SGEM#338: Are Children with CAP Safe and Sound if Treated for 5d Rather than 10d of Antibiotics?

Date: July 14th, 2021 Reference: Pernica et al. Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatr. 2021. Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder of website lead of Don’t Forget the Bubbles (DFTB). When not drinking coffee and reading Batman comics he is playing with his children. Case: Six-year-old Morten comes into your emergency department (ED) with what looks like pneumonia.  He has been febrile with a temp of 39 degrees Celsius, he is mildly tachypneic but shows no real signs of respiratory distress and you can hear some crackles in the right mid-zone.  His chest X-ray (CXR) confirms your findings, but he is well enough to be treated as an outpatient. Background: It is hard to believe we have not covered the common condition of pediatric community acquired pneumonia (CAP) on the SGEM. Perhaps it is because there is limited evidence on this common condition. However, we have covered other pediatric infectious issues like: Honey for Cough SGEM#26 Fever Fear SGEM#95 Lumbar Punctures SGEM#296 Bronchiolitis SGEM#228 Invasive Bacterial Infection SGEM#334 We do have high-quality evidence that a CXR is not necessary to confirm the diagnosis of CAP in patients who are well enough to be managed as outpatients. There is also high-quality evidence that pre-school children do not routinely need antibiotics. This is because most  pneumonias in this age-group are caused by viral pathogens (Bradley et al 2011). Antibiotics are recommended for school age children diagnosed with CAP. However, how long should they be treated is an open question. The IDSA guidelines provide a strong recommendations based on moderate quality of evidence to guide our care. (Bradley et al 2011). Treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for more mild disease managed on an outpatient basis. (strong recommendation; moderate-quality evidence) There is an RCT reporting five days of amoxicillin (80mg/kg divided TID) was non-inferior to ten days for CAP in children six months to 59 months of age (Greenberg et al 2014). This was a relatively small study (n=115) from Israel. A short course (five days) has also been recommended by the American Thoracic Society and the IDSA for adults with CAP under certain conditions (Metlay et al 2019). We recommend that the duration of antibiotic therapy should be guided by a validated measure of clinical stability (resolution of vital sign abnormalities [heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature], ability to eat, and normal mentation), and antibiotic therapy should be continued until the patient achieves stability and for no less than a total of 5 days (strong recommendation, moderate quality of evidence). Clinical Question: Is a five day course of antibiotic therapy non-inferior to a ten day course to achieve clinical cure for paediatric community-acquired pneumonia? Reference: Pernica et al. Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatr. 2021 Population: Children aged six months to ten years of age diagnosed with community acquired pneumonia (CAP) who are well enough to be treated as an outpatient. CAP was defined as fever (rectal, oral or axillary in 48 hours before presentation), tachypnea (based on age, accessory muscle use or auscultation findings), CXR, or primary diagnosis by the ED physician. Exclusions: Empyema or necrotizing pneumonia, preexisting pulmonary disease, congenital heart disease, history of aspiration, malignant neoplasm, immunodeficiency, kidney disfunction, on beta-lactam antibiotics for >24hrs at presentation,