Antibiotic Use and Outcomes in Children in the Emergency Department with Suspected Pneumonia.

Author

  • Sandy Arnold, MD, MSc
  • Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN

Peer Reviewers

  • Adeline Koay, MBBS, MSc; Children’s National Hospital, Washington, DC

Background

Community-acquired pneumonia (CAP) is a common infection for which antibiotics are frequently prescribed in the inpatient and outpatient setting. Pneumonia due to respiratory viruses is more common than bacterial infections in both settings. The 2011 IDSA and PIDS Pediatric CAP guidelines recommend against routinely obtaining chest radiography and prescribing antibiotics for children with CAP not requiring hospitalization. A large randomized trial in Africa demonstrated only minimal benefit from antibiotics but these results do not translate well in high-resource settings. This study examined the effect of antibiotics on a cohort of patients presenting to the Emergency Department with CAP not requiring hospitalization.

Methods and Results

This study was a secondary analysis of a prospective cohort study of children with CAP presenting to a tertiary-care pediatric ED. Children 3 months to 18 years were included if they had suspicion of pneumonia based on clinical findings and were excluded if they had recent hospitalization, history of aspiration or complex medical conditions or if they were already receiving antibiotics. The primary exposure was receipt of antibiotics or an antibiotic prescription. The primary outcome was treatment failure defined as having a return visit with hospitalization for pneumonia within 30 days, return visit with a change in antibiotics within 30 days or parental report of a change in antibiotics by a physician before the follow up phone call 7 to 15 days after discharge. Analysis was also done adjusting for chest radiograph impression. Secondary outcomes related to quality of life (ED revisit after 30 days, days to return to normal activity, presence and duration of symptoms, and unscheduled medical care). Propensity scores were generated to estimate the probability of receiving antibiotics using clinical and demographic variables (excluding race). A group of 294 from 337 children was generated by using 1:1 nearest neighbor matching without replacement based on propensity score.

There was no statistical difference between groups in treatment failure (3.4% with and 3.4% without antibiotics, P=0.99). There was no difference between groups when adjusted for chest radiograph impression. Children who received antibiotics had a small increase in risk of delay to return to normal activity (RR 1.3) which was rendered non-significant when adjusted for chest radiograph impression. There were no differences in parent-reported symptoms or antibiotic side effects.

Critique

This observational study demonstrates no effect of antibiotics on CAP in outpatients. Treatment failure rates and quality of life measure did not differ significantly between treated and untreated groups. Confounding was controlled through propensity matching but, as you know, propensity matching cannot account for unmeasured confounders. As the authors point out, 20% of children had radiographic pneumonia and almost all of these children were in the antibiotic group biasing results toward the null. However, an RCT performed in Malawi demonstrated similar findings with minimal difference between amoxicillin and placebo (4% vs 7% treatment failure, which made placebo inferior to amoxicillin). Also, the EPIC study demonstrated that only 7% of cases of hospitalized radiographic pneumonia had typical bacterial infection.

Conclusions

The results of this observational study suggest, along with evidence from other studies, that many children with CAP not requiring hospitalization can be managed without antibiotics. This study also suggests that a relatively low proportion of children with signs and symptoms of lower respiratory tract infection have radiographic CAP and simply limiting therapy to those patients would significantly reduce prescribing for this condition.

References

  1. Antibiotic Use and Outcomes in Children in the Emergency Department with Suspected Pneumonia. Lipshaw MJ, Eckerle M, Florin TA, et al. Pediatrics 2020;145(4):e20193138.
  2. Ginsburg AS, Mvalo T, Nkwopara E, et al. Placebo vs amoxicillin for nonsevere fast-breathing pneumonia in Malawian children aged 2 to 59 months: a doubleblind, randomized clinical noninferiority trial. JAMA Pediatr. 2019;173(1):21–28.
  3. Jain S, Williams DJ, Arnold SR, et al; CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med. 2015;372(9):835–845.