Antibiotic course for paediatric GBS bacteraemia: Less is enough
Shortening the 10-day course of intravenous (IV) antibiotic therapy by at least 2 days in the management of infants with uncomplicated, late-onset group B streptococcus (GBS) bacteraemia appears to be effective with low rates of disease recurrence and treatment failure, according to a study.
Guidelines recommend prolonged IV antibiotic therapy for treating the present population, although such a course may increase the risk of central line complications, including line breakage, thrombosis and infection, the authors said.
Despite the national recommendations, shortened IV antibiotic courses are being prescribed with greater frequency to older infants and those with a concomitant diagnosis of urinary tract infection, they added.
In the current observational study including 775 infants aged 7 days to 4 months with uncomplicated, late-onset GBS bacteraemia, 612 (79 percent) received 10 days of antibiotic therapy (prolonged) and 163 (21 percent) received ≤8 days (shortened). Those in the shortened group were more likely to be older, have a concomitant urinary tract infection and more frequently admitted in later years. [Pediatrics 2018;142:e20180345]
Rates of treatment with shortened IV courses varied by hospital (range, 0–67 percent). The primary outcome of disease recurrence rate was low in both shortened and prolonged treatment groups (1.8 percent vs 2.3 percent; adjusted absolute risk difference, −0.2 percent; 95 percent CI, −3.0 to 2.5).
Treatment failure was rare and independent of IV treatment duration (adjusted absolute difference, −0.3 percent; −1.8 to 1.1). There were eight patients (1 percent) who developed peripherally inserted central catheter charge complications during their index admission, seven of whom were in the prolonged IV therapy group.
“Infants without a history of significant prematurity who do not require intensive care for their GBS disease appear to have low rates of recurrence, whether treated with shortened or prolonged IV antibiotic courses,” the authors noted.
“Beyond decreased healthcare costs, shortened IV antibiotic courses provide the advantage of a diminished burden for families, allowing for patients to leave the hospital sooner, making it easier to administer the antibiotic at home, and decreasing the likelihood that they would develop a treatment-related complication,” they said, adding that early transition to oral antibiotic therapy may be appropriate for carefully selected infants.
However, the lack of data on total duration of antibiotic therapy made it impossible to identify which patients in the shortened IV antibiotic therapy group received further treatment with high-dose oral antibiotic after discharge. Furthermore, the total duration of antibiotic therapy was not addressed.
In a linked editorial, Dr Charles Woods from the University of Tennessee College of Medicine–Chattanooga, US, noted that oral antimicrobial therapy in the shortened IV group appears to represent an important unknown factor in the shortened IV group, as high-dose oral amoxicillin regimens (200–300 mg/kg per day) have been shown to generate therapeutic serum concentrations in term neonates with early onset GBS disease. [Pediatrics 2018;142:e20182623]
The broad message of the study is that in patients with uncomplicated, late-onset GBS bacteraemia, ≤8 days of IV antibiotic therapy appears to carry a risk of recurrent GBS infection that is not different from that posed by >8 to 10 days of therapy. “These are encouraging data that will provide some with enough comfort to select IV courses <10 days, whereas others will remain unconvinced,” Woods said.
The next step is to obtain data from more robust databases (ie, with more inpatient and outpatient diagnostic and therapeutic data elements) coupled with multicentre multidisciplinary consensus-based best-practice protocols, the expert pointed out. It will also help to identify biomarkers that correspond sufficiently with control of infection to allow safe discontinuation of antimicrobial therapies.