Penicillin for Pneumonia

Penicillin for Pneumonia

Infectious diseases are commonly considered when dealing with pediatric patients.  We have covered topics in this realm numerous times (I believe that this would be the 64th Morsel in the ID category).  One of the more prevalent considerations is pediatric pneumonia.

Previously, we have discussed the issues that surround making the diagnosis of pneumonia.  We have also touched on some complications and interesting pediatric findings.  Additionally, we covered the basic recommended therapies.  While the recommendations are for narrow spectrum antibiotics as 1st line (penicillin), many of us still see a lot of broad spectrum antibiotics being used, particularly for those who we admit to the hospital. While it may be fun to say “Cef-Kill-it-All,” is that the right answer for community acquired pneumonia in children?

 Community Acquired Pneumonia Basics

  • We see a lot of it – accounts for >500,000 ED visits annually!
  • Accounts for ~7% of pediatric admissions.
  • Streptococcus pneumoniae is the most common bacterial cause of community acquired pneumonia in kids.
    • Narrow spectrum beta-lactam antibiotics are still very effective against S. pneumoniae.
    • A significant amount of patients (even after published recommendations) continue to receive unnecessary broad spectrum antibiotics as initial therapy!

 

Penicillin Works Great!

  • Several recent studies (see references) support the fact that narrow spectrum antibiotics for community acquired pneumonia is an effective 1st line option.
    • Penicillin/Ampicillin/Amoxicillin treat uncomplicated community acquired pneumonia as effectively as broad spectrum agents.
    • Broad spectrum antibiotics also work, but increase risk for developing resistant organisms! (Oh, Darwin!)
  • S. pneumoniae is the primary target.
    • Narrow spectrum penicillins provide appropriate coverage for this bug!
    • S. pneumoniae can become resistant to penicillin; however, this is generally a more important consideration for CNS infections (not pneumonia).
  • This is true even for those that you are admitting to the hospital!
    • The adage “Go Big or Go Home,” does not apply to the selection of 1st line antibiotics for community acquired pneumonia!
    • Even if your patient is not going home… you still don’t need to use the “big gun.”
    • If they are not responding within 48 hours, then the decision to change therapies can be made.

     

The Therapeutic Recommendations

  • In 2011, the Pediatric Infectious Diseases Society and the Infectious Disease Society of America published guidelines for management of community acquired pneumonia.
  • OutPatient
    • Pre-School Age and Fully Immunized
      • 1st Line Therapy – Penicillin or Amoxicillin.
      • Honestly, the majority are viral pathogens.
    • School Age and Fully Immunized
      • 1st line therapy = Penicillin or Amoxicillin.
      • Consider Atypical Pathogens
  • InPatient
    • Fully Immunized Infants – School Aged Kids
      • If local epidemiologic data does not show high level of penicillin resistance, then
        • Ampicillin or Penicillin G
      • If local epidemiologic data shows high level of penicillin resistance, then
        • 3rd Generation Cephalosporin (ceftriaxone or cefotaxime)
      • Consider Macrolide for Atypical Pathogens
    • Not Fully Immunized or with Life-Threatening Infections (ex, Empyema)
      • 3rd Generation Cephalosporin (ceftriaxone or cefotaxime)
      • Vancomycin has not been shown to be more effective for empiric therapy in North America.
      • Vancomycin or Clindamycin should be consider if infection is consistent with S. aureus.

       

     

Moral of the Morsel

Obviously, selection of antibiotics for patients needs to be tailored to the specific individual patient (are they immunocompromised, do they have prior history of resistant organisms, are they not vaccinated, etc); however, the decision to admit the patient does not then mandate that the patient receive broad spectrum antibiotics.  Good old fashion penicillins are appropriate initial selections for the patient with uncomplicated community acquired pneumonia – whether admitted or discharged.

 

References

Ross RK1, Hersh AL, Kronman MP, Newland JG, Metjian TA, Localio AR, Zaoutis TE, Gerber JS. Impact of infectious diseases society of america/pediatric infectious diseases society guidelines on treatment of community-acquired pneumonia in hospitalized children. Clin Infect Dis. 2014 Mar;58(6):834-8. PMID: 24399088. [PubMed] [Read by QxMD]

Queen MA1, Myers AL, Hall M, Shah SS, Williams DJ, Auger KA, Jerardi KE, Statile AM, Tieder JS. Comparative effectiveness of empiric antibiotics for community-acquired pneumonia. Pediatrics. 2014 Jan;133(1):e23-9. PMID: 24324001. [PubMed] [Read by QxMD]

Iroh Tam PY. Approach to common bacterial infections: community-acquired pneumonia. Pediatr Clin North Am. 2013 Apr;60(2):437-53. PMID: 23481110. [PubMed] [Read by QxMD]

Williams DJ1, Hall M, Shah SS, Parikh K, Tyler A, Neuman MI, Hersh AL, Brogan TV, Blaschke AJ, Grijalva CG. Narrow vs broad-spectrum antimicrobial therapy for children hospitalized with pneumonia. Pediatrics. 2013 Nov;132(5):e1141-8. PMID: 24167170. [PubMed] [Read by QxMD]

Ambroggio L1, Taylor JA, Tabb LP, Newschaffer CJ, Evans AA, Shah SS. Comparative effectiveness of empiric β-lactam monotherapy and β-lactam-macrolide combination therapy in children hospitalized with community-acquired pneumonia. J Pediatr. 2012 Dec;161(6):1097-103. PMID: 22901738. [PubMed] [Read by QxMD]

Esposito S1, Principi N. Unsolved problems in the approach to pediatric community-acquired pneumonia. Curr Opin Infect Dis. 2012 Jun;25(3):286-91. PMID: 22421754. [PubMed] [Read by QxMD]

Bradley JS1, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH Jr, Moore MR, St Peter SD, Stockwell JA, Swanson JT, Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011 Oct;53(7):e25-76. PMID: 21880587. [PubMed] [Read by QxMD]

Bradley JS1, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH Jr, Moore MR, St Peter SD, Stockwell JA, Swanson JT, Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011 Oct;53(7):617-30. PMID: 21890766. [PubMed] [Read by QxMD]

Tsarouhas N1, Shaw KN, Hodinka RL, Bell LM. Effectiveness of intramuscular penicillin versus oral amoxicillin in the early treatment of outpatient pediatric pneumonia. Pediatr Emerg Care. 1998 Oct;14(5):338-41. PMID: 9814400. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

2 Responses

  1. July 10, 2015

    […] course, that sounds like pneumonia […]

  2. January 6, 2016

    […] week we discussed the value of the tried and trusted antibiotic, Penicillin, for pneumonia. In the past we have also mentioned Acute Rheumatic Fever and the management of Strep […]

Leave a Reply

Your email address will not be published. Required fields are marked *