Double gram-negative cover in gram-negative bacteraemia in children: is less actually more?


A recent US study challenges us to think about our approach in managing gram-negative bacteraemia in children and questions the dogma that ‘two drugs are better than one’.[1] In this retrospective study, the authors compared outcomes in children that received β-lactam monotherapy (MT) (n = 342) to combination β-lactam plus aminoglycoside (computerised tomography (CT)) (n = 537) as definitive treatment in gram-negative bacteraemia. Outcomes of interest included all-cause mortality (within 30 days) and nephrotoxicity. There was no overall difference in mortality between groups (23 MT vs. 41 CT, P = 0.61). However, children that received CT were more likely to develop significant acute nephrotoxicity, even after adjusting for potential confounders (odds ratio (OR), 2.15; 95% confidence interval (CI), 2.09–2.21). Importantly, there was increased odds of mortality in children that did not have their central line removed within 72 h of the first positive blood culture compared to those that did, even after adjustment (OR, 2.11; 95% CI, 2.07–2.15). Whist selecting the most appropriate initial antibiotic regimen in children will depend on local antimicrobial resistance patterns, the paper by Tamma et al. highlights the importance of potentially rationalising treatment once sensitivities are available. This may not only benefit the patient but also support antimicrobial stewardship programs that can only be beneficial long-term.

Reviewers: Laine Hosking, Benjamin Nind, Tom Connell, Royal Children's Hospital Melbourne