Three Days of Antibiotics May Suffice for Treatment of Nonsevere Pneumonia in Children CME
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.
Release Date: April 24, 2008;Valid for credit through April 24, 2009
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Learning Objectives
Upon completion of this activity, participants will be able to:
1. Compare the efficacy of short and longer courses of antibiotics for children with community-acquired pneumonia.
2. Compare the relapse rate for short and longer courses of antibiotics in children with community-acquired pneumonia.
Authors and Disclosures
Laurie Barclay, MD
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
Désirée Lie, MD, MSEd
Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.
Brande Nicole Martin
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.
April 24, 2008 — A short course (3 days) of antibiotic therapy is equally as effective as a longer treatment (5 days) of nonsevere, community-acquired pneumonia in children, according to the results of a review published in the April 16 Cochrane Database of Systematic Reviews.
"Treatment of pneumonia requires an effective antibiotic used in adequate doses for an appropriate duration," write Batool A. Haider, from the Aga Khan University in Karachi, Pakistan, and colleagues. "Recommended duration of treatment ranges between 7 and 14 days, but this is not based on any empirical evidence. Shorter duration of therapy, if found to be effective, could be particularly important in resource-poor settings where there is a high risk of death, poor access to medicines and health care, and limited budgets for medicines."
The goal of this review was to compare the efficacy of a short vs a long course of treatment with the same antibiotic for nonsevere, community-acquired pneumonia in children 2 to 59 months of age.
The reviewers searched The Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Effects (The Cochrane Library, 2007, Issue 3), MEDLINE (OVID; January 1966 to September 2007), EMBASE (Embase.com; 1974 to September 2007), and LILACS (1982 to September 2007), looking for all randomized controlled trials (RCTs) comparing the efficacy of a short vs a long course of treatment of the same antibiotic for nonsevere, community-acquired pneumonia in children. Two reviewers independently evaluated the quality of the studies and extracted data.
There were 3 studies identified meeting inclusion criteria; these enrolled a total of 5763 children with nonsevere pneumonia. Comparing 3 days vs 5 days of treatment with the same antibiotic showed no significant differences in the rates of clinical cure at the end of treatment (relative risk [RR], 0.99; 95% confidence interval [CI], 0.97 - 1.01), treatment failure at the end of treatment (RR, 1.07; 95% CI, 0.92 - 1.25), and relapse after 7 days of clinical cure (RR, 1.09; 95% CI, 0.83 - 1.42).
There were no significant differences for these outcomes with different durations of therapy with different antibiotics, based on subgroup analysis. When data were categorized based on antibiotics used, which included amoxicillin and cotrimoxazole, the differences remained nonsignificant.
Limitations of this review include small number of studies available, lack of data on other secondary outcomes (eg, mortality rate at 1 month and additional interventions), and use of a simplified definition of pneumonia according to the World Health Organization (WHO).
"The evidence of this review suggests that a short course (three days) of antibiotic therapy is as effective as a longer treatment (five days) for non-severe pneumonia in children under five years of age," the review authors write. "However, there is a need for more well-designed RCTs to support our review findings."
Cochrane Database Syst Rev. Published online April 16, 2008.
Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:
1. Compare the efficacy of short and longer courses of antibiotics for children with community-acquired pneumonia.
2. Compare the relapse rate for short and longer courses of antibiotics in children with community-acquired pneumonia.
Clinical Context
Pneumonia causing acute lower respiratory tract infection is among the leading causes of mortality in children younger than 5 years in low-income countries, with pneumonia accounting for 18% of all child deaths. The WHO developed standard guidelines for the management of acute lower tract respiratory infections, recommending the use of oral cotrimoxazole or amoxicillin as first-line drugs to reduce mortality. In developing countries, identification of the causative bacteria or viruses is not usually attempted, and empiric treatment is based on clinical assessment. Also, the optimal duration of antibiotic treatment in children aged 2 to 59 months is still uncertain.
This is a meta-analysis of 3 studies that compared short with longer durations of antibiotics for the treatment of nonsevere community-acquired pneumonia in children aged 2 to 59 months.
Study Highlights
· Included were RCTs evaluating the efficacy of short vs long courses of amoxicillin or cotrimoxazole for nonsevere pneumonia, defined as a cough or difficulty breathing (respiratory rate of ≥ 50 in children aged 2 to 11 months or respiratory rate of ≥ 40 in those aged 12 to 59 months).
· Excluded were nonrandomized studies, patients with severe or very severe pneumonia, patients with any chronic illness, or those using antibiotics within 48 hours.
· The duration of antibiotic use varied from 3 to 7 days.
· Primary outcome was clinical cure rate, defined as return of respiratory rate to normal range.
· Secondary outcomes were treatment failure, defined as clinical symptoms or respiratory rate outside normal range on treatment completion; oxygen saturation of 90% or lower or loss of follow-up from study; relapse rate, additional interventions, and mortality rate at 1 month.
· Searching was conducted in the Cochrane, MEDLINE, EMBASE, and LILACS databases, and conference proceedings and researchers and pharmaceutical companies were contacted for unpublished trials.
· 2 authors independently reviewed the trials and assessed methodologic quality.
· Data extraction was conducted, and only 3 studies with 6210 participants were included.
· 1 trial was conducted in India in 2004 and 1 in Pakistan in 2002 (both using amoxicillin), and 1 was conducted in Indonesia and Bangladesh (using cotrimoxazole).
· The first 2 trials compared 3 vs 5 days of oral amoxicillin given 3 times daily.
· The third trial evaluated 3 vs 5 days of cotrimoxazole.
· Loss to follow-up was 5%.
· The analysis included 5763 children from the 3 studies after exclusion criteria were applied.
· Diagnosis was not confirmed by radiologic testing, and the authors commented that in previous studies, only 14% of children diagnosed with pneumonia by WHO criteria had radiologic evidence of pneumonia.
· There were no significant differences in clinical cure at first follow-up at the end of treatment (RR, 0.99; 95% CI, 0.97 - 1.01) for the short vs long courses for either antibiotic studied.
· There were no significant differences in rates of treatment failure at the end of treatment (RR, 1.07; 95% CI, 0.92 - 1.25) or rate of relapse after 7 days of clinical cure (RR, 1.09; 95% CI, 0.83 - 1.42).
· Results were similar for cotrimoxazole and amoxicillin.
· Mortality rate at 1 month could not be evaluated because it was not reported.
· There was no significant heterogeneity by dosage and frequency of antibiotics used, baseline rate of infant mortality, different durations of short and long courses of antibiotics, bacterial vs a viral cause, characteristics of the study population, or technique for diagnosing pneumonia.
· The authors concluded that the shortened course of antibiotics was similar in efficacy to that of the longer courses for community-acquired pneumonia in children.
· However, they cautioned that the WHO criteria for community-acquired pneumonia were clinical, did not include radiologic confirmation, and that diagnosis of community-acquired pneumonia may have been overestimated.
· The authors recommended well-designed larger, randomized trials to support their findings.
Pearls for Practice
· Use of 3 vs 5 days of cotrimoxazole or amoxicillin in children aged 2 to 59 months with community-acquired pneumonia is associated with similar rates of clinical cure and treatment failure.
· Use of 3 vs 5 days of cotrimoxazole or amoxicillin in children aged 2 to 59 months is associated with similar rates of relapse in children with community-acquired pneumonia.
Principio del formulario
According to the review by Haider and colleagues, which of the following outcomes is most likely to be associated with a short vs a long course of antibiotics for community-acquired pneumonia in children aged 2 to 59 months?
/ Lower rate of clinical cure
/ Similar rate of mortality
/ Similar rate of treatment failure
/ Lower rate of adverse effects
Which of the following best describes the effect of treatment duration on rate of relapse after 7 days of cure in children aged 2 to 59 months with community-acquired pneumonia?
/ Decreased rate of relapse with longer duration of cotrimoxazole
/ Decreased rate of relapse with longer duration of amoxicillin
/ Similar rate of relapse with short vs long duration for amoxicillin and cotrimoxazole
/ Similar rate of relapse with long and short duration of treatment with amoxicillin only
Final del formulario
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Target Audience
This article is intended for primary care clinicians, infectious disease specialists, public health clinicians, and other specialists who care for children with community-acquired pneumonia.
Goal
The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.
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News Author
Laurie Barclay, MD
is a freelance reviewer and writer for Medscape.
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
CME Author
Désirée Lie, MD, MSEd
Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California
Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.
Brande Nicole Martin
is the News CME editor for Medscape Medical News.
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.
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