CAP-IT RCT | Low vs High and 3 vs 7 Days for Pediatric Pneumonia

December 15, 2021

Essentials of Emergency Medicine Education Fellowship

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Written by Vivian Lei

Spoon Feed
Outpatient treatment of community-acquired pneumonia (CAP) in children with a lower dose of amoxicillin was noninferior to traditional high-dose amoxicillin, and 3-days of antibiotics was noninferior to 7-days with regard to need for antibiotic retreatment within a month.

Why does this matter?
While most cases of pediatric pneumonia are viral, it remains difficult to distinguish which children diagnosed with CAP require antibiotics. As a result, amoxicillin will still be prescribed quite a bit for CAP in young children, and earlier studies like the SAFER trial suggest that a shorter duration of treatment is as effective. This study sheds further light on how we might balance antibiotic efficacy while limiting unnecessary exposure that can lead to unwanted side effects and antimicrobial resistance by reducing both dose and duration of amoxicillin treatment for CAP. 

Antibiotics for pediatric pneumonia: Should we CAP-IT at a lower dose for 3 days?
In this 2 x 2 multicenter RCT, 814 children who required amoxicillin for community-acquired pneumonia were randomized to receive either 35-50 mg/kg/d or 70-90 mg/kg/d of amoxicillin for a treatment duration of 3 or 7 days. The primary endpoint of retreatment with antibiotics within 28 days was required in 12.6 % of children receiving the lower dose of amoxicillin compared with 12.4% of those receiving a higher dose. Retreatment occurred in 12.5% of both the 3-day and 7-day treatment duration groups. Secondary outcomes, including multiple markers of symptom resolution, did not differ significantly between treatment groups. Cough persisted slightly longer in those treated for 3 days as opposed to 7 days. This trial only included children who were discharged with a diagnosis of CAP from the ED or hospital within 48 hours and does not inform decisions to treat children with more severe disease or underlying comorbidities who may require higher dose or longer treatment. Local epidemiology may also differ in terms of prevalence of pneumococcal penicillin resistance. However, for the typical well appearing child with pneumonia who can be discharged from the ED, a shorter course of amoxicillin seems very reasonable, and I will now consider lowering the dose as well.

Source
Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia: The CAP-IT Randomized Clinical Trial. JAMA. 2021 Nov 2;326(17):1713-1724. doi: 10.1001/jama.2021.17843.

Special thanks to Charlotte Brown for pointing this article out to me. ~Clay