Trial of Reducing Inpatient Antibiotic Durations in Children

Inclusion Criteria: We will include children and adolescents ages 60 days to 17 years and 10 months admitted to the hospital medicine service with a primary diagnosis of PNA, SSTI, or UTI receiving an antibiotic agent that is concordant with any microbiologic results and guideline-concordant. Children are eligible if they are prescribed a post-discharge antibiotic for home that is within our trial formulary. For PNA, children must have radiographic evidence of pneumonia as read by a radiologist, and clinical diagnosis of pneumonia, and clinician prescription of guideline-concordant antibiotics for pneumonia. For SSTI, we will include children with cellulitis alone or cellulitis with abscess that was either drained or deemed too small for drainage. For UTI, children must meet guideline-specified diagnostic criteria. Exclusion Criteria: We will exclude any patients who live independently (without a parent or guardian in the home), including those in county or state custody. We will exclude patients who previously enrolled (i.e., consented and randomized) in the study. We will exclude patients who are not discharging home from hospital medicine service. For all conditions, we will exclude children who require inpatient antibiotics longer than 4 days, as guidelines indicate that a child should be clinically improving to be a candidate for short duration treatment strategy. We will also exclude children discharged with \>1 systemic antibiotic prescription, as this may indicate greater severity of infection or greater diagnostic uncertainty. Other exclusion criteria are also all aligned with guidelines, which exclude children that may require longer duration antibiotics or have higher risk of infections with resistant or atypical organisms, including exclusion of patients requiring \>24 hours in intensive care, patients with immunodeficiency, patients who have been hospitalized in the preceding 30 days before the index hospitalization, patients who are admitted after completing more than 48 hours of outpatient antibiotics to treat the current infection, known pregnant patients, anyone who has an allergy to any of the components of the placebo, and anyone with clear alternate diagnosis, need for treatment of a concomitant diagnosis requiring antibiotics, or uncertainty regarding the qualifying diagnosis (PNA, SSTI, UTI). For pneumonia, we will exclude children with a parapneumonic effusion larger than "trace" or "small" (based on radiologist impression), tracheostomy, high intensity neurologic impairment, cystic fibrosis, sickle cell disease, chronic respiratory failure, or received 3 or more doses of azithromycin. For SSTI, we will exclude children with surgical site infections, cellulitis around a medical device, bone or joint infections, infectious myositis or pyomyositis, implanted hardware or other deep infections, have concomitant HSV, significant chronic dermatologic conditions other than eczema, or pre-septal or orbital cellulitis. Dental abscess without overlying facial cellulitis will also be excluded. We will exclude those discharged from the hospital with a drain in place. However, any abscess at the skin would qualify even if it is drained by a subspecialist, unless it connects with an internal cavity. For UTI, we will exclude children with major genitourinary anomalies, high-grade vesicoureteral reflux, history of urologic surgery other than circumcision, indwelling urinary catheters, need for regular intermittent catheterization, or current renal abscess.