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Nielsen AB, Holm M, Lindhard MS, Glenthøj JP, Borch L, Hartling U, Schmidt LS, Rytter MJH, Rasmussen AH, Damkjær M, Lemvik G, Petersen JJH, Søndergaard MJ, Thaarup J, Kristensen K, Jensen LH, Hansen LH, Lawaetz MC, Gottliebsen M, Horsager TH, Zaharov T, Hoffmann TU, Nygaard T, Justesen US, Stensballe LG, Vissing NH, Blanche P, Schmiegelow K, Nygaard U. Oral versus intravenous empirical antibiotics in children and adolescents with uncomplicated bone and joint infections: a nationwide, randomised, controlled, non-inferiority trial in Denmark. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:625-635. [PMID: 39025092 DOI: 10.1016/s2352-4642(24)00133-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Bone and joint infections (BJIs) are treated with intravenous antibiotics, which are burdensome and costly. No randomised controlled studies have compared if initial oral antibiotics are as effective as intravenous therapy. We aimed to investigate the efficacy and safety of initial oral antibiotics compared with initial intravenous antibiotics followed by oral antibiotics in children and adolescents with uncomplicated BJIs. METHODS From Sept 15, 2020, to June 30, 2023, this nationwide, randomised, non-inferiority trial included patients aged 3 months to 17 years with BJIs who presented to one of the 18 paediatric hospital departments in Denmark. Exclusion criteria were severe infection (ie, septic shock, the need for acute surgery, or substantial soft tissue involvement), prosthetic material, comorbidity, previous BJIs, or antibiotic therapy for longer than 24 h before inclusion. Patients were randomly assigned (1:1), stratified by C-reactive protein concentration (<35 mg/L vs ≥35 mg/L), to initially receive either high-dose oral antibiotics or intravenous ceftriaxone (100 mg/kg per day in one dose). High-dose oral antibiotics were coformulated amoxicillin (100 mg/kg per day) and clavulanic acid (12·5 mg/kg per day) in three doses for patients younger than 5 years or dicloxacillin (200 mg/kg per day) in four doses for patients aged 5 years or older. After a minimum of 3 days, and upon clinical improvement and decrease in C-reactive protein, patients in both groups received oral antibiotics in standard doses. The primary outcome was sequelae after 6 months in patients with BJIs, defined as any atypical mobility or function of the affected bone or joint, assessed blindly, in all randomised patients who were not terminated early due to an alternative diagnosis (ie, not BJI) and who attended the primary outcome assessment. A risk difference in sequelae after 6 months of less than 5% implied non-inferiority of the oral treatment. Safety outcomes were serious complications, the need for surgery after initiation of antibiotics, and treatment-related adverse events in the as-randomised population. This trial was registered with ClinicalTrials.gov, NCT04563325. FINDINGS 248 children and adolescents with suspected BJIs were randomly assigned to initial oral antibiotics (n=123) or initial intravenous antibiotics (n=125). After exclusion of patients without BJIs (n=54) or consent withdrawal (n=2), 101 patients randomised to oral treatment and 91 patients randomised to intravenous treatment were included. Ten patients did not attend the primary outcome evaluation. Sequelae after 6 months occurred in none of 98 patients with BJIs in the oral group and none of 84 patients with BJIs in the intravenous group (risk difference 0, one-sided 97·5% CI 0·0 to 3·8, pnon-inferiority=0·012). Surgery after randomisation was done in 12 (9·8%) of 123 patients in the oral group compared with seven (5·6%) of 125 patients in the intravenous group (risk difference 4·2%, 95% CI -2·7 to 11·5). We observed no serious complications. Rates of adverse events were similar across both treatment groups. INTERPRETATION In children and adolescents with uncomplicated BJIs, initial oral antibiotic treatment was non-inferior to initial intravenous antibiotics followed by oral therapy. The results are promising for oral treatment of uncomplicated BJIs, precluding the need for intravenous catheters and aligning with the principles of antimicrobial stewardship. FUNDING Innovation Fund Denmark and Rigshospitalets Forskningsfond.
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Affiliation(s)
- Allan Bybeck Nielsen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Hvidovre, Denmark
| | - Mette Holm
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Morten S Lindhard
- Department of Pediatrics and Adolescent Medicine, Regional Hospital Randers, Randers, Denmark
| | - Jonathan P Glenthøj
- Department of Paediatrics and Adolescent Medicine, Hillerød University Hospital, Hillerød, Denmark
| | - Luise Borch
- Department of Paediatrics and Adolescent Medicine, Gødstrup Hospital, Gødstrup, Denmark; NIDO Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - Ulla Hartling
- Department of Paediatrics and Adolescent Medicine, Hans Christian Andersen Children's Hospital, Odense, Denmark
| | - Lisbeth S Schmidt
- Department of Paediatrics and Adolescent Medicine, Herlev University Hospital, Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maren J H Rytter
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Paediatrics and Adolescent Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Annett H Rasmussen
- Department of Paediatrics and Adolescent Medicine, Hans Christian Andersen Children's Hospital, Odense, Denmark
| | - Mads Damkjær
- Department of Paediatrics and Adolescent Medicine, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Grethe Lemvik
- Department of Paediatrics and Adolescent Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Jens J H Petersen
- Department of Paediatrics and Adolescent Medicine, Esbjerg Central Hospital, Esbjerg, Denmark
| | - Mia J Søndergaard
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Thaarup
- Department of Paediatrics and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Kim Kristensen
- Department of Paediatrics and Adolescent Medicine, Zealand University Hospital, Nykobing Falster, Denmark
| | - Lise H Jensen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Paediatrics and Adolescent Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Lotte H Hansen
- Department of Paediatrics and Adolescent Medicine, Aabenraa Hospital, Aabenraa, Denmark
| | - Marie C Lawaetz
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Martin Gottliebsen
- Department of Paediatric Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Tanja H Horsager
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Paediatrics and Adolescent Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Tatjana Zaharov
- Department of Paediatrics and Adolescent Medicine, Zealand University Hospital, Nykobing Falster, Denmark
| | - Thomas U Hoffmann
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Hvidovre, Denmark
| | - Tobias Nygaard
- Department of Paediatric Orthopaedic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ulrik S Justesen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Lone G Stensballe
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nadja H Vissing
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Paul Blanche
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulrikka Nygaard
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Baba A, Aregbesola A, Caldwell PHY, Elliott SA, Elsman EBM, Fernandes RM, Hartling L, Heath A, Kelly LE, Preston J, Sammy A, Webbe J, Williams K, Woolfall K, Klassen TP, Offringa M. Developments in the Design, Conduct, and Reporting of Child Health Trials. Pediatrics 2024; 154:e2024065799. [PMID: 38832441 DOI: 10.1542/peds.2024-065799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 06/05/2024] Open
Abstract
To identify priority areas to improve the design, conduct, and reporting of pediatric clinical trials, the international expert network, Standards for Research (StaR) in Child Health, was assembled and published the first 6 Standards in Pediatrics in 2012. After a recent review summarizing the 247 publications by StaR Child Health authors that highlight research practices that add value and reduce research "waste," the current review assesses the progress in key child health trial methods areas: consent and recruitment, containing risk of bias, roles of data monitoring committees, appropriate sample size calculations, outcome selection and measurement, and age groups for pediatric trials. Although meaningful change has occurred within the child health research ecosystem, measurable progress is still disappointingly slow. In this context, we identify and review emerging trends that will advance the agenda of increased clinical usefulness of pediatric trials, including patient and public engagement, Bayesian statistical approaches, adaptive designs, and platform trials. We explore how implementation science approaches could be applied to effect measurable improvements in the design, conducted, and reporting of child health research.
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Affiliation(s)
- Ami Baba
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Alex Aregbesola
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Patrina H Y Caldwell
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
| | - Sarah A Elliott
- Cochrane Child Health
- Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ellen B M Elsman
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Ricardo M Fernandes
- Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Lisa Hartling
- Cochrane Child Health
- Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Anna Heath
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Statistical Science, University College London, London, United Kingdom
| | - Lauren E Kelly
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pharmacology and Therapeutics, Rady Faculty of Medicine, University of Manitoba, Winnipeg, Canada
| | - Jennifer Preston
- National Institute for Health and Care Research (NIHR) Alder Hey Clinical Research Facility, Liverpool, United Kingdom
| | - Adrian Sammy
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - James Webbe
- Section of Neonatal Medicine, Imperial College London, London, United Kingdom
| | - Katrina Williams
- Department of Paediatrics, Monash University and Developmental Paediatrics, Monash Children's Hospital, Melbourne, Australia
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, United Kingdom
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
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Baba A, Smith M, Potter BK, Chan AW, Moher D, Offringa M. Guidelines for reporting pediatric and child health clinical trial protocols and reports: study protocol for SPIRIT-Children and CONSORT-Children. Trials 2024; 25:96. [PMID: 38287439 PMCID: PMC10826142 DOI: 10.1186/s13063-024-07948-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/22/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Despite the critical importance of clinical trials to provide evidence about the effects of intervention for children and youth, a paucity of published high-quality pediatric clinical trials persists. Sub-optimal reporting of key trial elements necessary to critically appraise and synthesize findings is prevalent. To harmonize and provide guidance for reporting in pediatric controlled clinical trial protocols and reports, reporting guideline extensions to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) and Consolidated Standards of Reporting Trials (CONSORT) guidelines specific to pediatrics are being developed: SPIRIT-Children (SPIRIT-C) and CONSORT-Children (CONSORT-C). METHODS The development of SPIRIT-C/CONSORT-C will be informed by the Enhancing the Quality and Transparency of Health Research Quality (EQUATOR) method for reporting guideline development in the following stages: (1) generation of a preliminary list of candidate items, informed by (a) items developed during initial development efforts and child relevant items from recent published SPIRIT and CONSORT extensions; (b) two systematic reviews and environmental scan of the literature; (c) workshops with young people; (2) an international Delphi study, where a wide range of panelists will vote on the inclusion or exclusion of candidate items on a nine-point Likert scale; (3) a consensus meeting to discuss items that have not reached consensus in the Delphi study and to "lock" the checklist items; (4) pilot testing of items and definitions to ensure that they are understandable, useful, and applicable; and (5) a final project meeting to discuss each item in the context of pilot test results. Key partners, including young people (ages 12-24 years) and family caregivers (e.g., parents) with lived experiences with pediatric clinical trials, and individuals with expertise and involvement in pediatric trials will be involved throughout the project. SPIRIT-C/CONSORT-C will be disseminated through publications, academic conferences, and endorsement by pediatric journals and relevant research networks and organizations. DISCUSSION SPIRIT/CONSORT-C may serve as resources to facilitate comprehensive reporting needed to understand pediatric clinical trial protocols and reports, which may improve transparency within pediatric clinical trials and reduce research waste. TRIAL REGISTRATION The development of these reporting guidelines is registered with the EQUATOR Network: SPIRIT-Children ( https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-clinical-trials-protocols/#35 ) and CONSORT-Children ( https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-clinical-trials/#CHILD ).
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Affiliation(s)
- Ami Baba
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Maureen Smith
- Patient Partner, Canadian Organization for Rare Disorders, Ottawa, ON, Canada
| | - Beth K Potter
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - An-Wen Chan
- Department of Medicine, Women's College Research Institute, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - David Moher
- Centre for Journalology, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada.
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