Inappropriate Antibiotic Use in Children With Community-Acquired Pneumonia

Macrolides and broad-spectrum antibiotics are the most commonly prescribed antibiotics for ambulatory children with community acquired pneumonia (CAP), despite guidelines recommending the use of narrow-spectrum aminopenicillins, according to data published in The Journal of Pediatrics.

Among 252,177 Medicaid-enrolled children discharged from an ambulatory care setting with a diagnosis of CAP, the median patient age was 4 years (interquartile range [IQR], 2-7 years), 57,565 children (22.8%) had a history of asthma, and 34,104 children (13.5%) had an asthma co-diagnosis at the initial visit.

Macrolide monotherapy was prescribed in 43.2% of cases. Narrow- and broad-spectrum antibiotics were prescribed to 26.1% of children and 24.7% of children, respectively. A combination of a macrolide and narrow- or broad-spectrum antibiotic was used in 11,719 children (4.6%), and macrolide use increased with increasing age (P <.001). Investigators also observed an increase in narrow-spectrum antibiotic use from 20.1% to 31.8%, decrease in broad-spectrum antibiotic use from 28.8% to 21.2%, and decrease in macrolide monotherapy use from 45.8% to 40.5% from 2010 to 2016 (P <.001 for all trends).

In total, 1488 children (0.59%) were hospitalized and 117 children (0.05%) developed severe pneumonia. The odds of hospitalization were higher in children receiving broad-spectrum antibiotics compared to narrow-spectrum antibiotics (adjusted odds ratio [aOR], 1.34; 95% CI, 1.17-1.52) and lower for children receiving macrolide monotherapy (aOR, 0.64; 95% CI, 0.55-0.73) or macrolide plus narrow-spectrum combinations (aOR, 0.62; 95% CI, 0.39-0.97).  The odds of developing severe pneumonia was lower with macrolide monotherapy than narrow-spectrum antibiotics (aOR, 0.56; 95% CI, 0.33-0.93), but the absolute risk difference was less than 0.5% for all analyses.

Limitations of the study includes inability to generalize to all US children, use of administrative claims database that limits the analysis of clinically relevant variables, and the inability to rule out residual confounding from severity.

While the odds of subsequent hospitalization or development of severe pneumonia were lower in children receiving macrolides and broad-spectrum antibiotics, these outcomes were rare overall, investigators noted. “Broad-spectrum antibiotic agents are not associated with improved clinical outcomes, and their use should be discouraged in children with CAP treated in the outpatient setting,” investigators concluded.

Reference

Lipsett SC, Hall M, Ambroggio L, et al. Antibiotic choice and clinical outcomes in ambulatory children with community-acquired pneumonia. J Pediatr. Published online October 9, 2020. doi: 10.1016/j.jpeds.2020.10.005.