case - standard of care - american academy of pediatrics · 2015-10-15 · bcx positive for group b...

The Standard of Care

60 do girlfever, fussy, poor PO intake

The Case

Ctx, amp, gentUA, CBC, CSF reassuringDefervesces immediatelyBCx positive for group B streptococcus CSF, urine NGrepeat BCx NG

What is appropriate antibiotic therapy for this infant?

Late Onset GBS Bacteremia

Gras-Le Guen et al. Eur J Clin Pharmacol. 2007 Jul.

Schroeder and Ralston. J Hosp Med. 2014 Sep.

“In fact, we are unaware of any published trials in pediatrics demonstrating superiority of IV over oral antibiotics.”

Pannaraj and Baker. Textbook of Pediatric Infectious Disease, Feigin and Cherry. 7th edition.

“Infants with bacteremia without a focus should receive intravenous therapy for a total of 10 days. A shorter duration has not been documented to be efficacious, and relapses, although rare, have been reported in these circumstances. Oral therapy has no place in the management of infants with GBS disease.”

Broughton et al. J Pediatr. 1976 Aug.

“A shorter duration has not been documented to be efficacious, and relapses, although rare, have been

reported in these circumstances.”

Walker et al. J Pediatr. 1976 Aug.

“A shorter duration has not been documented to be efficacious, and relapses, although rare, have been

reported in these circumstances.”

Edwards, Nizet, and Baker. Infectious Diseases of the Fetus and Newborn Infant. 6th edition.

“Although the total duration of treatment is arbitrary, good outcomes have been noted when parenteral therapy is given for 10 days for bacteremia without a focus.”

Filleron et al. Arch Dis Child Fetal Neonatal Ed. 2014 Jan.Paredes et al. J Pediatr. 1976 Aug.Hansen et al. J Clin Microbiol. 2004 Jan.

Late Onset and Recurrent Infections May be Unrelated to Initial Antibiotic

Therapy

• Breast Milk• Infant Colonization• Parent Colonization

Standard of CareWho decides the standard of care?What is standard of care for GBS bacteremia?How much evidence is required to call something a

standard of care?

Standard of Care

Isaac et al. Pediatrics. 2013 April.

“The level-of-evidence categories used, from highest to lowest quality, were as follows: randomized controlled trial, controlled clinical trial without randomization, observational cohort study, case-control study, pre-post study, cross-sectional study, time series, case series, expert opinion, and no reference.”

Kaempf et al. Pediatrics. 2003 Apr.

More is Better

Wilson-Costello et al. Pediatrics. 2009 Mar.

“This is water”