Antibiotic duration is an essential consideration in the management of infectious diseases. This session explores the optimal duration of antibiotic treatment for various conditions.
Case-1
A 7-year-old male who is healthy and has completed his vaccinations has been experiencing fever, cough, and a running nose for four days. During the pulmonary examination, the left lung base showed hypoventilation and subcreplants, and the chest X-ray showed consolidation, suggesting pneumonia. Amoxicillin 80 mg/kg/day has been chosen for empirical treatment. It is important to gather additional information before starting antibiotics, such as if the patient's condition worsens on the fourth day or if CopK is significantly high. In outpatient treatment for pneumonia, the optimal duration of antibiotics is typically 3-5 days. In children under 2-3 years old, 90% of pneumonia cases are viral, whereas, in older children, half are bacterial, typically atypical pneumonia. Data from studies, mainly from lower and middle-income countries (LMIC), indicate that the clinical scenario should guide the duration of antibiotics, typically three days. In non-LMIC, such as the US, 5-10 days show similar benefits. Antibiotics may be continued for five days if the fever persists.
After 48 hours of treatment, a consultation was necessary due to persistent fever, weakening, decreased intake, and left chest pain. A chest ultrasound revealed pleural effusion measuring 12.8 mm, and blood tests showed a CRP level of 109 mg/L and a leukocyte count of 12,000. As a result, Ampicillin IV 200 mg/kg/day has been indicated for treatment. In the case of para-pneumonic pleural effusion, the optimal duration of antibiotics is typically ten days. However, several factors, such as the clinical prediction of the patient, severity of effusion, whether it's drained, the characteristics of the outflow, and which pathogens have affected it, can influence the duration of treatment. In addition, it can be more challenging to define the duration of treatment if the patient is immunocompromised.
Case 2
A 5-month-old female, who is healthy and has received vaccinations, has been experiencing a fever of up to 39 °C for the past three days, along with one vomiting episode. The urine analysis indicated the presence of leukocytes (10-30 field), and nitrates and bacteria were detected. The blood test showed elevated levels of white blood cells (37,000) and neutrophils (25,000), as well as CRP (277.1 mg/dl), leading to a diagnosis of febrile UTI. Gentamycin IV 5mg/kg/d is the recommended empirical antibiotic treatment for severe or high fever patients. The optimal duration of antibiotics in acute febrile UTI is seven days of treatment, generally started orally but can be administered intravenously in patients below two months of age. The duration of treatment can vary based on the patient's improvement. Oral therapy is effective in older infants.
Case 3
An 18-month-old male with a recent onset of cough, runny nose, and fever. An otoscopic examination showed a bulging tympanic membrane indicative of acute otitis media. The patient received empirical treatment with amoxicillin at 80 mg/kg/day. While antibiotics are generally unnecessary for uncomplicated cases of acute otitis media in children under two years of age, they may be considered if the fever persists for more than three days or if there are signs of a bulging, red tympanic membrane. A treatment duration of 5 days is usually sufficient, but monitoring of clinical improvement is necessary. Streptococcus pneumoniae is the causative agent in outpatient pneumonia, for which amoxicillin or ampicillin IV is the preferred treatment. Second-generation cephalosporins and amoxicillin are also effective as first-line therapy. Augmentin Co-amoxyclav can be used if the child is not responding to treatment.
Despite three days of antibiotic treatment, the fever and ear symptoms persist in an 18-month-old male patient. He develops swelling and redness in the retroauricular region, leading to a diagnosis of mastoiditis confirmed by cranial CT. The patient is admitted and treated with cefotaxime at 150mg/kg/day. Pus drainage can help reduce the need for prolonged antibiotic treatment in infectious diseases. In this case, after drainage, the recommended duration of treatment is 10-14 days. Some literature suggests that in controlled intra-abdominal infections, seven days of treatment with antibiotics is sufficient, whereas luminal sepsis may require up to 3 weeks. The duration of IV antibiotic treatment generally depends on the patient's clinical improvement. Augmentin is an excellent alternative to clindamycin due to its high resistance to the latter.
Case 4
A 12-year-old female with no prior medical conditions and completed vaccinations presented with a fever of up to 39°C and an intense sore throat accompanied by petechiae on the soft palate. Rapid antigen detection test for group A streptococcus (GAS) confirmed GAS SGA pharyngitis. The selected treatment was penicillin V at a dosage of 500mg every 12 hours for ten days. Although the clinical resolution of symptoms occurs within 24 hours of treatment, the reason for treatment is to prevent supportive and non-supportive complications of rheumatic fever.
After 48 hours of initial treatment, the patient returned with worsening symptoms, including intense pain that radiates to the ear, dysphagia, and trismus. The physical exam revealed a medially displaced tonsil with a contralateral deviation of the uvula. A cervical CT confirmed the presence of a rim-enhancing fluid collection near an enlarged and inflamed tonsil. The patient was then started on IV treatment with amoxicillin-clavulanic acid IV 100mg/kg/day. The recommended duration of treatment was ten days. Still, it's vital to assess compliance with oral antibiotics given at home to determine whether a switch to a different antibiotic is necessary.
European Society for Paediatric Infectious Diseases (ESPID) 41st Annual Meeting, 8-12 May, 2023
