Multicenter Interim Guidance on Use of Antivirals for Children With Coronavirus Disease 2019/Severe Acute Respiratory Syndrome Coronavirus 2

BACKGROUND

Although coronavirus disease 2019 (COVID-19) is a mild infection in most children, a small proportion develop severe or critical illness. Data describing agents with potential antiviral activity continue to expand such that updated guidance is needed regarding use of these agents in children.

METHODS

A panel of pediatric infectious diseases physicians and pharmacists from 20 geographically diverse North American institutions was convened. Through a series of teleconferences and web-based surveys, a set of guidance statements was developed and refined based on review of the best available evidence and expert opinion.

RESULTS

Given the typically mild course of COVID-19 in children, supportive care alone is suggested for most cases. For children with severe illness, defined as a supplemental oxygen requirement without need for noninvasive or invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO), remdesivir is suggested, preferably as part of a clinical trial if available. Remdesivir should also be considered for critically ill children requiring invasive or noninvasive mechanical ventilation or ECMO. A duration of 5 days is appropriate for most patients. The panel recommends against the use of hydroxychloroquine or lopinavir-ritonavir (or other protease inhibitors) for COVID-19 in children.

CONCLUSIONS

Antiviral therapy for COVID-19 is not necessary for the great majority of pediatric patients. For children with severe or critical disease, this guidance offers an approach for decision-making regarding use of remdesivir.

Epidemiology of Bloodstream Infections in Hospitalized Children in the United States, 2009-2016

BACKGROUND

Bloodstream infections (BSIs) cause significant morbidity and mortality in children. Recent pediatric epidemiological data may inform prevention strategies and empiric antimicrobial therapy selection.

METHODS

We conducted a retrospective cohort study from 2009 through 2016 utilizing demographic and microbiologic data on inpatients aged <19 years using the Premier Healthcare Database. BSIs were positive blood cultures without known contaminants. Hospitalization rate was the number of BSI-positive encounters per 1000 admissions. Community-acquired infections (CAIs) were cultures positive ≤2 days of admission among nonneonates. BSI patients were compared to documented positive BSI patients (non-BSI); differences were analyzed using χ2 test, t test, and Cochran-Armitage test for time trends.

RESULTS

Among 1 809 751 encounters from 162 US hospitals, 5340 (0.30%) were BSI positive; CAIs were most common (50%). BSI patients were more often aged 1-5 years and had complex chronic conditions or central lines compared to non-BSI patients. The BSI hospitalization rate declined nonsignificantly over time (3.13 in 2009 to 2.98 in 2016, P = .08). Among pathogens, Escherichia coli (0.80 to 1.26), methicillin-sensitive Staphylococcus aureus (0.83 to 1.98), and group A Streptococcus (0.16 to 0.37) significantly increased for nonneonates, while Streptococcus pneumoniae (1.07 to 0.26) and Enterococcus spp. (0.60 to 0.17) declined. Regional differences were greatest for E. coli and highest in the New England and South Atlantic regions.

CONCLUSIONS

Trends in pediatric BSI hospitalization rates varied by pathogen and regionally. Overall the BSI hospitalization rate did not significantly decline, indicating a continued need to improve pediatric BSI assessment and prevention.

Multicenter Initial Guidance on Use of Antivirals for Children With Coronavirus Disease 2019/Severe Acute Respiratory Syndrome Coronavirus 2

BACKGROUND

Although coronavirus disease 2019 (COVID-19) is mild in nearly all children, a small proportion of pediatric patients develop severe or critical illness. Guidance is therefore needed regarding use of agents with potential activity against severe acute respiratory syndrome coronavirus 2 in pediatrics.

METHODS

A panel of pediatric infectious diseases physicians and pharmacists from 18 geographically diverse North American institutions was convened. Through a series of teleconferences and web-based surveys, a set of guidance statements was developed and refined based on review of best available evidence and expert opinion.

RESULTS

Given the typically mild course of pediatric COVID-19, supportive care alone is suggested for the overwhelming majority of cases. The panel suggests a decision-making framework for antiviral therapy that weighs risks and benefits based on disease severity as indicated by respiratory support needs, with consideration on a case-by-case basis of potential pediatric risk factors for disease progression. If an antiviral is used, the panel suggests remdesivir as the preferred agent. Hydroxychloroquine could be considered for patients who are not candidates for remdesivir or when remdesivir is not available. Antivirals should preferably be used as part of a clinical trial if available.

CONCLUSIONS

Antiviral therapy for COVID-19 is not necessary for the great majority of pediatric patients. For those rare cases of severe or critical disease, this guidance offers an approach for decision-making regarding antivirals, informed by available data. As evidence continues to evolve rapidly, the need for updates to the guidance is anticipated.