Improving Guideline-Concordant Antibiotic Use in Children

Reviewed by: Rupak Datta, MD PhD; Yale School of Medicine andVanessa Stevens, PhD; University of Utah School of Medicine

Two articles this month promote importance of guideline-concordant antibiotic use in hospitalized children.

McMullan and colleagues1 evaluated antimicrobial prescribing and appropriateness, as well as guideline adherence, in hospitalized children across Australia.  Using 2014-2017 data from the National Antimicrobial Prescribing Survey (NAPS), risk factors for inappropriate prescribing were explored using logistic regression and the frequency of guideline concordance was assessed in hospitalized children <18 years old.  NAPS data were obtained by trained local surveyors, and appropriateness was defined using structured algorithms.  Among 6219 prescriptions from 3715 children in 253 facilities, 19.6% of prescriptions were deemed inappropriate.  Risk factors for inappropriate prescriptions include non-tertiary pediatric hospital admission (OR 1.37, 95% CI: 1.20-1.55) and non-major city location (OR 1.52, 95% CI: 1.30-1.77).  Prescriptions for neonates, immunocompromised children, and intensive care unit patients were less frequently inappropriate.  Surgical prophylaxis was inappropriate in 59% of prescriptions.  Overall, 20.4% of prescriptions were non-adherent with the national Australian antibiotic guidelines, Therapeutic Guidelines, or local guidelines.  Limitations include the potential variability in agreement for assessment of antibiotic appropriateness between NAPS surveyors.  Nevertheless, these findings identify gaps in appropriateness of antibiotic prescribing for children and motivate further exploration of barriers to best practices in this population.

There are an estimated 1.2 million cases of sepsis among children globally each year, and mortality rates are as high as 50%. In 2004 the Surviving Sepsis Campaign (SSC), a joint initiative of the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, published its first guidelines on the management of sepsis. For the first time, recommendations specific to the management of septic shock and sepsis-related organ dysfunction in children are now available.2 A panel of international experts representing 12 organizations, methodologists, and members of the public jointly adopted more than 70 recommendations and best practice statements. In keeping with the original surviving sepsis guidelines, children experiencing symptoms of septic shock are recommended to receive antimicrobial therapy within 1 hour of diagnosis. Unlike the original guidelines, a more conservative approach to antimicrobial therapy is suggested for children with suspected sepsis but no evidence of shock. In these patients, the authors advocate for starting antimicrobial therapy within 3 hours of initial suspicion of sepsis if further diagnostic workup suggests organ dysfunction or if shock develops during evaluation. The SSC also published a companion infographic3 to aid clinicians in understanding and applying the new recommendations. The development of guidelines specific to pediatric patients in whom the epidemiology, presentation, and severity of illness may differ considerably from among adults, is critically important. Unfortunately, high quality evidence is often unavailable due to the relative lack of randomized controlled trials and large-scale observational studies in children. The overall low quality of supporting evidence and few “strong” recommendations (6 of 77) highlight the need to further explore optimal methods for diagnosis and treatment of sepsis among children. In addition to the recommendations and best practice statements, the SSC pediatric guidelines include 52 research priorities to guide these future research efforts.


  1. McMullan BJ, Hall L, James R, et al. Antibiotic appropriateness and guideline adherence in hospitalized children: results of a nationwide study. Journal of Antimicrobial Chemotherapy. 2019; 75: 738-46. DOI: 10.1093/jac/dkz474
  2. Weiss SL, Peters MJ, Alhazzani W et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis‑associated organ dysfunction in children. Intensive Care Med. 2020; 46: (Suppl 1) S10 – S67.
    DOI: 10.1007/s00134-019-05878-6
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