Reply to Tamma & Cosgrove and Esposito

Abstract

TO THE EDITOR—We are grateful for the comments of Drs Tamma and Cosgrove [1] on the issue of duration of therapy, particularly as it impacts antibiotic exposure in the child and the community. Greater antibiotic exposure is associated with greater antimicrobial resistance and also adds to costs and toxicities of therapy. This particular issue prompted considerable discussion within the writing group. However, with no scientific evidence in children from randomized controlled trials or even high-quality observational studies conducted in North American centers, the extrapolated data from community-acquired pneumonia (CAP) in adults, well-reviewed by Tamma and Cosgrove, was not felt to be of sufficient relevance to make these recommendations for children. Although children may have fewer comorbid conditions than adults, our guidelines do review the many other differences, including the relative immune incompetence in preschool-aged children compared with adults, as well as the role of viral coinfections. Differences in outcomes for children compared with adults with urinary tract infections highlight the challenges of extrapolating adult treatment protocols to children [2]. However, we certainly agree with the critical importance of this issue and included it as one of our research priorities, as provided in our Table 10: “Develop clinical trial designs that can provide information on the lowest effective antimicrobial dose for the shortest duration of therapy to decrease the development of antimicrobial resistance and the risk of antimicrobial toxicity.” Although the guidelines are unable to address the duration of antibiotic therapy based on adequate evidence, they do emphasize the importance of viral infection as a cause of pneumonia in the preschool-aged child and state that “antimicrobial therapy is not routinely required for preschool-aged children with CAP, because viral pathogens are responsible for the great majority of clinical disease.” We believe that if this recommendation is followed, it will significantly decrease the use of inappropriate antimicrobials in children and is well aligned with the goals expressed by Drs Tamma and Cosgrove. We also thank Dr Esposito for her letter citing 8 concerns regarding the Executive Summary of the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America clinical practice guidelines on the management of CAP in children >3 months [3, 4]. In her review of the Executive Summary, she may have overlooked the reference (p 618) to the full-text electronic article for the guidelines that provides a detailed description of the methods, background, and, most important, the Evidence Summaries that support each recommendation. The comments and questions she raises are all addressed within the full text that is available online (doi: 10.1093/cid/cir531).