The participation of children and adolescents in medical decision-making should always be sought, and their involvement should be proportionate with their capacity and circumstances. Their consent, assent or dissent as defined below must be respected whenever possible. When disagreement exists, a stepwise approach that ensures due attention to transparency and process, including consultation should be employed to resolve the conflict. No universally applicable, validated tool exists in the paediatric world to determine capacity .
Infants and preschool children have not yet attained even a very limited definition of capacity. In school-aged children, a developing self-awareness is acknowledged, as is the need for clinicians to respect and nurture the signs of emerging self-determination. Assent should be sought and strong indicators of dissent should be given serious consideration —.
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Nevertheless, many patients in this age group demonstrate signs of assent or dissent without fully understanding the circumstances driving a particular medical decision. Ultimately, legal decision-making authority rests with the SDM, who is required to act in the best interests of the child. HCPs have an essential role in communicating treatment-related information to both the child and the SDM s , promoting assent where possible with the child, helping the SDM consider the risks and benefits associated with a proposed decision, and ensuring the best interests of the child are met.
HCPs are tasked with recognizing a minimum standard of acceptable care, meaning a treatment course that is beneficial, needed to maintain life or health in a paediatric patient, and below which a SDM is not permitted to act. Medical decision-making in adolescents is more complicated. While adolescents may demonstrate comparable decision-making capacity to adults in empirical studies —, their ability to make appropriate decisions are affected—and perhaps impaired—by different psychosocial factors, such as peer pressure, impulsivity and risk-seeking behaviours .
Natural developmental changes that follow from physiologic maturation and integrating life experiences help to reconcile the cognitive and psychosocial factors involved in decision-making. The dynamic and progressive nature of capacity makes hard and fast definitions of attainment based on age thresholds impossible in this population. Instead, HCPs, legally and ethically, must ascertain individual patient capacity in case-specific circumstances. When risks are minimal and the benefits of a proposed therapy are clear, for example, when considering treatment for a local infection, a year-old may have sufficient capacity to understand and consent.
But when refusing experimental chemotherapy, the same patient might not have the capacity to reason through the complex issues involved. If the youth is deemed capable and requirements for informed consent are met, authorization of treatment by an SDM is not legally required. Common law recognizes the special status of emancipated and mature minors . Emancipated minors are adolescents who live independently from parent s or guardian s , or who are parents themselves. In some jurisdictions, mature minor status is conferred as part of a formal legal process. In others, the designation is used informally for adolescents who have met the criteria for capacity according to their HCP.
HCPs should be aware of definitions operating in their province or territory. Some jurisdictions define a legal age of majority for consent to treatment Table 1 . Variations among legal statutes regulating health care consent and individual medical situations may lead care providers to seek advice from experts, such as hospital risk managers, ethics committees or legal counsel. A family-centred, shared decision-making approach may support the needs of the child and adolescent most appropriately .
Children should be provided with developmentally appropriate information and options, such that they know what to expect—and what is expected of them—and can participate, in a developmentally appropriate way, in their own care. For example, a young child should be offered the choice of where to receive an injection, rather than whether to receive the injection.
Patient engagement is usually possible without giving the impression that they have more control than they really do . When this is achieved, the child may still object strongly to a proposed treatment or procedure. This dissent should be recognized and acknowledged. In cases of overt dissent, a careful reconsideration of the medical necessity, risks and benefits of a proposed treatment is an essential step before continuing.
The Health Care Consent and Care Facility Admission Act stipulates that all adults anyone who has reached 19 years of age are presumed to be capable until the contrary is demonstrated. The Infants Act applies to persons under 19 years of age.
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Infants can provide consent if capacity is demonstrated. Adults can give an advance directive unless they are deemed incapable of understanding the nature and consequences of a proposed advance directive. SDMs must be age of majority. Any person who is at least 18 years of age and understands the nature and effect of a personal directive can make a personal directive and is presumed to understand its nature and possible effects. A person under 18 years of age who is assessed and deemed capable of consenting to treatment a mature minor is allowed to make treatment decisions. Any person 16 years of age or more who has capacity to make a health care decision can make a directive.
SDMs must be age of majority unless they are a spouse, who then has capacity to make health care decisions. It is presumed that persons 16 years of age or more have capacity to make health care decisions and that persons under 16 years of age do not have this capacity, although the latter presumption can be rebutted with evidence to the contrary.
Any person having capacity to make health care decisions can make a health care directive. The Health Care Consent Act stipulates that all persons including minors are presumed to be capable i. The Substitute Decisions Act presumes that persons 16 years of age or more are capable of giving or refusing consent in connection with their own care, unless there are reasonable grounds to believe otherwise.
Findings of incapacity may be appealed to the Consent and Capacity Review Board. SDMs must be at least 16 years old, unless they are parents of an incapable patient. SDMs must be at least 16 years old. Health Care Consent Act , c. Substitute Decisions Act , c. The lifetime risk of being discharged from the hospital with a diagnosis of gastroenteritis is estimated to be 1 in 8 among adults in the United States . Norovirus and Salmonella enterica subspecies were the leading pathogens among the 24 gastroenteritis pathogens transmissible by food that were assessed.
Norovirus has assumed the lead since introduction of rotavirus vaccine, and is associated with nearly 1 million ambulatory care visits and hospitalizations annually [19, 20]. Together these 5 pathogens caused an estimated illnesses, physician visits, hospitalizations, and 64 deaths yearly. Most acute diarrhea episodes in previously healthy, immunocompetent people are of short duration and self-resolving, and are of viral or unknown etiology. Therefore, laboratory investigation generally is not warranted.
However, many factors may justify the expense and complexity of laboratory testing including epidemiologic Table 2 and clinical features Table 3 , which encompass diarrhea in immunocompromised people, noninfectious and extraintestinal manifestations associated with enteric pathogens Table 4 , the potential for results of laboratory investigation to impact management, and suspicion of an outbreak situation.
Clinically significant disease and hospitalization and office visits have been decreased in infants who have received a rotavirus vaccine direct protection as well as in adults through community protection of unvaccinated infants and age-ineligible children and adults [23, 24] indirect, or community protection living in high- and middle-income countries and reductions in all-cause diarrhea deaths in several middle-income countries.
Reduction of acute infectious diarrhea also can be achieved through general measures, including use of hand hygiene; proper food preparation and storage; avoidance of high-risk foods such as undercooked meat and seafood, unpasteurized milk, and soft cheese made with unpasteurized milk; avoidance of unsafe water; use of infection prevention and control measures in hospitals, childcare, and nursing home settings; appropriate use of antimicrobial agents; and appropriate pet selection and supervision of contact with animals, specifically in public settings.
In addition, people with diarrhea should refrain from recreational water activities, food preparation or service, and sexual activities while symptomatic. Specific preventive measures, in addition to routine use of rotavirus vaccine in infants , include typhoid and cholera vaccines for travelers when indicated . Highly effective measures are available to prevent and treat diarrheal disease and its complications. Avoiding dehydration by ensuring adequate fluid and electrolyte intake for replacement and maintenance is the mainstay of diarrheal illness management.
Increasing resistance to antimicrobial agents and risk of worsening illness such as diarrhea associated with C. A panel of multidisciplinary experts in management of infectious diarrhea in children and adults was convened in The panel consisted of pediatricians and internists with expertise in clinical medicine, infectious disease, epidemiology, gastroenterology, preventive medicine, nutrition, microbiology, and enteric disease. The panel applied GRADE to the assessment of quality of evidence and development of recommendations [3—7].
The quality of evidence is categorized as high, moderate, low, or very low; the strength of recommendation is categorized as strong or weak Figure 2. Key factors that determine the strength of recommendation include quality of evidence, balance between desirable and undesirable effects, and values and preferences. Teleconferences and face-to-face meetings were held in which a list of 21 clinical questions to be addressed in the guidelines was generated, discussed, and prioritized. The panel identified current and valid studies from both the Medline and Embase databases, with a focus on randomized controlled trials RCTs , allowing for admission of systematic reviews and extant practice guidelines if adequate RCTs and method validation studies for diagnostics did not exist.
The search period included 1 January —31 December Data published after 1 January also were considered in the final preparation of the manuscript. English-language studies with European authors also were included for the purpose of determining diagnostic guidelines. For international travel—associated infections, such as enteric fever and cholera, geographic restrictions were not applied. Selected references with relevant updates to practice were included. Articles were evaluated for relevance to each of the focus sections in the guidelines, up to and including: background; clinical presentations; diagnostics; treatment of nonresponders and persistence; management specific treatment, supportive treatment, empiric treatment, ancillary treatment ; epidemiology and surveillance; prevention; and future treatments.
Primary key search terms were as follows: acute gastroenteritis, antimotility agents, antimicrobial agents, antiparasitic agents, cholera, C. All panel members complied with IDSA policy on conflict of interests, which requires disclosure of any financial or other interest that might be construed as constituting an actual, potential, or apparent conflict. Information was requested regarding employment, consultancies, stock ownership, honoraria, research funding, expert testimony, speaking engagements, and membership on company advisory committees. Potential conflicts of interest are listed in the Notes section.
At annual intervals, the panel chair, SPGC liaison advisor, and SPGC chair will determine the need for guideline revisions by reviewing current literature. If necessary, the entire panel will be reconvened. A broad range of exposures or conditions have been implicated as sources of infections with specific pathogens Table 2. Exposures or conditions that may suggest certain causes of infectious diarrhea include consumption of shellfish, raw milk, unpasteurized juice, undercooked meats, fish, or eggs, or contaminated fruits or vegetables; exposure to contaminated drinking or recreational water; contact with animals or their feces or environment; recent antimicrobial therapy; international travel; institutional exposure; and anal or oral sexual contact [27—47].
Of great importance are exposures associated with food. Outbreaks were most commonly reported to be associated with commercial food preparation; this is likely to reflect that outbreaks associated with a single restaurant or other establishment may be more likely than other outbreaks to be noticed, reported to public health officials, and investigated. Other important exposures implicated in outbreaks include animal contact [41, 50, 51], recreational water exposure , and sexual practices  Table 2. Outbreaks of diarrhea in institutional settings are a substantial public health problem.
The National Outbreak Reporting System  collects data on waterborne and foodborne disease outbreaks, person-to-person transmitted disease outbreaks, animal contact disease outbreaks, environmental contamination disease outbreaks, and other enteric illness outbreaks. During —, the National Outbreak Reporting System reported acute gastroenteritis outbreaks for which the primary mode of transmission occurred through person-to-person contact, environmental contamination, and unknown modes of transmission.
These outbreaks resulted in reported illnesses, hospitalizations, and deaths. During —, norovirus accounted for most deaths and healthcare visits associated with acute gastroenteritis outbreaks. Specific infection control guidelines are recommended for control of norovirus and the extremely chlorine-tolerant Cryptosporidium in institutional settings [56, 57].
Although bacterial causes of diarrhea can have similar clinical presentations, they differ with regard to clinical management. For example, whereas antimicrobial agents may be indicated for Campylobacter or Shigella infections, they are not indicated for STEC or for most Salmonella infections.
Identification of bacterial agents can prevent other unnecessary procedures such as colonoscopy, abdominal surgery, or medical treatment for suspected ulcerative colitis. Conversely, negative stool studies for infectious pathogens increase suspicion for noninfectious conditions such as inflammatory bowel disease IBD. Salmonella enterica serovar Typhi and Paratyphi A and Paratyphi B cause bacteremic illnesses referred to respectively as typhoid and paratyphoid fever, and collectively as enteric fever.
These conditions are characterized by fever that may be associated with headache, lethargy, malaise, and abdominal pain, followed by hepatosplenomegaly and stupor. While the portal of entry is the gastrointestinal tract, diarrhea is an uncommon feature . Typhoid fever outbreaks in the United States are uncommon and usually associated with foodborne transmission from an asymptomatic carrier . Typhoid fever may be difficult to distinguish from other febrile conditions in returned travelers, and can present with fever without focus, abdominal pain without diarrhea, or with extraintestinal foci of infection .
Volume depletion is a frequently identified risk factor for diarrhea-related deaths in people of all ages in the United States; other related risk factors include fluid and electrolyte disorders, nontraumatic shock, and acute renal failure [63, 64]. In addition, dehydration at the time of admission among children with postdiarrheal HUS is associated with an increased need for dialysis .
Intravenous fluid administered during the diarrhea phase of STEC infections reduces the risk of oligoanuric renal failure among those children who subsequently develop HUS . In addition to patient reported bloody diarrhea or visibly bloody stool, other factors independently associated with increased risk of STEC O infection compared with other enteric infections in patients of all ages include abdominal tenderness and absence of fever at first medical evaluation . Early identification of STEC infections is important to reduce the risk of complications and the risk of person-to-person transmission.
It is important to perform both cultures for STEC O and test for Shiga toxin either in broth cultures, not stool or the genes that encode this toxin family, because STEC O is the most consistently virulent STEC in the United States, and early identification through culture can aid in clinical management and public health control measures. Detection of all other STEC serotypes first requires detection of Shiga toxin or the genes that encode them . New multiplex nucleic acid amplification tests MP-NAATs that can detect evidence of multiple pathogens and toxins can distinguish between Shiga toxins 1 and 2 and some assays also distinguish E.
Although clinical laboratories cannot typically differentiate between subtypes of Shiga toxin 2, subtypes 2a, 2c, and 2d are associated with more severe disease . Known postinfectious manifestations of infections with their associated enteric organisms are listed in Table 4.
When a clinical syndrome consistent with one of these manifestations is encountered, an exposure history should be obtained along with a diagnostic evaluation and directed management, which may have public health or outbreak evaluation implications. Early identification of particularly virulent STEC infection eg, STEC O and other Shiga toxin 2—producing strains facilitates rapid implementation of measures in the home that prevent cross-contamination .
Determination of the precise cause of diarrhea is not always necessary. Assessment of a stool specimen to determine the cause should be performed on patients at high risk of severe illness and for whom identification of a pathogen would be important for the patient or for public health reasons. As first described in the original IDSA guidelines on management of infectious diarrhea , diagnostic algorithms that combine clinical and epidemiologic factors that meet requirements of clinical medicine and public health are needed.
Although the majority of diarrheal illnesses are self-limited and identification of the infectious etiology often has little value to these individual patients, for certain infections, an organism-specific diagnosis is important to guiding clinical management. Furthermore, from a public health perspective, an organism-specific diagnosis is valuable for the majority of diarrheal illnesses because identification of an organism facilitates outbreak detection and monitoring of disease trends.
Selective testing recommendations below are based on clinical management needs as well as on the efficient use of diagnostic testing to meet the needs of public health surveillance systems. Identification of bacterial pathogens can be important for both clinical management and public health disease control efforts. However, testing all patients with acute diarrhea for these pathogens would be inefficient. Restricting testing to patients with bloody stools, fever, or abdominal tenderness can increase the likelihood of identifying a bacterial pathogen [68, 76—79] Table 5.
Risk factors for invasive nontyphoidal Salmonella infection include young and advanced age, impaired immunity due to human immunodeficiency virus HIV infection and cytotoxic chemotherapy, malnutrition, hemoglobinopathies, recent malaria, and cirrhosis [80—82]. Other bacterial infections, including Campylobacter  and Shigella [44, 84] and Listeria infections are more likely to be severe or recurrent in patients with HIV infection.
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Aneurysms of the aorta and aortitis can occur in elderly patients with invasive nontyphoidal salmonellosis or yersiniosis [85, 86]. Risk factors for invasive noncholera vibriosis, especially Vibrio vulnificus infections, are chronic liver disease including cirrhosis, alcoholic liver disease, and hepatitis , iron overload states hemochromatosis, hemolytic anemia, or chronic renal failure and other immunocompromising conditions [87, 88]. Yersinia enterocolitica can be associated with an array of clinical presentations including, but not limited to, nonbloody diarrhea, bloody diarrhea, and a febrile pseudoappendicular syndrome that can mimic appendicitis.
Invasive yersiniosis in an adult may be associated with the presence of mycotic aneurysms . Foods that have been associated with Y. Higher risk groups in the United States include young African American and Asian children, especially during winter months, as well as diabetics and those with chronic liver disease, malnutrition, or iron-overload states. The higher rates among African American children had been attributable to cross-contamination within the home during preparation of chitterlings, a seasonal dish prepared from pig intestines.
However, the high incidence rates in African American children observed in the late s have declined dramatically following preventive health campaigns focusing on avoidance of cross-contamination in the kitchen . Identification and investigation of outbreaks together serve important roles in reducing the burden of diarrheal illnesses by truncating the duration of the outbreak and uncovering the contributing factors that led to the outbreak so that those factors can be addressed to prevent future outbreaks and illnesses.
An organism-specific diagnosis usually is necessary for public health control efforts, because clinical factors alone rarely are sufficient to distinguish between etiologic agents. Identifying the etiologic agent s from ill people is important for case finding and investigating possible sources of infection.
The most common cause of diarrheal disease outbreaks is norovirus, but a broad range of bacterial and parasitic agents have been implicated in outbreaks [90—94]. The specific pathogens for which to test may vary by clinical presentation and exposures. Health departments can provide guidance on testing, and often public health laboratories can assist in testing for agents that exceed the diagnostic capacity of the clinical laboratory. Immunocompromised people are more likely to experience severe or prolonged illness. Diarrhea in immunocompromised patients may involve a broad spectrum of potential causes, including bacterial, viral, parasitic, and fungal pathogens depending on underlying immune status .
In addition, people with HIV-associated immune compromise are at risk for diarrhea due to enteroaggregative E. Besides stool examination, other investigations may be necessary for the HIV-infected patient, including blood cultures for diagnosis of MAC infection and colonoscopy with biopsy for CMV enteritis. Diarrhea caused by some protozoa eg, Cryptosporidium , Cyclospora , Cystoisospora or microsporidia is more likely to be severe, chronic, or relapsing in immunocompromised people, particularly those with impaired cell-mediated immunity, including advanced HIV infection .
Noninfectious etiologies including adverse effects of antiretroviral therapy or chemotherapy also may account for persistent diarrhea in immunocompromised hosts. Chronic and severe norovirus infection has been reported in patients receiving immunosuppression following organ transplantation . Patients who acquire norovirus infection while hospitalized, especially people with immunocompromising conditions and people of advanced age, may be more likely to die.
Guidelines for prevention and control of norovirus gastroenteritis outbreaks in healthcare settings have been published . However, diagnosis of norovirus infections largely has been limited to infections occurring as part of outbreaks. Localized outbreaks affecting hospital wards and long-term care facilities may be more likely to be investigated [—]. Investigations to assess the endemic rates of norovirus infection are ongoing. Persistent non-vaccine-related and vaccine-related rotavirus diarrhea has been reported in young children with primary immunodeficiency [, ], but rotavirus disease and hospitalizations overall have been reduced markedly since licensure of the 2 ACIP-recommended rotavirus vaccines .
Most TD is self-treatable with oral rehydration therapy, and, for nonbloody diarrhea in adults, an antimotility agent . The distribution of gastrointestinal tract pathogens varies substantially by region of travel. In a US FoodNet study between and , the majority of cases of typhoid fever, paratyphoid fever, and Shigella dysenteriae infection among others, were associated with travel . An abnormal D-xylose absorption test indicates the possibility of tropical sprue, which is most common in adults visiting tropical areas for long periods of time.
Multipathogen nucleic acid amplification tests can simultaneously detect viral, parasitic, and bacterial agents, including some pathogens that previously could not be easily detected in the clinical setting such as norovirus, and enterotoxigenic E. The short time to results could reduce inappropriate use of antimicrobial agents to treat infections that do not require antimicrobial therapy and could shorten the time to targeted management and isolation measures for certain infections such as STEC O The importance of detection of multiple pathogens in the same specimen is often unclear; it is unknown if all pathogens detected in the specimen are clinically relevant or if one is more strongly associated with the illness.
Interpretation of results will improve as more data become available regarding the performance of these assays. For at least one assay, current data show that concordance with traditional diagnostic methods may vary by pathogen . Some experts have proposed that these assays may be particularly well suited for making an organism-specific diagnosis in immunocompromised patients . The current FDA-cleared multiplex assays do not quantify the amount of nucleic acid present. Development of quantitative assays may aid in interpretation of results . Guidelines by IDSA and the American Society for Microbiology ASM on utilization of the clinical microbiology laboratory describe optimal tests for detection of pathogens, including those causing diarrhea .
The complete findings are summarized in Table 5. The availability of one of these panels as well as other assays may vary among clinical laboratories, making requisitions unique to the laboratory to which the sample is submitted. There are important drawbacks to the increasing use of culture-independent diagnostic tests CIDTs , including enzyme immunoassays and NAATs in the clinical setting. First, replacement of culture by CIDT in clinical laboratories will impede outbreak detection and investigation.
Public health has made important strides in detecting, investigating, and controlling outbreaks of enteric illness using molecular subtyping of the infecting bacterial strains in public health laboratories . The net effect of this enhanced surveillance and control has been to prevent thousands of illnesses . Replacement of culture by CIDT without preserving access to isolates will impede detection of dispersed outbreaks, and thus reduce the capacity of public health to control and to prevent them. Second, for the individual, CIDTs do not provide information on antimicrobial susceptibility to guide clinical management.
Actions are needed to avoid this negative impact on public health. In the short term, specimens that test positive for a bacterial pathogen by a CIDT for which isolate submission is requested or required under public health reporting rules should be cultured, either at the clinical laboratory or at a public health laboratory. Cultured organisms can be sent to public health laboratories for species identification, serotyping and further subtyping by molecular methods eg, pulsed-field gel electrophoresis, and, more recently, whole-genome sequencing.
Subtyping enables detection of increases in infections caused by a specific strain and also facilitates outbreak investigations by increasing the probability that case-patients included in an investigation are likely to have had a common exposure. In the longer term, culture-independent methods that serve clinical diagnostic needs and are able to provide subtyping information to distinguish strains are needed [—]. Bone marrow culture is likely to be more sensitive than blood culture for diagnosis of invasive nontyphoidal Salmonella enterica infection [, ].
Routine aerobic blood culture is recommended as the routine practical conventional diagnostic and for the initial diagnostic assessment in people with suspected enteric fever or invasive salmonellosis [—]. In enteric fever, culture of other samples such as stool, duodenal fluid, and urine may be helpful. Due to poor performance characteristics, serologic tests should not be used for diagnosis of enteric fever.
Nucleic acid amplification tests lack sensitivity for detection of Salmonella enterica serovar Typhi in blood, but may be useful for rapid detection and identification of Salmonella enterica serovar Typhi in research settings [, ]. Blood culture should be performed in all people with signs of septicemia and when enteric fever is suspected. Blood cultures may be considered in immunocompromised people who are febrile or from whom bacterial pathogens are detected by stool testing. Some clinical laboratories are now using blood culture technology that can identify a pathogen without isolation .
In these situations, it is essential to isolate the organism to facilitate antimicrobial susceptibility testing and additional molecular characterization by public health laboratories. As the median magnitude of bacteremia in enteric fever and invasive nontyphoidal Salmonella enterica disease are low at 0. Two to three mL blood cultures are adequate for detection of bacteremia in adults . Lower volumes may be sufficient for detection in infants and children who have higher magnitudes of bacteremia than adults .
Blood cultures may be drawn simultaneously and should be collected prior to administration of antimicrobial agents to maximize sensitivity. Continuously monitored blood culture systems may shorten the time to detection and improve sensitivity compared with manual blood culture methods. However, the strength of association between antibiotic classes and development of CDI may be confounded by hospitalization, use of multiple antibiotic classes, and duration of exposure. There is increasing recognition of community-acquired C. Children occasionally develop severe C.
Concomitantly with adults, the incidence of infection has increased among hospitalized children, and community-acquired infections with hypervirulent strains have emerged, but the severity of disease has not increased as it has with adults. In this severe case of S. When the scenario was altered to include a rising vancomycin MIC of 2. Willingness to enrole patients in a trial randomizing to an adjunctive protein synthesis inhibitor vs. Table 2. Clinician-ranked clinical trial priorities for pediatric S. Treatment decisions by ID physicians managing pediatric SAB showed significant variation, highlighting the paucity of evidence and the importance of developing prioritized research agendas for SAB trials.
The national antibiotic handbook recommendations and a lack of randomized controlled trial RCT data comparing ASP with cefazolin support this preference 3. This may reflect clinician concern regarding poorly defined pediatric vancomycin dosing targets 2 , observational data showing vancomycin therapy as a risk factor for poor outcome in children irrespective of methicillin susceptibility 2 , and greater availability of newer alternative MRSA agents. In support of this preference, salvage therapy studies suggest this distinction in vitro , may not correlate with clinical outcome 5.
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Similarly, observational data supports linezolid's role for the treatment of pediatric skeletal infection 6. Whilst a RCT of daptomycin vs. Optimal duration of therapy for pediatric SAB is poorly defined. This is reflected in the variation in duration of treatment selected amongst clinicians, particularly for persisting multifocal MRSA-B. The randomized trial supporting short course therapy in Finnish children with skeletal infection had, however, an absence of MRSA and excellent outcomes despite minimal surgical procedures 10 , which are inconsistent with local clinical experience.
This underscores the need for further multi-site trials to evaluate the duration of treatment of pediatric SAB that are inclusive of children with MRSA and severe disease. Local resistance rates were cited in decision making by respondents but consensus on the threshold for introducing dual cover varies. Other variables including case severity and ethnicity likely influenced decision making. Some limitations include that surveyed responses may not reflect actual treatment decisions; and complete responses from all surveyed participants were not captured.
Study bias was reduced with free text and multiple answer options available where appropriate and randomization of the order of answers presented. Large variation in antibiotic prescribing for pediatric SAB is demonstrated amongst clinicians within the same jurisdiction and internationally. In addition, variation in practice increased, corresponding with escalating case complexity and highlights the paucity of evidence directing management. Furthermore, clinician-ranked trial priorities and clinician equipoise summarized from this survey should guide the design of pediatric SAB clinical trials to optimize patient outcomes.
The study was exempt from the above requirement given the survey did not involve patients or their families and was a clinician based survey. Data collected was all non-identifiable information that was presented in a summarized format. All of the authors have contributed to editing the manuscript.
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