The Case

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.

Clinical Question

Is five days of oral antibiotic therapy noninferior to 10 days to achieve clinical cure in children with CAP?

Background

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)
• Outcome:
  • 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

Authors’ Conclusions

“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.”