Empiric Antibiotics for Childhood CAP: Go Narrow- or Broad-Spectrum?

William T. Basco, Jr., MD, MS


April 09, 2014

Comparative Effectiveness of Empiric Antibiotics for Community-Acquired Pneumonia

Queen MA, Myers AL, Hall M, et al
Pediatrics. 2014;133:e23-e29

Study Summary

The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America published a guideline in 2011 detailing recommended treatment for children with community-acquired pneumonia (CAP).[1] As a method of improving antibiotic stewardship, the committee recommended using narrow-spectrum empirical antibiotic coverage (such as ampicillin or even penicillin G) for children with uncomplicated CAP. However, there is little prospective or even comparative data evaluating how these narrow-spectrum approaches compare with drugs such as cephalosporins, which are more typically used to treat hospitalized children with CAP.

This study used data from 4 free-standing children's hospitals in the United States. The investigators evaluated outcomes for children aged 2 months to 18 years who were hospitalized in 2010 with a diagnosis of CAP. Inclusion criteria included a diagnosis of pneumonia within the first 48 hours of hospitalization, fever or abnormal white blood cell count within the first 48 hours, evidence of respiratory symptoms, and a positive chest radiograph. Children with chronic medical conditions that would predispose to pneumonia or recurrent pneumonia were excluded. Patients with "complicated pneumonia" were also eliminated, such as those with moderate or large pleural effusions or abscesses, or who had pleural fluid drained.

The primary outcome of interest was length of stay in hours and the frequency of readmission within 7 days of discharge. The researchers also evaluated the duration of fever and oxygen use. The investigators defined "narrow spectrum" as initial treatment with either ampicillin, penicillin, or amoxicillin/clavulanic acid. A regimen in which a macrolide was added would also be considered narrow spectrum. The analyses controlled for fever (temperature ≥ 38°C), tachypnea, and abnormal white blood cell count. To address the nonrandom assignment of the children to the treatment group, the propensity scores were calculated to account for the unmeasured factors that correlate with a patient being treated with either narrow-spectrum or broad-spectrum antibiotics. Propensity scores are designed to limit the bias that might be associated with the nonrandom assignment and allow the investigator to better assess the true contribution of the treatment rather than the unmeasured factors that correlate with treatment group choice by the practitioners.


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