The Association of Antibiotic Duration With Successful Treatment of Community-Acquired Pneumonia in Children

Rebecca G Same, Joe Amoah, Alice J Hsu, Adam L Hersh, Daniel J Sklansky, Sara E Cosgrove, Pranita D Tamma, Rebecca G Same, Joe Amoah, Alice J Hsu, Adam L Hersh, Daniel J Sklansky, Sara E Cosgrove, Pranita D Tamma

Abstract

Background: National guidelines recommend 10 days of antibiotics for children with community-acquired pneumonia (CAP), acknowledging that the outcomes of children hospitalized with CAP who receive shorter durations of therapy have not been evaluated.

Methods: We conducted a comparative effectiveness study of children aged ≥6 months hospitalized at The Johns Hopkins Hospital who received short-course (5-7 days) vs prolonged-course (8-14 days) antibiotic therapy for uncomplicated CAP between 2012 and 2018 using an inverse probability of treatment weighted propensity score analysis. Inclusion was limited to children with clinical and radiographic criteria consistent with CAP, as adjudicated by 2 infectious diseases physicians. Children with tracheostomies; healthcare-associated, hospital-acquired, or ventilator-associated pneumonia; loculated or moderate to large pleural effusion or pulmonary abscess; intensive care unit stay >48 hours; cystic fibrosis/bronchiectasis; severe immunosuppression; or unusual pathogens were excluded. The primary outcome was treatment failure, a composite of unanticipated emergency department visits, outpatient visits, hospital readmissions, or death (all determined to be likely attributable to bacterial pneumonia) within 30 days after completing antibiotic therapy.

Results: Four hundred and thirty-nine patients met eligibility criteria; 168 (38%) patients received short-course therapy (median, 6 days) and 271 (62%) received prolonged-course therapy (median, 10 days). Four percent of children experienced treatment failure, with no differences observed between patients who received short-course vs prolonged-course antibiotic therapy (odds ratio, 0.48; 95% confidence interval, .18-1.30).

Conclusions: A short course of antibiotic therapy (approximately 5 days) does not increase the odds of 30-day treatment failure compared with longer courses for hospitalized children with uncomplicated CAP.

Keywords: antibiotics; bacterial pneumonia; duration of therapy; pediatrics.

© The Author(s) 2020. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Figures

Figure 1.
Figure 1.
Design of a study to compare treatment outcomes in hospitalized children receiving short-course vs prolonged-course antibiotic therapy for uncomplicated CAP. Abbreviations: CAP, community-acquired pneumonia; ICD, International Classification of Diseases, Ninth Revision and Tenth Revision.
Figure 2.
Figure 2.
Histogram depicting the duration of antibiotic therapy prescribed for 439 children hospitalized for uncomplicated community-acquired pneumonia.
Figure 3.
Figure 3.
Standardized mean differences in baseline characteristics comparing the full unweighted cohort with the inverse probability of treated weighted cohort incorporating propensity scores.

References

    1. Witt WP, Weiss AJ, Elixhauser AA.. Overview of Hospital Stays for Children in the United States, 2012. HCUP Statistical Brief #187. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
    1. Gerber JS, Kronman MP, Ross RK, et al. . Identifying targets for antimicrobial stewardship in children’s hospitals. Infect Control Hosp Epidemiol 2013; 34:1252–8.
    1. Bradley JS, Byington CL, Shah SS, et al. ; Pediatric Infectious Diseases Society and the Infectious Diseases Society of America . The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011; 53:e25–76.
    1. Siegel RE, Alicea M, Lee A, Blaiklock R. Comparison of 7 versus 10 days of antibiotic therapy for hospitalized patients with uncomplicated community-acquired pneumonia: a prospective, randomized, double-blind study. Am J Ther 1999; 6:217–22.
    1. Léophonte P, Choutet P, Gaillat J, et al. . [Efficacy of a ten day course of ceftriaxone compared to a shortened five day course in the treatment of community-acquired pneumonia in hospitalized adults with risk factors]. Med Mal Infect 2002; 32:369–81.
    1. el Moussaoui R, de Borgie CA, van den Broek P, et al. . Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study. BMJ 2006; 332:1355.
    1. Uranga A, España PP, Bilbao A, et al. . Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med 2016; 176:1257–65.
    1. Dunbar LM, Khashab MM, Kahn JB, et al. . Efficacy of 750-mg, 5-day levofloxacin in the treatment of community-acquired pneumonia caused by atypical pathogens. Curr Med Res Opin 2004; 20:555–63.
    1. Dunbar LM, Wunderink RG, Habib MP, et al. . High-dose, short-course levofloxacin for community-acquired pneumonia: a new treatment paradigm. Clin Infect Dis 2003; 37:752–60.
    1. File TM Jr, Mandell LA, Tillotson G, et al. . Gemifloxacin once daily for 5 days versus 7 days for the treatment of community-acquired pneumonia: a randomized, multicentre, double-blind study. J Antimicrob Chemother 2007; 60:112–20.
    1. Li JZ, Winston LG, Moore DH, Bent S. Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis. Am J Med 2007; 120:783–90.
    1. Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, et al. . Short- versus long-course antibacterial therapy for community-acquired pneumonia: a meta-analysis. Drugs 2008; 68:1841–54.
    1. Tansarli GS, Mylonakis E. Systematic review and meta-analysis of the efficacy of short-course antibiotic treatments for community-acquired pneumonia in adults. Antimicrob Agents Chemother 2018; 62:e00635–18.
    1. Metlay JP, Waterer GW, Long AC, et al. . Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019; 200:e45–67.
    1. Tamma PD, Cosgrove SE. Duration of antibiotic therapy for community-acquired pneumonia in children. Clin Infect Dis 2012; 54:883–4; author reply 5.
    1. Hsu AJ, Tamma PD. Johns Hopkins Hospital antibiotic treatment guidelines 2019–2020. Available at: . Accessed November 24, 2019.
    1. Williams DJ, Shah SS, Myers A, et al. . Identifying pediatric community-acquired pneumonia hospitalizations: accuracy of administrative billing codes. JAMA Pediatr 2013; 167:851–8.
    1. 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; 372:835–45.
    1. Neuman MI, Hall M, Gay JC, et al. . Readmissions among children previously hospitalized with pneumonia. Pediatrics 2014; 134:100–9.
    1. Ambroggio L, Herman H, Fain E, et al. . Clinical risk factors for revisits for children with community-acquired pneumonia. Hosp Pediatr 2018; 8:718–23.
    1. Greenberg D, Givon-Lavi N, Sadaka Y, et al. . Short-course antibiotic treatment for community-acquired alveolar pneumonia in ambulatory children: a double-blind, randomized, placebo-controlled trial. Pediatr Infect Dis J 2014; 33:136–42.
    1. Interventional (Clinical Trial Identifier: NCT02891915). A Phase IV Double-Blind, Placebo-Controlled, Randomized Trial to Evaluate Short Course vs.Standard Course Outpatient Therapy of Community Acquired Pneumonia in Children (SCOUT-CAP). 2016. .
    1. Gupta S, Lodha R, Kabra SK. Antimicrobial therapy in community-acquired pneumonia in children. Curr Infect Dis Rep 2018; 20:47.
    1. Shah SN, Bachur RG, Simel DL, Neuman MI. Does this child have pneumonia?: The rational clinical examination systematic review. JAMA 2017; 318:462–71.
    1. Rambaud-Althaus C, Althaus F, Genton B, D’Acremont V. Clinical features for diagnosis of pneumonia in children younger than 5 years: a systematic review and meta-analysis. Lancet Infect Dis 2015; 15:439–50.
    1. Elemraid MA, Muller M, Spencer DA, et al. ; North East of England Paediatric Respiratory Infection Study Group . Accuracy of the interpretation of chest radiographs for the diagnosis of paediatric pneumonia. PLoS One 2014; 9:e106051.
    1. Neuman MI, Hall M, Lipsett SC, et al. . Utility of blood culture among children hospitalized with community-acquired pneumonia. Pediatrics 2017; 140:e20171013.
    1. Fritz CQ, Edwards KM, Self WH, et al. . Prevalence, risk factors, and outcomes of bacteremic pneumonia in children. Pediatrics 2019; 144:e20183090.
    1. Lipsett SC, Hall M, Ambroggio L, et al. . Predictors of bacteremia in children hospitalized with community-acquired pneumonia. Hosp Pediatr 2019; 9:770–8.
    1. Spellberg B. The new antibiotic mantra— “shorter is better.” JAMA Intern Med 2016; 176:1254–5.
    1. Wald-Dickler N, Spellberg B. Short-course antibiotic therapy-replacing Constantine units with “shorter is better.” Clin Infect Dis 2019; 69:1476–9.
    1. Vaughn VM, Flanders SA, Snyder A, et al. . Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a multihospital cohort study. Ann Intern Med 2019; 171:153–63.
    1. Amoah J, Stuart EA, Cosgrove SE, et al. . Comparing propensity score methods versus traditional regression analysis for the evaluation of observational data: a case study evaluating the treatment of gram-negative bloodstream infections [published online ahead of print February 18, 2020]. Clin Infect Dis 2020. doi:10.1093/cid/ciaa169.

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