American Academy of Pediatrics – Committee on Infectious Diseases and the Pediatric Infectious Diseases Society
View all recommendations from this societyNovember 12, 2018
Don’t initiate empiric antibiotic therapy in the patient with suspected invasive bacterial infection without first confirming that blood, urine or other appropriate cultures have been obtained, excluding exceptional cases.
For suspected invasive bacterial infections, diagnostic testing should include blood cultures and appropriate culture of specimens from the suspected infected site. Not all specimens may be obtained prior to antibiotics but optimally a blood culture can be obtained at the time of intravenous access. In cases where antibiotics are started due to clinical instability, or when there is a requirement for coordination for surgically accessed cultures, cultures should still be obtained at that time. In certain cases, PCR testing may be helpful to guide therapy (eg, CSF, synovial fluid, pleural fluid). Diagnostic testing should be considered for suspected systemic viral infection that may mimic bacterial sepsis, and may allow more timely initiation of antiviral therapy and discontinuation of antibiotics if bacterial infection is excluded. In neonates where bacterial or viral sepsis cannot be differentiated based on the clinical presentation, and both antibiotics and antivirals are initiated, blood cultures should be prioritized and cultures from additional sites (eg, CSF) and PCR testing (eg, HSV) should be obtained as soon as is clinically feasible.
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
Wong D, Wong T, Romney M, and Leung V. Comparison of outcomes in patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia who are treated with β-lactam vs vancomycin empiric therapy: a retrospective cohort study. BMC Infect Dis. 2016 May 23;16:224. doi: 10.1186/s12879-016-1564-5.
Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. SUBCOMMITTEE ON URINARY TRACT INFECTION, STEERING COMMITTEE ON QUALITY IMPROVEMENT AND MANAGEMENT. Pediatrics. Aug 2011, peds.2011-1330; DOI: 10.1542/peds.2011-1330.
Shah SS, Aronson PL, Mohamad Z, Lorch SA. Delayed acyclovir therapy and death among neonates with herpes simplex virus infection. Pediatrics 2011; 128:1153.
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine. 2013 Feb;41(2):580-637.
