Testing and Antibiotic Use in Children With Community-Acquired Pneumonia

Child coughing sick in bed
Child coughing sick in bed
Despite national guideline recommendations and the high prevalence of viral etiology of CAP in children, the use of antibiotics remains high.

Despite national guideline recommendations and the high prevalence of viral etiology of community-acquired pneumonia (CAP) in children, the use of, primarily broad spectrum, antibiotics remains high, and further, healthcare providers frequently use testing that do not affect outcomes, according to a study published in the Journal of the Pediatric Infectious Diseases Society.

Researchers of this cross-sectional study identified children from age 1 to <6 years with CAP using data from 2 nationally representative surveys of outpatient clinic visits and emergency departments (EDs): the 2008-2015 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Over this 8-year period, 601 children representing approximately 6.3 million pediatric visits for CAP (95% CI, 5.3-7.4 million) were included. The median age of these children was 1.7 years (interquartile range 1.0-3.2 years), 55.1% were boys (95% CI, 47.8%-62.4%), 68.9% were white (95% CI, 62.1%-75.7%), and 41.1% were publicly insured (95% CI, 33.3%-48.9%). ED visits accounted for 34.9% of the included cases (95% CI, 28.8%-41%), and 65.1% were clinic visits (95% CI, 59%-71.2%). No significant differences in demographics were found in the study populations.

Among the study cohort,  complete blood count (CBC) was ordered in 8.6% of visits (95% CI, 6.1%-11.1%), blood culture in 11.1% (95% CI, 7.4%-14.8%), a chest radiography (CXR) was performed in 43% (95% CI, 36%-50%), and antibiotics were prescribed in 73.9% (95% CI, 67.1%-80.7%), with most common agent identified as second-line broad-spectrum antibiotics (ie, cephalosporins, macrolides). The Pediatric Infectious Diseases Society/Infectious Diseases Society of America 2011 pediatric CAP guidelines recommend against routinely obtaining CBC or blood cultures, performing CXR, and providing antimicrobial therapy in preschool-aged children treated as outpatients. Between the preguideline and postguideline periods, no differences in CBC, blood culture, CXR, and antibiotic orders were found overall or according to antibiotic class.

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Results also demonstrated that CXR and CBCs more frequently ordered in the ED setting, compared with clinics, but no significant differences in antibiotic use or class were found according to setting. Over the course of the study, no change was found in the percentage of children with CAP for whom a CXR (P =.73), CBC (P =.76), blood culture (P =.23), any antibiotic (P =.13), or a narrow-spectrum antibiotic (P =.88) was ordered according to year.

Study investigators concluded, “Despite the high prevalence of viral infection in young children with CAP, the use of antibiotics (mostly broad spectrum) remained high, inconsistent with national guideline recommendations. In addition, testing that does not routinely change outcomes is used frequently. Effective interventions are needed to decrease potentially unnecessary diagnostic testing and treatment.”


Florin TA, Byczkowski T, Gerber JS, Ruddy R, Kuppermann N. Diagnostic testing and antibiotic use in young children with community-acquired pneumonia in the United States, 2008–2015 [published online May 20, 2019]. J Pediatric Infect Dis Soc. doi: 10.1093/jpids/piz026