A 5-year-old girl comes into your emergency department with what seems like community-acquired pneumonia (CAP). She has been febrile with a temp of 102° F and is mildly tachypneic but shows no real signs of respiratory distress. On examination, you can hear some crackles in the right mid-zone. Her chest X-ray (CXR) confirms your findings of CAP, and she is well enough to be treated as an outpatient with oral antibiotics.
Explore This IssueACEP Now: Vol 40 – No 09 – September 2021
Is five days of oral antibiotic therapy noninferior to 10 days to achieve clinical cure in children with CAP?
Pediatric CAP is a common occurrence.1,2 The Infectious Diseases Society of America (IDSA) guidelines from 2011 make several recommendations in the management of these children:3
- They do not support routinely obtaining a chest X-ray to confirm the diagnosis in CAP patients who are well enough to be managed as outpatients.
- They do not support preschool children routinely being prescribed antibiotics. This is because most of these CAPs in this age group are caused by viral pathogens.
- They do recommend antibiotics for school-age children diagnosed with CAP.
- How long school-age children should be treated for CAP is an open question. The guidelines provide a strong recommendation based on moderate quality of evidence that a 10-day course has been best studied, but a shorter course may be just as effective.
There is a relatively small (n=115) randomized controlled trial reporting five days of amoxicillin (80 mg/kg divided three times a day [TID]) was noninferior to 10 days for CAP in children 6 months to 59 months of age.4 A five-day course has also been recommended by the American Thoracic Society and the IDSA for adults with CAP under certain conditions.5
Reference: Pernica JM, Harman S, Kam AJ, et al. Short-course antimicrobial therapy for pediatric community-acquired pneumonia: the SAFER randomized clinical trial. JAMA Pediatr. 2021;175(5):475-482.
- Population: Children age 6 months to 10 years diagnosed with CAP who are well enough to be treated as outpatients
- Exclusions: See paper for list of exclusions
- Intervention: Five days of high-dose amoxicillin (90 mg/kg/d divided TID) followed by five days of placebo
- Comparison: 10 days of high-dose amoxicillin (90 mg/kg/d divided TID)
- Primary Outcome: Clinical cure at 14–21 days defined as meeting all three criteria: significant improvement in dyspnea and increased work of breathing, and no recorded tachypnea, at the day 14–21 follow-up visit; no more than one fever spike as a result of bacterial respiratory illness from day four up to and including the day 14–21 follow-up visit; and lack of a requirement for additional antibacterials or admission to hospital because of persistent/progressive lower respiratory illness during the two weeks after enrollment
- Secondary Outcomes: Days off school or child care, missed work days for caregivers, adverse reactions, and adherence
“Short-course antibiotic therapy appeared to be comparable to standard care for the treatment of previously healthy children with CAP not requiring hospitalization. Clinical practice guidelines should consider recommending 5 days of amoxicillin for pediatric pneumonia management in accordance with antimicrobial stewardship principles.”