American Academy of Pediatrics – Committee on Infectious Diseases and the Pediatric Infectious Diseases Society

View all recommendations from this society

November 12, 2018

Don’t place peripherally inserted central catheters and/or use prolonged IV antibiotics in otherwise healthy children with infections that can be transitioned to an appropriate oral agent.

Peripherally inserted central catheters (PICC) are often used for children requiring long-term intravenous antibiotics. The most common infections for which PICCs are placed in children, however, respond well to orally administered antibiotics after a brief course of intravenous therapy. Following hospital discharge, up to 40% of children with PICCs will return to the emergency department with a PICC complication. Studies of children with complicated pneumonia, ruptured appendicitis, and osteomyelitis have demonstrated that, compared with oral conversion prior to hospital discharge, extended intravenous therapy with a PICC does not improve clinical cure rates but is often associated with PICC line complications.


This list from the American Academy of Pediatrics is developed with judicious use of antimicrobials in mind, however, when a patient has suddenly and inexplicably become severely ill, the short-term, empiric use of broad-spectrum antibiotics is warranted, and should be left to the discretion of the medical team.

How The List Was Created

The American Academy of Pediatrics Committee on Infectious Diseases’ Subcommittee on Antimicrobial Resistance and Stewardship identified the need to promote the judicious use of antibiotics in the inpatient setting at their strategic planning session held in October 2015. A workgroup of pediatric experts was formed with representatives from the Academy’s Committee on Infectious Diseases, Committee on Fetus and Newborn, Section on Infectious Diseases, and external partners from the Pediatric Infectious Diseases Society. A modified Delphi process was used to create the list for Choosing Wisely. Experts from the workgroup were asked to create an initial list of what practices may be included– 15 practices for inpatient antimicrobial stewardship were identified through email and conference calls.

The workgroup reviewed and ranked via survey which practices within the list of 15 were the most important to include. The survey also asked for any additional suggestions for inpatient AS practices that were not included on the list. This survey was then simultaneously sent to the Antimicrobial Resistance Stewardship workgroup, as well as, internally, to the following Executive Committees: 1. Committee on Hospital Care, 2. Committee on Fetus and Newborn, 3. Committee on Pediatric Emergency Medicine, Section on Critical Care, Section on Emergency Medicine, Section on Infectious Diseases, and Section on Neonatal-Perinatal Medicine and externally to the Pediatric Infectious Diseases Society Executive Committee and their antimicrobial stewardship workgroup. The list was edited based on the feedback received and narrowed down to a new top ten list. The workgroup reviewed the list and voted on their top five based on the following criteria: 1. Feasibility, 2. Supported by Evidence, 3. Not Duplicative, 4. Free from Harm, and 5. Truly Necessary. The list was peer reviewed by relevant expert Committee, Council and Section leadership. The AAP Executive Committee approved this publication of the list.

AAP’s disclosure and conflict of interest policy can be found at www.aap.org.

Sources

Ruebner R, Keren R, Coffin S et al. Complications of central venous catheters used for the treatment of acute hematogenous osteomyelitis. Pediatrics. 2006 Apr;117(4):1210-5.

Kovacich A, Tamma PD, Advani S, et al. Peripherally Inserted Central Venous Catheter Complications in Children Receiving Outpatient Parenteral Antibiotic Therapy (OPAT). Infect Control Hosp Epidemiol. 2016 Apr;37(4):420-4. doi: 10.1017/ice.2015.317. Epub 2016 Jan 12.

Keren R, Shah SS, Srivastava R et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015 Feb;169(2):120-8. doi: 10.1001/jamapediatrics.2014.2822.

Rangel SJ, Anderson BR, Srivastava R, et al. Intravenous Versus Oral Antibiotics for the Prevention of Treatment Failure in Children With Complicated Appendicitis: Has the Abandonment of Peripherally Inserted Catheters Been Justified? Ann Surg. 2016 Jul 15. [Epub ahead of print]

Shah SS, Srivastava R, Wu S, et al. Intravenous Versus Oral Antibiotics for Postdischarge Treatment of Complicated Pneumonia. Pediatrics. 2016 Dec;138(6). pii: e20161692. Epub 2016 Nov 17.