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]
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.