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.
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]
Narrow-spectrum antibiotics are recommended as the first-line agent for children hospitalized with community-acquired pneumonia (CAP). There is little scientific evidence to support that this consensus-based recommendation is as effective as the more commonly used broad-spectrum antibiotics. The objective was to compare the effectiveness of empiric treatment with narrow-spectrum therapy versus broad-spectrum therapy for children hospitalized with […]
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]
Community-acquired pneumonia (CAP) occurs more often in early childhood than at almost any other age. Many microorganisms are associated with pneumonia, but individual pathogens are difficult to identify, which poses problems in antibiotic management. This article reviews the common as well as new, emerging pathogens, as well as the guidelines for management of pediatric CAP. Current guidelines for pediatric CAP continue to recommend the use of h […]
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]
The 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America community-acquired pneumonia (CAP) guideline recommends narrow-spectrum antimicrobial therapy for most children hospitalized with CAP. However, few studies have assessed the effectiveness of this strategy. […]
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 renowned 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.
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 renowned 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.
[…] 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 […]
[…] 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 […]
[…] course, that sounds like pneumonia […]