Hold the Z-Pak for Pediatric Pneumonia

Spoon Feed
Young children with community acquired pneumonia seemed to do fine with a beta-lactam antibiotic only and didn't appear to benefit from adding a macrolide.

Why does this matter?
Antibiotic resistance is a growing problem.  If we can target therapy to the narrowest spectrum possible, this will reduce the development of resistance.  Often children have a macrolide added to CAP therapy to cover for potential atypical pathogens, such as Mycoplasma.  But is this beneficial?

Hold the kiddie Z-Pak...maybe
This was an analysis of prospectively collected data, nested within the CDC Etiology of Pneumonia in the Community (EPIC) Study, including 1418 children (median age 27 months) from 3 centers with radiographically-confirmed CAP.  When comparing any beta-lactam antibiotic alone (72%) vs a beta-lactam + macrolide combination (28%), there was no advantage to adding the macrolide in decreasing length of stay or other secondary outcomes, "including intensive care admission, rehospitalizations, and self-reported recovery at follow up."  However, atypical pneumonia was rare in preschoolers, and the median age in the study was 27 months.  What made it credible for me that a beta-lactam alone was adequate was that propensity score matching also showed no advantage with the addition of a macrolide.  Also reassuring was that the subgroup aged 5 years and older and children with confirmed atypical infection had no improvement in time to discharge, suggesting that adding a macrolide was not beneficial. Finally, 70% of pneumonia cases were determined to be of viral etiology, which would have done just as well with placebo.  The take home for me is that a beta-lactam agent alone is probably all that is needed in children with routine community acquired pneumonia.

Effectiveness of β-Lactam Monotherapy vs Macrolide Combination Therapy for Children Hospitalized With Pneumonia.  JAMA Pediatr. 2017 Oct 30. doi: 10.1001/jamapediatrics.2017.3225. [Epub ahead of print]

Another Spoonful
A RCT in adults (aka CAP-START) showed that beta-lactam monotherapy, as opposed to a beta-lactam + macrolide or respiratory fluoroquinolone was not inferior.

Peer reviewed by Thomas Davis, MD.

Member Login
Welcome, (First Name)!

Forgot? Show
Log In
Enter Member Area
My Profile Sign up to get full access. Log Out