Short-Course Antimicrobial Therapy Noninferior for Pediatric Pneumonia

Short-course antimicrobial therapy was noninferior to standard of care for treatment of pediatric community-acquired pneumonia (CAP) in an outpatient setting, a new study found.

The SAFER randomized clinical trial, published in JAMA Pediatrics, included 281 patients ages 6 months to 10 years with a primary diagnosis of pneumonia at McMaster Children’s Hospital and the Children’s Hospital of Eastern Ontario.

“The biggest takeaway is that community-acquired pneumonia in children can safely be treated with only 5 days of amoxicillin,” Jeffrey Pernica, MD, FRCPC, DTMH, head of the Division of Infectious Diseases and associate professor of pediatrics at McMaster University, told Contagion. “Over the past decade, we have learned that many common infections can be effectively cleared with many fewer days of antibiotics than were traditionally recommended -- which is good, because we have become much more aware of the harms of using antimicrobials. Overuse of antibiotics has definitely been linked to the rise of antimicrobial resistant organisms (‘superbugs’).”

Children were included in the study if they had fever within 48 hours, respiratory symptoms, chest radiography findings consistent with pneumonia as per the emergency department physician and a primary diagnosis of pneumonia.

“I was surprised to see how much variability there was in the diagnosis of ‘pneumonia’ among emergency department clinicians,” Pernica said. “I think both laypeople and doctors think that there are tests—such as chest X-rays—that clearly distinguish pneumonia from other respiratory illnesses, or bacterial from viral pneumonia, but it is not that simple.”

The 2-center, parallel-group, randomized clinical trial included a pilot study from Dec. 1, 2012, to March 31, 2014, and a follow-up study from Aug. 1, 2016, to Dec. 31, 2019.

The intervention group received 5 days of high-dose amoxicillin therapy followed by 5 days of placebo. The control group received 5 days of high-dose amoxicillin followed by a different formulation of 5 days of high-dose amoxicillin.

The primary outcome of clinical cure at 14 to 21 days was observed in 85.7% of the intervention group and 84.1% of the control group (risk difference, 0.023; 97.5% confidence limit, −0.061).

“Clinicians/HCPs should aim to prescribe fewer days of antibiotics for pediatric community-acquired pneumonia,” Pernica said. “I think it is also very important to remember that viruses commonly cause pneumonia in young children—so if fever does not go away after starting antibiotics, or fever recurs after going away, to think about viral causes (and avoid needlessly prolonging antibiotic therapy).”

The study suggests short-course therapy should be considered for treatment guidelines.

A recent study showed that children with community-acquired pneumonia often get unnecessary tests and antimicrobial therapy. It found that 74% of outpatients were prescribed antibiotics despite guidelines advising the opposite.

Evidence supports shorter courses of antibiotics, at least to adult patients, for many conditions, including for pneumonia, Sharon V. Tsay, MD, Adam L Hersh, MD, PhD, and Katherine E. Fleming-Dutra, MD, wrote in an associated editorial.

“This is welcome news to anyone who has taken antibiotics themselves or given their child an antibiotic and experienced diarrhea or a yeast infection; adverse events and effects are common, especially in children,” they noted.

The American College of Physicians recently issued best practice advice for the appropriate use of short-course antibiotics in the treatment of 4 common infections, including community-acquired pneumonia.