A5V4d

Recommendations
Number Recommendation
Oral antibiotics
Management by the non-paediatric practitioner
45 Do not prescribe oral antibiotics to children with fever without apparent source.
[2007]
Empirical treatment with parenteral antibiotics
Review question
When should children in primary care be treated with empirical parenteral antibiotics in an attempt to
decrease mortality or morbidity?
Narrative evidence
Two studies 159,160 that reported on the effect of empirical antibiotics on reducing mortality and
morbidity were identified. An EL 2++ SR 159 comprising 14 studies evaluated the effectiveness of such
antibiotics in reducing case fatality in meningococcal disease in patients of all ages. Twelve of the
papers contained information on parenteral antibiotics given before admission and outcome, of which
eight showed that there was a beneficial effect in giving parenteral antibiotics before admission and
four reported an adverse effect. Risk ratios for mortality in these studies ranged from 0.16 (95% CI
0.01 to 2.63) to 2.36 (95% CI 0.25 to 22.54). Only one study reported a statistically significant result
(risk ratio 0.35, 95% CI 0.16 to 0.80). 161 Since the proportion of cases treated differed among the
reported studies (differences ranged from 15% to 59%, chi-squared for heterogeneity was 11.02
(P = 0.09), I2 = 46% [95% uncertainty interval 0% to 77%]), studies were reported and examined on
an individual basis. The reviewers could not conclude whether or not antibiotics given before
admission had an effect on case fatality. However, they stated that the data are consistent with
benefit when a substantial proportion of cases are treated.
A recent EL 2++ 160 case–control study that was not included in the SR was also found. The study
looked at the use of parenteral penicillin by GPs who had made the diagnosis of meningococcal
disease in 26 children who died from the condition, and 132 survivors. Administration of parenteral
penicillin was associated with increased risk of death (OR 7.4, 95% CI 1.5 to 37.7). Children who
received penicillin had more severe disease on admission (median Glasgow meningococcal
septicaemia prognostic score 6.5 versus 4.0, P = 0.002). The association between parenteral
penicillin and poor outcome may be because children who were more severely ill were given penicillin
before admission.
Evidence summary
In meningococcal disease, the evidence cannot conclude whether or not parenteral antibiotics given
before admission have an effect on case fatality. However, the data are consistent with benefit when
a substantial proportion of cases are treated.
Health economics
Since the evidence of effectiveness is equivocal, the cost-effectiveness of parenteral antibiotics
cannot be established.
GDG translation
The GDG noted that all good-quality evidence referred to meningococcal disease and therefore
looked at meningococcal disease in great detail compared with the other SBIs. Meningococcal
disease is the leading infectious cause of mortality among children in the UK. No evidence on
empirical treatment with parenteral antibiotics was found for other conditions, including meningitis,
and therefore these conditions do not appear in the evidence tables. However, the GDG noted that
current advice on immediate treatment in primary care refers to meningitis as well as meningococcal
disease.
Children with meningococcal disease may benefit from pre-admission parenteral antibiotics,
especially if most children with meningococcal disease are treated.
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