Comparison of ampicillin/sulbactam plus aminoglycoside vs. ampicillin plus clindamycin plus aminoglycoside in the treatment of intraabdominal infections in children. The Multicenter Group

Antibiotic regimens for early-onset neonatal sepsis

BACKGROUND

Neonatal sepsis is a major cause of morbidity and mortality. It is the third leading cause of neonatal mortality globally constituting 13% of overall neonatal mortality. Despite the high burden of neonatal sepsis, high-quality evidence in diagnosis and treatment is scarce. Possibly due to the diagnostic challenges of sepsis and the relative immunosuppression of the newborn, many neonates receive antibiotics for suspected sepsis. Antibiotics have become the most used therapeutics in neonatal intensive care units. The last Cochrane Review was updated in 2004. Given the clinical importance, an updated systematic review assessing the effects of different antibiotic regimens for early-onset neonatal sepsis is needed.

OBJECTIVES

To assess the beneficial and harmful effects of different antibiotic regimens for early-onset neonatal sepsis.

SEARCH METHODS

We searched the following electronic databases: CENTRAL (2020, Issue 8); Ovid MEDLINE; Embase Ovid; CINAHL; LILACS; Science Citation Index EXPANDED and Conference Proceedings Citation Index - Science on 12 March 2021. We searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

We included RCTs comparing different antibiotic regimens for early-onset neonatal sepsis. We included participants from birth to 72 hours of life at randomisation.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. Our primary outcome was all-cause mortality, and our secondary outcomes were: serious adverse events, respiratory support, circulatory support, nephrotoxicity, neurological developmental impairment, necrotising enterocolitis, and ototoxicity. Our primary time point of interest was at maximum follow-up.

MAIN RESULTS

We included five RCTs (865 participants). All trials were at high risk of bias. The certainty of the evidence according to GRADE was very low. The included trials assessed five different comparisons of antibiotics. We did not conduct any meta-analyses due to lack of relevant data. Of the five included trials one trial compared ampicillin plus gentamicin with benzylpenicillin plus gentamicin; one trial compared piperacillin plus tazobactam with amikacin; one trial compared ticarcillin plus clavulanic acid with piperacillin plus gentamicin; one trial compared piperacillin with ampicillin plus amikacin; and one trial compared ceftazidime with benzylpenicillin plus gentamicin. None of the five comparisons found any evidence of a difference when assessing all-cause mortality, serious adverse events, circulatory support, nephrotoxicity, neurological developmental impairment, or necrotising enterocolitis; however, none of the trials were near an information size that could contribute significantly to the evidence of the comparative benefits and risks of any particular antibiotic regimen. None of the trials assessed respiratory support or ototoxicity. The benefits and harms of different antibiotic regimens remain unclear due to the lack of well-powered trials and the high risk of systematic errors.

AUTHORS' CONCLUSIONS

Current evidence is insufficient to support any antibiotic regimen being superior to another. Large RCTs assessing different antibiotic regimens in early-onset neonatal sepsis with low risk of bias are warranted.

Antibiotic regimens for late-onset neonatal sepsis

BACKGROUND

Neonatal sepsis is a major cause of morbidity and mortality. It is the third leading cause of neonatal mortality globally constituting 13% of overall neonatal mortality. Despite the high burden of neonatal sepsis, high-quality evidence in diagnosis and treatment is scarce. Due to the diagnostic challenges of sepsis and the relative immunosuppression of the newborn, many neonates receive antibiotics for suspected sepsis. Antibiotics have become the most used therapeutics in neonatal intensive care units, and observational studies in high-income countries suggest that 83% to 94% of newborns treated with antibiotics for suspected sepsis have negative blood cultures. The last Cochrane Review was updated in 2005. There is a need for an updated systematic review assessing the effects of different antibiotic regimens for late-onset neonatal sepsis.

OBJECTIVES

To assess the beneficial and harmful effects of different antibiotic regimens for late-onset neonatal sepsis.

SEARCH METHODS

We searched the following electronic databases: CENTRAL (2021, Issue 3); Ovid MEDLINE; Embase Ovid; CINAHL; LILACS; Science Citation Index EXPANDED and Conference Proceedings Citation Index - Science on 12 March 2021. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

We included RCTs comparing different antibiotic regimens for late-onset neonatal sepsis. We included participants older than 72 hours of life at randomisation, suspected or diagnosed with neonatal sepsis, meningitis, osteomyelitis, endocarditis, or necrotising enterocolitis. We excluded trials that assessed treatment of fungal infections.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. Our primary outcome was all-cause mortality, and our secondary outcomes were: serious adverse events, respiratory support, circulatory support, nephrotoxicity, neurological developmental impairment, necrotising enterocolitis, and ototoxicity. Our primary time point of interest was at maximum follow-up.

MAIN RESULTS

We included five RCTs (580 participants). All trials were at high risk of bias, and had very low-certainty evidence. The five included trials assessed five different comparisons of antibiotics. We did not conduct a meta-analysis due to lack of relevant data. Of the five included trials one trial compared cefazolin plus amikacin with vancomycin plus amikacin; one trial compared ticarcillin plus clavulanic acid with flucloxacillin plus gentamicin; one trial compared cloxacillin plus amikacin with cefotaxime plus gentamicin; one trial compared meropenem with standard care (ampicillin plus gentamicin or cefotaxime plus gentamicin); and one trial compared vancomycin plus gentamicin with vancomycin plus aztreonam. None of the five comparisons found any evidence of a difference when assessing all-cause mortality, serious adverse events, circulatory support, nephrotoxicity, neurological developmental impairment, or necrotising enterocolitis; however, none of the trials were near an information size that could contribute significantly to the evidence of the comparative benefits and risks of any particular antibiotic regimen. None of the trials assessed respiratory support or ototoxicity. The benefits and harms of different antibiotic regimens remain unclear due to the lack of well-powered trials and the high risk of systematic errors.

AUTHORS' CONCLUSIONS

Current evidence is insufficient to support any antibiotic regimen being superior to another. RCTs assessing different antibiotic regimens in late-onset neonatal sepsis with low risks of bias are warranted.

Ampicillin-sulbactam: an update on the use of parenteral and oral forms in bacterial infections

Ampicillin-sulbactam has a wide range of antibacterial activity that includes Gram-positive and Gram-negative aerobic and anaerobic bacteria. However, the drug is not active against Pseudomonas aeruginosa and pathogens producing extended-spectrum beta-lactamases. The combination could be considered particularly active against Acinetobacter baumannii infections due to the intrinsic activity of sulbactam. The drug is indicated as empirical therapy for a broad range of community acquired infections supervened in adults or children and is effective in either parenteral (ampicillin-sulbactam) or oral (as a mutual prodrug sultamicillin) form. In clinical trials, sultamicillin has proved clinically and bacteriologically effective in adults and children against a variety of frequently encountered infections, including mild upper and lower respiratory tract infections, urinary tract infections, diabetic foot and skin and soft tissue infections. Furthermore, adverse effects rarely occur with the diarrhoea to represent the most commonly reported. The parenteral ampicillin-sulbactam is indicated for community infections of mild-to-moderate severity acquired infections such as intra-abdominal or gynecological. Moreover, it seems to represent the alternative of choice for the treatment of A. baumannii infections for carbapenem-resistant strains in the nosocomial setting. Thus, ampicillin-sulbactam remains a valuable agent in the physician's armamentarium in the management of adult and pediatric infections.

Rational antibiotic therapy and the position of ampicillin/sulbactam

In the current context of increasing antimicrobial resistance, it is important to use antibiotics rationally and to re-assess regularly the clinical usefulness of commonly used agents. This review focuses on the efficacy of the beta-lactam ampicillin co-administered with the beta-lactamase inhibitor sulbactam, either parenterally (ampicillin/sulbactam) or orally (sultamicillin), for the treatment of bacterial infections. Clinical findings from the past decade confirm the results of numerous older studies and together provide good evidence to support the continued use of ampicillin/sulbactam and sultamicillin in hospital- and community-acquired infections both in adults and children. This is also recognised in recent published national and international guidelines, many of which recommend ampicillin/sulbactam as first-line therapy for various respiratory and skin infections.

Update on clindamycin in the management of bacterial, fungal and protozoal infections

Lincomycin and clindamycin are the only members of the relatively small lincosamide antimicrobial class marketed for use in humans. This paper only reviews data regarding clindamycin, with an emphasis on data published over the last decade. Clindamycin exhibits a broad spectrum of antimicrobial activity, including Gram-positive aerobes/anaerobes, Gram-negative anaerobes and select protozoa (Toxoplasma gondii, Plasmodium falciparum, Babesia spp.) and fungi (Pneumocystis jiroveci). It still enjoys use in the therapy and prophylaxis of a large number of bacterial, protozoal and fungal infections, despite > 40 years of clinical use. However, the spectre of resistance by an increasing number of microorganisms is beginning to cast a shadow over the future use of this valuable agent. With the emergence and spread of infections due to community-acquired methicillin-resistant Staphylococci (for which clindamycin is a first-line agent), it is hoped that the issues of resistance can be mitigated and the use of clindamycin extended for at least the foreseeable future.

Ampicillin/Sulbactam

Ampicillin/sulbactam is a beta-lactam/beta-lactamase inhibitor combination with a broad spectrum of antibacterial activity against Gram-positive, Gram-negative and anaerobic bacteria. Data from comparative studies justify the use of ampicillin/sulbactam in a 2 : 1 ratio in various severe bacterial infections. In comparative clinical trials, ampicillin/sulbactam has proved to be a significant drug in the therapeutic armamentarium for lower respiratory tract infections and aspiration pneumonia, gynaecological/obstetrical infections, intra-abdominal infections, paediatric infections such as acute epiglottitis and periorbital cellulitis, diabetic foot infections, and skin and soft tissue infections. Of particular interest during this era of increasing antimicrobial resistance in various settings and populations is the effectiveness of sulbactam against a considerable proportion of infections due to Acinetobacter baumannii.

The Surgical Infection Society guidelines on antimicrobial therapy for intra-abdominal infections: an executive summary

The Surgical Infection Society last published guidelines on antimicrobial therapy for intra-abdominal infections in 1992 (Bohnen JMA, et al., Arch Surg 1992;127:83-89). Since then, an appreciable body of literature has been published on this subject. Therefore, the Therapeutics Agents Committee of the Society undertook an effort to update the previous guidelines, primarily using data published over the past decade. An additional goal of the Committee was to characterize its recommendations according to contemporary principles of evidence-based medicine. To develop these guidelines, the Committee carried out a systematic search for all English language articles published between 1990 and 2000 related to antimicrobial therapy for intra-abdominal infections. This literature was reviewed individually and collectively by the Committee, and categorized according to the type of study and its quality. Additional articles published prior to 1990 were also utilized when necessary. By a process of iterative consensus, the Committee developed provisional guidelines for antimicrobial therapy for intra-abdominal infections based on this evidence. Following extensive review by members of the Society, these guidelines were approved for publication in final form by the Council of the Surgical Infection Society. This executive summary delineates the Society's current recommendations for antimicrobial therapy of patients with intra-abdominal infections. Topics discussed include the selection of patients needing therapeutic antimicrobials, duration of antimicrobial therapy, acceptable antimicrobial regimens, and identification and treatment of higher-risk patients. Guidelines for patient selection and specific antimicrobial regimens were based on relatively good evidence, but those regarding optimal duration of therapy and treatment of higher-risk patients relied mostly on expert opinion, since there was a paucity of high-quality studies on those issues. Relevant areas for future investigation include the safety, convenience, and cost-effectiveness of available antimicrobial regimens for lower-risk patients, and better means for identifying and treating higher-risk patients with intra-abdominal infections.

The Surgical Infection Society guidelines on antimicrobial therapy for intra-abdominal infections: evidence for the recommendations

Revised guidelines for the use of antimicrobial therapy in patients with intra-abdominal infections were recently developed by the Therapeutic Agents Committee of the Surgical Infection Society (Mazuski et al., Surg Infect 2002;3:161-173). These were based, insofar as possible, on evidence published over the past decade. The objective of this document is to describe the process by which the Committee identified and reviewed the published literature utilized to develop the recommendations and to summarize the results of those reviews. English-language articles published between 1990 and 2000 related to antimicrobial therapy for intra-abdominal infections were identified by a systematic MEDLINE search and an examination of references included in recent review articles. If current literature with regard to a specific issue was lacking, relevant articles published prior to 1990 were identified. All prospective randomized controlled trials, as well as other articles selected by the Committee, were evaluated individually and collectively. Data with regard to patient numbers, types of infections, and results of interventions were abstracted. Studies were categorized according to their design, and all included trials were graded according to quality. On the basis of this evidence, the Committee formulated recommendations for antimicrobial therapy for intra-abdominal infections and graded those recommendations. After receiving comments from invited reviewers and the general membership of the Society, the guidelines were finalized and submitted to the Council of the Surgical Infection Society for approval. The final recommendations related to the selection of patients needing therapeutic antimicrobials, acceptable antimicrobial regimens, duration of antimicrobial use, and the identification and treatment of higher-risk patients. Although numerous publications pertaining to these topics were identified, but nearly all of the prospective randomized controlled trials represented comparisons of different antimicrobial regimens for the treatment of intra-abdominal infections. A few prospective trials evaluated the need for therapeutic antimicrobial therapy in patients with peritoneal contamination following abdominal trauma. The quality of these prospective trials was highly variable. Many did not limit enrollment to patients with complicated intra-abdominal infections, lacked blinding of treatment assignment, did not provide a complete description of the criteria used to determine therapeutic success or failure, failed to identify the reasons why patients were excluded from analysis, or did not include an intention-to-treat analysis. For many issues, no prospective randomized controlled trials were encountered, and guidelines had to be formulated using evidence from studies with historical controls or uncontrolled data, or on the basis of expert opinion

Experience with ampicillin/sulbactam in severe infections

The emergence of beta-lactamase-mediated resistance to established beta-lactam antibiotics prompted the development of beta-lactamase inhibitors for co-administration. Ampicillin has been combined with sulbactam for both parenteral and oral (as the mutual pro-drug sultamicillin) administration. The combination is active in vitro against a wide variety of Gram-positive and Gram-negative pathogens, including aerobic and anaerobic organisms. In clinical trials, ampicillin/sulbactam has proved clinically and bacteriologically effective against a variety of frequently encountered pediatric infections, including mild-to-moderate upper respiratory tract infections (acute otitis media, sinusitis, pharyngitis, and tonsillitis), severe post-operative and intra-abdominal infections, periorbital infections (which, left untreated, can lead to blindness, brain abscess, or death), acute epiglottitis, bacterial meningitis, and brain abscess. Ampicillin/sulbactam has also proved effective in the prevention of post-operative surgical infections in pediatric patients. The clinical efficacy profile of ampicillin/sulbactam and sultamicillin, combined with their excellent tolerability profile, make these agents attractive options for the management of many life-threatening infections in pediatric patients.

Use of ampicillin/sulbactam and sultamicillin in pediatric infections: a re-evaluation

Ampicillin/sulbactam is an effective solution to the emergence of beta-lactamase-mediated resistance among common pediatric pathogens, and is a widely recognized treatment option for a variety of pediatric infections. Recent antimicrobial surveillance data confirm the continued susceptibility of many Gram-positive and Gram-negative aerobes and anaerobes to ampicillin/sulbactam. Pharmacokinetic studies have demonstrated high drug concentrations at a variety of infection sites, including cerebrospinal fluid and bone. Furthermore, clinical studies have shown that ampicillin/sulbactam, administered intravenously, intramuscularly or orally (as the mutual prodrug sultamicillin), is clinically and bacteriologically effective against upper and lower respiratory tract infections, urinary tract infections, skin, bone and soft-tissue infections, and meningitis, and provides effective surgical prophylaxis. Sultamicillin has an excellent tolerability profile, which is associated with a low rate of treatment discontinuation. Accordingly, ampicillin/sulbactam and sultamicillin should be considered first-choice options for the management of a variety of pediatric infections.