ReviewAntibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines
Introduction
Antibiotics are commonly prescribed for children in hospital, but few data are available to inform optimal duration of therapy. In view of the global crisis of antimicrobial resistance, the need for evidence-based recommendations for the optimal duration of intravenous and oral antibiotics, and when to switch from the intravenous to the oral route, is crucial (appendix reference [AR] 1). Shorter antibiotic courses can potentially affect antimicrobial resistance, and have already been advocated for a few infections (AR 2 and 3). So far, there has been no systematic review of the evidence guiding the minimum duration of intravenous antibiotics before switching to oral treatment for infections in children.
We aimed to determine, in children younger than 18 years with bacterial infections, the minimum intravenous and total antibiotic duration required to achieve outcomes similar to or better than those with traditional longer durations administered for specific infections. We then aimed to make evidence-based recommendations for optimal intravenous and total antibiotic duration and criteria for intravenous to oral switch.
Section snippets
Methods
The Australian and New Zealand Paediatric Infectious Diseases Australasian Stewardship of Antimicrobials in Paediatrics (ANZPID-ASAP) group of the Australasian Society for Infectious Diseases collaborated on this study. Using 2009 PRISMA guidelines (appendix), the group systematically reviewed the literature on intravenous and total duration of antibiotics and the timing of switching from the intravenous to oral route for 36 infections in children younger than 18 years. Evidence-based
Findings
Our search identified 4090 abstracts. 671 potentially relevant articles were assessed for eligibility, of which 170 studies met the inclusion criteria (figure). Most studies were not of high quality, with only 61 (36%) being randomised controlled trials or systematic reviews (appendix). Specific infections were reviewed individually, and for most of them there were no systematic reviews or trials of antibiotic duration or intravenous to oral switch.
Discussion
We have reviewed the evidence for minimum intravenous and total antibiotic duration in children younger than 18 years with bacterial infections, comparing shorter courses with traditionally longer durations. In many infections, especially when clinical improvement is rapid, emerging data suggest that traditional long durations of intravenous antibiotics might be unnecessary and that intravenous to oral switch can occur earlier. In most of the other infections evidence for routine longer courses
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