‘Shorter is better, just enough is best’ for antibiotic therapy in kids
NEW YORK — Physicians historically have relied on arbitrary lengths of antibiotic therapy for a variety of infections in pediatric patients, according to C. Buddy Creech, MD, MPH, associate professor of pediatrics and director of the pediatric infectious disease fellowship program at Vanderbilt University.
“Now, with improved diagnostics and with novel study designs, we are able to personalize antimicrobial therapy more than before,” he told Infectious Diseases in Children.
Creech emphasized that prolonged antibiotic therapy can cause drug resistance, although there are circumstances in which longer courses are needed to achieve optimal clinical outcomes in children. He advocated for the idea that “shorter is better” but “just enough is best.”
“The concept is that unless the antibiotic course works and prevents failure or recurrence, then we are missing the boat,” said Creech, who is also an Infectious Diseases in Children Editorial Board Member. “That’s the first goal of therapy — everything else is secondary.”
During a presentation at the Infectious Diseases in Children symposium, Creech said the guiding principle for antibiotic therapy in children is the “right antibiotic, the right route, the right dose, for the right duration.” He explained that infections can be put in “buckets,” some of which can be treated with a single dose of antibiotics, like certain STDs; some of which are treated with lengthy courses of therapy, like tuberculosis; and some of which require 1 to 2 weeks of therapy, like acute otitis media (AOM), osteomyelitis and bacterial pneumonia.
Only a few studies have compared shorter courses of antibiotic therapy with longer ones in children with pneumonia, and the results of these studies can be difficult to generalize. One of the more recent studies Creech mentioned — a double-blind, randomized, placebo-controlled trial of younger children in Israel — found that a 5-day course with high-dose oral amoxicillin was noninferior to a 10-day course in pediatric outpatients aged 6 to 59 months with community-acquired alveolar pneumonia.
Creech and colleagues at Vanderbilt recently completed a multicenter clinical trial to evaluate whether a shorter course of antibiotics — 5 days vs. the recommended 10 — is effective at treating community-acquired pneumonia. The goal of the study, called SCOUT-CAP, is to lay the groundwork for reducing children’s exposure to antibiotics and stem the development of drug resistance.
Creech said the results of this study and additional trials looking at AOM and urinary tract infections will help to inform clinical decision-making. He explained that convincing doctors to shorten antibiotic therapy durations for children will be less challenging once they are informed of its equal level of benefit for specific infections.
“We’re used to seeing side effects from drugs when we use them for extended periods,” Creech said in the interview. “If we know that the course is as effective at 7 days vs. 10 days, I think most will appreciate shorter courses of therapy.”
“What we hope is that we can shorten some treatment courses and confirm adequate lengths for others,” he added. – by Eamon Dreisbach
Creech CB. The long and the short of it: reassessing durations of therapy for common infections. Presented at: Infectious Diseases in Children Symposium. Nov. 23-24; New York.
Greenberg D, et al. Peiatr Infect Dis j. 2014;doi:10.1097/INF.0000000000000023.
Disclosure: Creech reports no relevant financial disclosures.