife with dogma that underpins much clinical practice. In this study, we discuss 2 specific examples of historical practice that have been overturned recently by numerous prospective studies: traditional durations of antimicrobial therapy and the necessity of intravenous (IV)-only therapy for specific infectious syndromes. These dogmas are based on uncontrolled case series from >50 years ago, amplified by the opinions of eminent experts. In contrast, more than 120 modern, randomized controlled trials have established that shorter durations of therapy are equally effective for many infections. Furthermore, 21 concordant randomized controlled trials have demonstrated that oral antibiotic therapy is at least as effective as IV-only therapy for osteomyelitis, bacteremia, and endocarditis. Nevertheless, practitioners in many clinical settings remain refractory to adopting these changes. It is time for Infectious Diseases to move beyond its history of eminent opinion-based medicine and truly into the era of evidenced-based medicine.

Short-Course vs Long-Course Antibiotic Therapy for Children With Nonsevere Community-Acquired Pneumonia: A Systematic Review and Meta-analysis

Importance

Short-course antibiotic therapy could enhance adherence and reduce adverse drug effects and costs. However, based on sparse evidence, most guidelines recommend a longer course of antibiotics for nonsevere childhood community-acquired pneumonia (CAP).

Objective

To determine whether a shorter course of antibiotics was noninferior to a longer course for childhood nonsevere CAP.

Data Sources

MEDLINE, Embase, Web of Science, the Cochrane Library, and 3 Chinese databases from inception to March 31, 2022, as well as clinical trial registries and Google.com.

Study Selection

Randomized clinical trials comparing a shorter- vs longer-course therapy using the same oral antibiotic for children with nonsevere CAP were included.

Data Extraction and Synthesis

Random-effects models were used to pool the data, which were analyzed from April 15, 2022, to May 15, 2022. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to rate the quality of the evidence.

Main Outcomes and Measures

Treatment failure, defined by persistence of pneumonia or the new appearance of any general danger signs of CAP (eg, lethargy, unconsciousness, seizures, or inability to drink), elevated temperature (>38 °C) after completion of treatment, change of antibiotic, hospitalization, death, missing more than 3 study drug doses, loss to follow-up, or withdrawal of informed consent.

Results

Nine randomized clinical trials including 11 143 participants were included in this meta-analysis. A total of 98% of the participants were aged 2 to 59 months, and 58% were male. Eight studies with 10 662 patients reported treatment failure. Treatment failure occurred in 12.8% vs 12.6% of participants randomized to a shorter vs a longer course of antibiotics. High-quality evidence showed that a shorter course of oral antibiotic was noninferior to a longer course with respect to treatment failure for children with nonsevere CAP (risk ratio, 1.01; 95% CI, 0.92-1.11; risk difference, 0.00; 95% CI, -0.01 to 0.01; I2 = 0%). A 3-day course of antibiotic treatment was noninferior to a 5-day course for the outcome of treatment failure (risk ratio, 1.01; 95% CI, 0.91-1.12; I2 = 0%), and a 5-day course was noninferior to a 10-day course (risk ratio, 0.87; 95% CI, 0.50-1.53; I2 = 0%). A shorter course of antibiotics was associated with fewer reports of gastroenteritis (risk ratio, 0.79; 95% CI, 0.66-0.95) and lower caregiver absenteeism (incident rate ratio, 0.74; 95% CI, 0.65-0.84).

Conclusions and Relevance

Results of this meta-analysis suggest that a shorter course of antibiotics was noninferior to a longer course in children aged 2 to 59 months with nonsevere CAP. Clinicians should consider prescribing a shorter course of antibiotics for the management of pediatric nonsevere CAP.

A Systematic Review of Applications of Machine Learning and Other Soft Computing Techniques for the Diagnosis of Tropical Diseases

This systematic literature aims to identify soft computing techniques currently utilized in diagnosing tropical febrile diseases and explore the data characteristics and features used for diagnoses, algorithm accuracy, and the limitations of current studies. The goal of this study is therefore centralized around determining the extent to which soft computing techniques have positively impacted the quality of physician care and their effectiveness in tropical disease diagnosis. The study has used PRISMA guidelines to identify paper selection and inclusion/exclusion criteria. It was determined that the highest frequency of articles utilized ensemble techniques for classification, prediction, analysis, diagnosis, etc., over single machine learning techniques, followed by neural networks. The results identified dengue fever as the most studied disease, followed by malaria and tuberculosis. It was also revealed that accuracy was the most common metric utilized to evaluate the predictive capability of a classification mode. The information presented within these studies benefits frontline healthcare workers who could depend on soft computing techniques for accurate diagnoses of tropical diseases. Although our research shows an increasing interest in using machine learning techniques for diagnosing tropical diseases, there still needs to be more studies. Hence, recommendations and directions for future research are proposed.