Choosing Wisely:

Don’t initiate empiric antibiotic therapy in the patient with suspected invasive bacterial infection without first confirming that blood, urine, or other appropriate cultures have been obtained, excluding exceptional cases.

Rationale and Comments: For suspected invasive bacterial infections, diagnostic testing should include blood cultures and appropriate culture of specimens from the suspected infected site. Not all specimens may be obtained prior to antibiotics but optimally a blood culture can be obtained at the time of intravenous access. In cases where antibiotics are started due to clinical instability, or when there is a requirement for coordination for surgically accessed cultures, cultures should still be obtained at that time. In certain cases, polymerase chain reaction testing may be helpful to guide therapy (e.g., cerebrospinal fluid, synovial fluid, pleural fluid). Diagnostic testing should be considered for suspected systemic viral infection that may mimic bacterial sepsis, and may allow more timely initiation of antiviral therapy and discontinuation of antibiotics if bacterial infection is excluded. In neonates where bacterial or viral sepsis cannot be differentiated based on the clinical presentation, and both antibiotics and antivirals are initiated, blood cultures should be prioritized and cultures from additional sites (e.g., cerebrospinal fluid) and polymerase chain reaction testing (e.g., herpes simplex virus) should be obtained as soon as is clinically feasible.
Sponsoring Organizations:
  • American Academy of Pediatrics – Committee on Infectious Diseases and the Pediatric Infectious Diseases Society
  • Sources:
  • American Academy of Pediatrics guidelines
  • Disciplines:
  • Infectious disease
  • References: • Wong D, Wong T, Romney M, Leung V. Comparison of outcomes in patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia who are treated with β-lactam vs vancomycin empiric therapy: a retrospective cohort study. BMC Infect Dis. 2016 May 23;16:224. doi: 10.1186/s12879-016-1564-5.
    • Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Pediatrics. Aug 2011, peds.2011-1330; DOI: 10.1542/peds.2011-1330.
    • Shah SS, Aronson PL, Mohamad Z, Lorch SA. Delayed acyclovir therapy and death among neonates with herpes simplex virus infection. Pediatric 2011;128:1153.
    • Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine. 2013 Feb;41(2):580-637.

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