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Hold the Z-Pak for Pediatric Pneumonia

December 28, 2017

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.

Source
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.