Antibiotics in critically ill children-a narrative review on different aspects of a rational approach

Abstract

Especially critically ill children are exposed to antibiotic overtreatment, mainly caused by the fear of missing out a severe bacterial infection. Potential adverse effects and selection of multi-drug resistant bacteria play minor roles in decision making. This narrative review first describes harm from antibiotics and second focuses on different aspects that could help to reduce antibiotic overtreatment without harming the patient: harm from antibiotic treatment, diagnostic approaches, role of biomarkers, timing of antibiotic therapy, empiric therapy, targeted therapy, and therapeutic drug monitoring. Wherever possible, we linked the described evidence to the current Surviving Sepsis Campaign guidelines. Antibiotic stewardship programs should help guiding antibiotic therapy for critically ill children. IMPACT: Critically ill children can be harmed by inadequate or overuse of antibiotics. Hemodynamically unstable children with a suspicion of infection should be immediately treated with broad-spectrum antibiotics. In contrast, in hemodynamically stable children with sepsis and organ dysfunction, a time frame of 3 h for proper diagnostics may be adequate before starting antibiotics if necessary. Less and more targeted antibiotic treatment can be achieved via antibiotic stewardship programs.

Fig. 1. Key questions to guide decision-making in antibiotic treatment in critically ill children.

MDR multi-drug resistant, ASP antibiotic stewardship program; *¹ Septic workup: blood and urine studies including appropriate cultures, diagnostic imaging of the chest and abdomen/pelvis, if applicable: studies and appropriate cultures of tracheal fluid, cerebrospinal fluid and drains, wound swabs; *²E.g., viral infection, macrophage activation, pediatric inflammatory multisystem syndrome, etc.