JOURNAL WATCH

https://doi.org/10.5005/jp-journals-10081-1474
Pediatric Infectious Disease
Volume 7 | Issue 2 | Year 2025

Lifelong Learning in Pediatrics

Vikram S Kumarhttps://orcid.org/0000-0002-1369-7682

Department of Pediatrics, Subbaiah Medical College, Shivamogga, Karnataka, India

Corresponding Author: Vikram S Kumar, Department of Pediatrics, Subbaiah Medical College, Shivamogga, Karnataka, India, Phone: +91 9241495056, e-mail: vikramskumar@yahoo.co.in

How to cite this article: Kumar VS. Lifelong Learning in Pediatrics. Pediatr Inf Dis 2025;7(2):72–76.

1. Mass Azithromycin Distribution and its Impact on Pediatric Respiratory Pathogens: Implications for High-mortality and Resource-limited Settings

This study examines the impact of biannual mass azithromycin distribution on respiratory pathogens in children from Niger, focusing on its potential role in reducing vaccine-preventable infections. The findings suggest that azithromycin treatment significantly reduces the prevalence of Bordetella pertussis and Haemophilus influenzae type b (Hib) in symptomatic children, with these pathogens detected in approximately 16 and 7% of cases in placebo-treated communities, compared to 8 and 3% in azithromycin-treated communities. Since B. pertussis and Hib are rarely carried asymptomatically, their reduction in nasopharyngeal samples suggests a direct protective effect against these severe respiratory infections.

The high prevalence of B. pertussis observed aligns with prior reports from Niger, where pertussis has been documented even among fully vaccinated children. The study also notes that Hib, which can cause both respiratory illness and meningitis, was significantly reduced in azithromycin-treated communities, reinforcing earlier findings from verbal autopsy studies that suggested a decrease in meningitis-related deaths. These results raise important questions about vaccine coverage and efficacy in high-mortality settings and suggest that mass azithromycin distribution may provide an additional protective layer for under-vaccinated or vaccine-nonresponsive children.

Interestingly, no significant reduction was found for Streptococcus pneumoniae or non-Hib H. influenzae, both of which are common nasopharyngeal colonizers. The absence of effect could be due to high background carriage rates or rapid reinfection posttreatment. Similarly, viral pathogen prevalence remained largely unchanged, apart from a slight increase in respiratory syncytial virus (RSV) and cytomegalovirus (CMV), the reasons for which remain unclear but could involve pathogen replacement dynamics.

Despite its strengths, the study has notable limitations. Since it only included symptomatic children presenting at health centers, it does not provide incidence estimates of respiratory infections in the broader population. Additionally, data on individual vaccine status and prior azithromycin exposure were not available, limiting the ability to assess interactions between antibiotic treatment and immunization. Furthermore, the absence of baseline pathogen prevalence data before azithromycin distribution makes it difficult to determine preintervention levels of these infections.

These findings have significant implications for child health interventions in high-mortality settings. The observed reductions in B. pertussis and Hib suggest that mass azithromycin distribution could complement existing vaccination programs, particularly in areas with suboptimal vaccine uptake. Given pertussis’ high mortality in infants and the known burden of Hib-related diseases, these results support further investigation into how azithromycin might be integrated into broader child survival strategies. Future research should explore vaccine coverage in these communities, assess the long-term sustainability of pathogen reductions, and determine whether azithromycin influences antibiotic resistance patterns or microbiome composition in treated populations.

India, with its diverse healthcare landscape, high burden of respiratory infections, and varying vaccine coverage across states, presents a unique context where findings from this study could hold significant relevance. While mass azithromycin distribution has shown a protective effect against B. pertussis and Hib in Niger, similar challenges exist in many parts of India, particularly in rural and tribal regions where immunization rates remain suboptimal and access to healthcare is limited.

Pertussis outbreaks still occur in certain regions despite widespread vaccination efforts, and Hib-related pneumonia and meningitis remain important contributors to childhood morbidity and mortality. Given the evidence that biannual azithromycin administration may reduce these infections, its potential as a supplementary intervention, especially in areas with low vaccine penetration, warrants further exploration in the Indian context.

Liu J, Brennhofer SA, Zhang J, et al. Effect of biannual azithromycin on respiratory pathogens among symptomatic children: results from the randomised Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) I trial. BMJ Glob Health 2025;10(2):e016043. DOI: 10.1136/bmjgh-2024-016043

2. Post-infectious Anorexia Nervosa: A Novel Perspective on Autoimmune and Inflammatory Triggers in Eating Disorders

This study sheds light on the intriguing but underexplored relationship between infections and the abrupt onset or exacerbation of anorexia nervosa (AN), with a focus on potential autoimmune and inflammatory mechanisms. While previous research has suggested links between infections and neuropsychiatric disorders under the pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) framework, evidence regarding AN remains sparse, contradictory, and largely based on case reports.

A key finding of this review is the considerable variability in clinical presentations, psychometric assessments, and serological markers across the limited cases reported. While some patients exhibit a clear infectious trigger preceding eating disorder onset, others present with a more ambiguous history. This heterogeneity challenges the hypothesis of a distinct postinfectious anorexia phenotype and suggests that infections may act as a precipitating, rather than primary, factor in certain cases.

A major limitation in the current body of literature is the predominant focus on pediatric cases, despite the peak onset of AN occurring in mid-to-late adolescence. The inclusion of a late-adolescent case in this study adds to the novelty of the findings and suggests that the role of infections in eating disorders may extend beyond childhood. The case’s rapid and favorable course further differentiates it from classical AN, raising the possibility of a unique subset of postinfectious eating disorders with distinct prognosis and treatment implications.

From a broader perspective, this study aligns with growing interest in the intersection of autoimmunity, neuroinflammation, and psychiatric disorders. Emerging genetic evidence suggests a weak but notable link between autoimmune diseases and AN, paralleling research in neurodevelopmental and mood disorders. Additionally, the neuroimmune disturbances observed in long-COVID provide a contemporary framework for investigating the impact of infections on psychiatric and behavioral health.

In India, where infections such as streptococcal pharyngitis, gastrointestinal infections, and postviral syndromes are highly prevalent, understanding their potential neuropsychiatric consequences is crucial. Cultural perceptions of weight and diet, coupled with underdiagnosis of eating disorders, make it particularly challenging to identify atypical presentations of AN. Moreover, access to advanced immunological testing, such as anti-neuronal antibodies or inflammatory biomarkers, remains limited in most settings, complicating research efforts into autoimmune-driven psychiatric conditions.

Given India’s heterogeneity in healthcare infrastructure, dietary practices, and genetic predispositions, further research is essential to explore whether postinfectious AN follows a similar trajectory across diverse populations. Standardized diagnostic protocols—including routine infection screening in patients with abrupt eating restriction—could offer new insights into disease mechanisms and inform treatment strategies. Collaborative studies integrating psychiatry, immunology, and infectious disease research would be particularly valuable in expanding the scope of AN pathophysiology beyond the conventional psychosocial and genetic models.

While the current evidence base remains inconclusive, this study highlights the need for a standardized, interdisciplinary approach to investigating postinfectious AN. Recognizing infections as potential contributors to eating disorder pathogenesis may open new avenues for diagnosis and treatment, ultimately improving outcomes for patients with atypical or rapid-onset restrictive eating behaviors.

Raffaele L, Cristina T, Serena R, et al. Abrupt onset or exacerbation of anorexia nervosa following recent infections: a mini-review and a case report with an atypical manifestation of PANS. Eat Weight Disord 2025;30(1):13. DOI: 10.1007/s40519-025-01721-8

3. Evaluating the Efficacy of a Reduced 1 + 1 Pneumococcal Conjugate Vaccine Schedule: Implications for Cost-effective Immunization Strategies

This study provides compelling evidence supporting a transition from the conventional 2 + 1 pneumococcal conjugate vaccine (PCV) schedule to a reduced 1 + 1 dosing schedule without compromising immunogenicity. Findings demonstrate that serotype-specific immunoglobulin G (IgG) levels and nasopharyngeal colonization patterns remain comparable between children receiving a single primary dose and those receiving two doses, reinforcing the feasibility of dose reduction in routine immunization programs.

A single-center, open-label, randomized trial conducted in Soweto, South Africa, evaluated the immunogenicity of different PCV10 and PCV13 dosing schedules in 600 children randomized into six study arms. The study aimed to determine whether the 1 + 1 schedule was noninferior to the 2 + 1 schedule based on geometric mean concentrations (GMCs) for vaccine serotypes.

The United Kingdom’s transition to a 1 + 1 PCV schedule in 2020 serves as a precedent, with recent analyses showing no significant differences in invasive pneumococcal disease (IPD) incidence, serotype distribution, clinical outcomes, or case-fatality rates between cohorts vaccinated under the two schedules. However, given the disruptions in pneumococcal transmission during the COVID-19 pandemic, long-term surveillance remains essential to assess the durability of protection.

Additionally, as higher-valency PCVs (e.g., PCV15, PCV20) are introduced, further studies will be required to evaluate the optimal dosing schedule for expanded serotype coverage. Previous data from South Africa and the UK suggest that some serotypes (e.g., 1 and 19F) may exhibit stronger immunogenicity under a 1 + 1 schedule, whereas others (e.g., 4, 6B, 23F) may have slightly reduced responses.

In India, where childhood pneumonia remains a major cause of morbidity and mortality, optimizing vaccine schedules is essential for improving coverage while ensuring cost-effectiveness. The PCV program in India currently follows a 2 + 1 schedule, which places a financial strain on public health resources. A transition to a 1 + 1 schedule could reduce vaccine procurement costs and improve compliance by minimizing the number of injections, a critical factor in a country with diverse healthcare accessibility.

However, given the heterogeneity in pneumococcal serotype prevalence across different regions of India, additional research is needed to assess whether a single-dose primary series provides adequate protection in high-burden areas. Surveillance of serotype replacement, breakthrough infections, and long-term immune responses will be crucial before implementing a nationwide transition.

India’s immunization program has expanded PCV coverage through Gavi support, but as the country moves toward self-financing, a cost-effective 1 + 1 schedule could enhance sustainability. Real-world data from diverse regions, along with modeling studies assessing serotype-specific immunity, will be critical in guiding policy decisions. If found effective, a reduced-dose schedule could free up resources for expanding immunization programs to include newer vaccines and addressing other pediatric infectious disease priorities.

The results from this study, along with data from South Africa and the UK, support the case for transitioning to a single priming dose of PCV followed by a booster in settings with well-established vaccination programs. This shift could reduce the number of vaccine injections, lower program costs, and maintain high levels of protection against pneumococcal disease. However, ongoing surveillance and further research on newer PCVs are necessary before large-scale implementation, particularly in regions with high pneumococcal transmission and serotype diversity such as India.

Izu A, Mutsaerts EA, Olwagen C, et al. Serotype-specific serum immunoglobulin G at 18 months of age following one or two doses of a primary series of 10-valent or 13-valent pneumococcal conjugate vaccine and a booster dose at nine months of age: a randomized controlled study. Expert Rev Vaccines 2025;24(1):121–127. DOI: 10.1080/14760584.2025.2458179

4. Optimizing Pediatric and Adolescent Multidrug-resistant/Rifampicin-resistant Tuberculosis Care: Largest Individual Participant Data Meta-analysis to Date

This individual participant data meta-analysis, the largest of its kind, synthesizes data from over 20,000 children and adolescents with multidrug-resistant (MDR) and rifampicin-resistant (RR) tuberculosis globally. It builds upon a 2014 meta-analysis that included only 1,009 children and lacked data on newer treatment regimens. Since then, the MDR/RR tuberculosis treatment landscape has evolved, with improved access to novel and repurposed drugs, including linezolid, clofazimine, bedaquiline, and delamanid, but pediatric data have remained limited.

One of the major advancements of this study is the inclusion of older adolescents (15–19 years), a group historically overlooked in both pediatric and adult tuberculosis trials. Most individuals in this dataset were adolescents (10–19 years), with microbiologically confirmed disease. The study provides new insights into the efficacy of priority group A drugs (fluoroquinolones, linezolid, and bedaquiline) in shorter, injectable-free regimens.

Comparison to Previous Findings

India has one of the highest burdens of pediatric MDR and RR tuberculosis globally. This study highlights several urgent priorities for India’s tuberculosis program:

Policy Implications and Future Directions

This study provides critical evidence supporting the need for tailored, child-friendly MDR/RR TB regimens and more inclusive case-finding efforts. While treatment outcomes remain better in children and adolescents than in adults, they are still below WHO’s End TB target of 90% treatment success. Rapid scale-up of optimal pediatric treatment regimens and earlier access to novel drugs are essential to achieving tuberculosis elimination goals in India and globally.

5. Procalcitonin-guided Antibiotic Stewardship: A Costly Misstep or an Overhyped Solution?

This study provides important insights into the effectiveness of a procalcitonin-guided algorithm in guiding intravenous antibiotic duration in children hospitalized with suspected or confirmed serious bacterial infections. Contrary to findings from previous studies in specific patient populations, our results indicate that procalcitonin-based decision-making did not significantly reduce antibiotic duration compared to usual care and was more costly without providing added benefits in terms of safety. These findings challenge the widespread assumption that procalcitonin can be a universally applicable tool for antibiotic stewardship in pediatric settings.

Several explanations emerge for why our findings differ from studies conducted in high-income settings with tightly defined patient groups. First, our study population was highly heterogeneous, including both critically ill children in intensive care units and those in general pediatric wards, with varied infections ranging from pneumonia to urinary tract infections to sepsis and bone or joint infections. This broad inclusion contrasts with prior studies that focused on specific high-risk groups, such as neonates with suspected early-onset sepsis, acutely ill adults, or postcardiovascular surgery patients, where procalcitonin guidance proved effective. Second, the implementation of the procalcitonin algorithm faced significant challenges, with adherence rates at just 36% at the first clinical review and 54% at any clinical review. Despite extensive clinician training and reinforcement tools such as algorithm cards and staff lanyards, there was a lack of confidence in procalcitonin as a decision-making tool, likely due to limited prior exposure to procalcitonin testing in routine pediatric practice.

Additionally, the hospitals contributing the majority of participants had well-established, consultant-led pediatric antimicrobial stewardship programs, conducting regular stewardship rounds and already following stringent evidence-based recommendations for antibiotic use. This suggests that procalcitonin may offer little added value in settings where robust antimicrobial stewardship is already in place. In contrast, studies showing benefit from procalcitonin-based decision-making were often conducted in environments with less stringent antibiotic control, where there was greater potential to shorten antibiotic duration.

The cost-effectiveness analysis further strengthens the argument against routine use of procalcitonin in pediatric antimicrobial stewardship. Not only did the intervention fail to reduce antibiotic exposure, but it also introduced additional costs without measurable clinical benefits. While previous studies in adult populations have suggested that procalcitonin guidance can lead to small but meaningful reductions in antibiotic duration and even lower mortality rates, these effects were not observed in our pediatric cohort.

Our findings have several implications for future research and clinical practice. First, they highlight the importance of careful patient selection when evaluating biomarker-driven interventions. Rather than adopting a broad, one-size-fits-all approach, future studies should aim to identify specific pediatric subgroups where procalcitonin may have the greatest impact, such as children at risk of prolonged antibiotic exposure or those with high diagnostic uncertainty. Second, improving implementation fidelity is critical. The low adherence to the procalcitonin algorithm suggests that simply introducing a biomarker test is insufficient; instead, comprehensive implementation strategies, including clinician education, decision support systems, and real-time feedback, are essential for successful integration into clinical workflows.

Furthermore, this study underscores the broader need for an adaptive and multifaceted approach to antibiotic stewardship. While biomarker-driven strategies hold promise, they should be integrated into a holistic framework that includes clinical judgment, microbiological testing, and established stewardship interventions. Future research should focus on embedding procalcitonin and other biomarkers within adaptive platform trials that allow for real-time evaluation of multiple diagnostic strategies, ensuring rapid and evidence-based implementation.

In conclusion, our results suggest that procalcitonin-guided antibiotic stewardship does not offer additional benefits over existing antimicrobial stewardship programs in hospitalized children receiving intravenous antibiotics. These findings emphasize the need for targeted, well-implemented strategies that align with real-world clinical practice rather than universal adoption of biomarker-based decision-making tools. Future research should explore the role of procalcitonin in antibiotic initiation decisions, particularly in emergency department settings, and examine whether improved implementation strategies can enhance its utility in select pediatric populations.

Waldron CA, Pallmann P, Schoenbuchner S, et al. Procalcitonin-guided duration of antibiotic treatment in children hospitalised with confirmed or suspected bacterial infection in the UK (BATCH): a pragmatic, multicentre, open-label, two-arm, individually randomised, controlled trial. Lancet Child Adolesc Health 2025;9(2):121–130. DOI: 10.1016/S2352-4642(24)00306-7

6. Levofloxacin for MDR-TB Prevention: A 60% Reduction, but at What Cost?

The pooled analysis of tuberculosis child multidrug-resistant preventive therapy (TB-CHAMP) and Vietnam household contact investigation for multidrug-resistant tuberculosis (VQUIN-MDR) trials provided a clearer picture of the potential of levofloxacin as a preventive therapy for multidrug-resistant (MDR)-TB, demonstrating a 60% relative reduction in TB incidence over one year. However, the findings raise critical questions about its long-term effectiveness, tolerability, and feasibility in routine practice. While the study confirms prior observational data suggesting that MDR-TB preventive therapy is beneficial, the limited duration of protection—primarily during the treatment phase—suggests that reinfection or incomplete clearance of latent Mycobacterium tuberculosis infection may be an issue, particularly in high-burden settings. This mirrors findings from isoniazid preventive therapy trials, where protection waned after treatment cessation.

One of the most pressing concerns remains the risk-benefit trade-off of levofloxacin, especially given its potential musculoskeletal adverse effects. While the study reported mostly mild events, musculoskeletal toxicity is a well-documented concern with fluoroquinolones. The absence of severe tendonitis or long-term effects in this analysis is reassuring, but longer follow-up is needed, especially in younger children who might be more susceptible to such side effects. Additionally, the development of fluoroquinolone-resistant bacteria due to widespread levofloxacin use remains an underexplored concern.

From an implementation perspective, the high number needed to treat (NNT) to prevent one case of TB, particularly among adults, poses logistical and economic challenges. While mathematical models suggest that widespread MDR-TB preventive therapy could substantially reduce transmission and MDR-TB prevalence, its cost-effectiveness is not yet established, especially in resource-limited settings where latent TB screening and adherence monitoring are difficult. Further, this analysis does not address whether alternative preventive strategies—such as shorter regimens or newer drugs—might offer similar or better protection with fewer side effects.

The study also highlights a critical gap in MDR-TB prevention efforts: the underrepresentation of high-risk groups such as people living with HIV. The tolerability and efficacy of levofloxacin in immunocompromised populations remain unknown, which is concerning given that people with HIV are disproportionately affected by MDR-TB. Moreover, further investigation is required to determine whether incident TB cases in the trial were due to primary infection, reinfection, or reactivation of latent MDR-TB, as this has significant implications for treatment strategies.

A key strength of this analysis was the prespecified harmonization of trial methodologies, reducing potential biases. However, the study was not powered to detect efficacy differences across subgroups, and Bayesian analyses had to contend with sparse event data, making some estimates less robust. Additionally, follow-up periods varied between the two trials, with most post-72-week data coming from VQUIN, which could introduce bias in long-term outcome assessment.

Ultimately, while this analysis strengthens the case for levofloxacin as an MDR-TB preventive therapy, it also underscores the need for more comprehensive evaluations. Future studies should explore alternative drug regimens, longer follow-up for safety monitoring, cost-effectiveness analyses, and better stratification of high-risk populations to refine MDR-TB prevention strategies.

Duong T, Brigden J, Schaaf HS, et al. A meta-analysis of levofloxacin for contacts of multidrug-resistant tuberculosis. NEJM Evid 2025;4(1):EVIDoa2400190. DOI: 10.1056/EVIDoa2400190

7. Antiretroviral Therapy and Adverse Perinatal Outcomes in Women Living with HIV: Weighing the Risks and Benefits

This systematic review and meta-analysis examined the association between antiretroviral therapy (ART) initiation and adverse perinatal outcomes in women living with HIV (WLHIV). The findings revealed that WLHIV who initiated ART either preconception or antenatally had an increased risk of preterm birth (PTB), low birth weight (LBW), very low birth weight (VLBW), small for gestational age (SGA), and very small for gestational age (VSGA) compared to HIV-negative women. Additionally, those who initiated ART preconceptionally had a higher risk of very preterm birth (VPTB) compared to women without HIV. Compared to ART-naïve WLHIV, those on ART preconception or antenatally had an increased risk of SGA and VSGA. These results are consistent with previous meta-analyses, reaffirming that ART initiation in pregnancy or before conception is linked to adverse perinatal outcomes.

While the study provides compelling evidence, the role of different ART regimens remains unclear. Prior meta-analyses have suggested that protease inhibitor (PI)-based ART is associated with an increased risk of SGA and VSGA compared to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART, but no significant differences were observed for other perinatal outcomes. Most of the studies included in this review involved women receiving NNRTI-based or mixed ART regimens, while only a small number examined integrase strand transfer inhibitor (INSTI)-based ART, the current first-line treatment. The limited data available prevented subgroup analyses based on specific ART regimens, highlighting the need for further research on the perinatal effects of different ART classes.

A major strength of this study is its large sample size, comprising 1,99,156 women across 19 countries, and its rigorous methodology, adhering to Cochrane and PRISMA guidelines. The comprehensive literature search ensured that all relevant studies were included, with most originating from low- and middle-income countries (LMICs), thereby improving the external validity of the findings. Additionally, predefined outcome definitions and multiple sensitivity analyses minimized the risk of misclassification bias and reinforced the robustness of the results.

However, the study has several limitations. As it is based on observational data rather than randomized controlled trials (RCTs), there is a risk of bias and confounding. RCTs were excluded because they typically enroll participants during pregnancy and lack comparator groups of HIV-negative or ART-naive women. The timing of ART initiation introduces potential selection bias, as women who start ART antenatally have a shorter exposure period than those who initiate it preconceptionally. This may partially explain why preconception ART initiation was associated with a slightly higher risk of PTB. Furthermore, differences in access to care and maternal health among women initiating ART at different time points could introduce additional confounding.

The underlying mechanisms driving the increased risk of adverse perinatal outcomes among WLHIV on ART remain poorly understood. HIV infection itself leads to immune dysfunction, chronic inflammation, and CD4 depletion, which may contribute to adverse pregnancy outcomes. ART may modulate these effects but has also been implicated in placental dysfunction, alterations in hormone levels, and immune imbalances that could impact fetal development. PI-based ART, in particular, has been linked to uteroplacental dysfunction, reduced progesterone levels, and hormonal disturbances, all of which correlate with poor birth outcomes.

Despite the risks, the benefits of ART in preventing vertical HIV transmission and maintaining maternal health are well established. These findings emphasize the urgent need for well-conducted prospective studies that evaluate perinatal outcomes across different ART regimens, including newer agents such as dolutegravir, raltegravir, bictegravir, and long-acting injectable cabotegravir. Future research should ensure detailed reporting on ART regimens, timing of initiation, and potential confounders to facilitate more precise risk assessments. Additionally, mechanistic studies are needed to elucidate the biological pathways linking ART to adverse birth outcomes, which could inform targeted interventions to mitigate risks while maintaining the benefits of ART for maternal and child health.

Boering P, Murray C, Portwood C, et al. Perinatal outcomes among pregnant women living with HIV initiating antiretroviral therapy preconception and antenatally: systematic review and meta-analysis. AIDS 2025. DOI: 10.1097/QAD.0000000000004104

8. Evidence and Gaps in Preventing Peripherally Inserted Central Catheter-associated Complications

This systematic review and meta-analysis provide a comprehensive evaluation of interventions aimed at preventing complications associated with peripherally inserted central catheters (PICCs), a device with a well-documented 29% complication rate. Examining 74 studies, including both randomized and nonrandomized trials, the analysis focused on 25 different interventions across a diverse patient population. Despite this breadth, evidence was conclusive for only a few interventions, underscoring the persistent gaps in knowledge regarding effective PICC management strategies.

Among the findings, ultrasound-guided catheter insertion emerged as a reliable strategy for reducing the risk of phlebitis and thrombophlebitis in adults, with a pooled risk ratio of 0.19 based on five randomized controlled trials (RCTs). Similarly, the analysis revealed that silicone catheters doubled the risk of phlebitis compared to non-silicone alternatives, further reinforcing the importance of catheter material selection in clinical practice. Additionally, bundle interventions—combinations of multiple preventive measures—demonstrated a protective effect, reducing both local infections and phlebitis/thrombophlebitis. However, for most other interventions, the certainty of evidence remained too low to draw definitive conclusions.

The predominance of studies conducted in high-income countries raises concerns about the generalizability of these findings to resource-limited settings, where factors such as infection control practices and catheter availability may differ. Additionally, over half of the included studies focused on neonates, reflecting a population at high risk for PICC-related complications but also highlighting the need for broader research encompassing other vulnerable groups.

The implications of these findings are clear: while ultrasound guidance and non-silicone catheters should be prioritized in clinical practice, substantial uncertainty remains around many other interventions. Future research must address these gaps through well-designed trials assessing multimodal prevention strategies, particularly in diverse healthcare settings. Given the widespread use of PICCs and the high burden of complications, advancing evidence-based preventive strategies remains a critical priority in patient safety and vascular access management.

Dobrescu A, Constantin AM, Pinte L, et al. Effectiveness and safety of methods to prevent bloodstream and other infections and noninfectious complications associated with peripherally inserted central catheters: a systematic review and meta-analysis. Clin Infect Dis 2025:ciaf063. DOI: 10.1093/cid/ciaf063

ORCID

Vikram S Kumar https://orcid.org/0000-0002-1369-7682

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