Review
Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines

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Summary

Few studies are available to inform duration of intravenous antibiotics for children and when it is safe and appropriate to switch to oral antibiotics. We have systematically reviewed antibiotic duration and timing of intravenous to oral switch for 36 paediatric infectious diseases and developed evidence-graded recommendations on the basis of the review, guidelines, and expert consensus. We searched databases and obtained information from references identified and relevant guidelines. All eligible studies were assessed for quality. 4090 articles were identified and 170 studies were included. Evidence relating antibiotic duration to outcomes in children for some infections was supported by meta-analyses or randomised controlled trials; in other infections data were from retrospective series only. Criteria for intravenous to oral switch commonly included defervescence and clinical improvement with or without improvement in laboratory markers. Evidence suggests that intravenous to oral switch can occur earlier than previously recommended for some infections. We have synthesised recommendations for antibiotic duration and intravenous to oral switch to support clinical decision making and prospective research.

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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