Antibiotics for Pediatric CAP: Narrow- or Broad-Spectrum?
Data were obtained from 492 children, 42% of whom were aged 2 months to 2 years. Another 56% were in the 2- to12-year-old range, leaving only 2% of the children aged 12 years and older. The sample was 54.7% white, non-Hispanic; 16.3% non-Hispanic black; 10.8% Hispanic; and 3% Asian. At enrollment, 45% of the children had a fever, 22% had tachypnea, 36% had abnormal serum white blood cell counts, and 26% had bronchiolitis. Before admission, 24% had been on antibiotics, and 18% of children were treated with macrolides in addition to their initial antibiotic choice.
Despite the nonrandom assignment, the groups were similar on many clinical characteristics. However, the children who received broad-spectrum treatments were more likely to have had a blood culture obtained, more likely to have been treated with a macrolide as well as their original treatment drug, more than 50% more likely to have received antibiotics before admission, and slightly older than the cohort who received narrow-spectrum treatment. In the adjusted outcomes, the children who received narrow-spectrum antibiotics did just as well as those who received broad-spectrum antibiotics. In fact, their length of stay was almost 10 hours shorter (43 hours vs 52.3 hours). The duration of supplemental oxygen use was lower in the broad-spectrum-treated children, as was the duration of fever, but those differences did not reach statistical significance. The frequency of readmission did not differ between the 2 groups.
Queen and colleagues conclude that the narrow-spectrum approach to treating CAP is not inferior to broad-spectrum coverage. They comment that only 33% of the children overall received narrow-spectrum antibiotics, suggesting that many more children are eligible to receive narrow-spectrum therapy.
The investigators are correct that this study is unique in its comparison of 2 groups of children with CAP who receive very different antibiotic regimens. These findings support the 2011 guideline recommendations to use narrow-spectrum antibiotics for CAP, but I suspect that many clinicians would still rather see randomized data. Queen and colleagues admit that there are probably many unmeasured factors that go into the initial antibiotic selection, so it is unlikely that they were able to remove all selection bias from the group assignment. Nevertheless, the data do suggest that significant numbers of patients with CAP can be safely and effectively treated with narrow-spectrum regimens. The secret for implementing this approach is very careful selection of children so as not to improperly treat children with chronic conditions or other scenarios that would warrant broad-spectrum coverage.
Abstract
Study Findings
Data were obtained from 492 children, 42% of whom were aged 2 months to 2 years. Another 56% were in the 2- to12-year-old range, leaving only 2% of the children aged 12 years and older. The sample was 54.7% white, non-Hispanic; 16.3% non-Hispanic black; 10.8% Hispanic; and 3% Asian. At enrollment, 45% of the children had a fever, 22% had tachypnea, 36% had abnormal serum white blood cell counts, and 26% had bronchiolitis. Before admission, 24% had been on antibiotics, and 18% of children were treated with macrolides in addition to their initial antibiotic choice.
Despite the nonrandom assignment, the groups were similar on many clinical characteristics. However, the children who received broad-spectrum treatments were more likely to have had a blood culture obtained, more likely to have been treated with a macrolide as well as their original treatment drug, more than 50% more likely to have received antibiotics before admission, and slightly older than the cohort who received narrow-spectrum treatment. In the adjusted outcomes, the children who received narrow-spectrum antibiotics did just as well as those who received broad-spectrum antibiotics. In fact, their length of stay was almost 10 hours shorter (43 hours vs 52.3 hours). The duration of supplemental oxygen use was lower in the broad-spectrum-treated children, as was the duration of fever, but those differences did not reach statistical significance. The frequency of readmission did not differ between the 2 groups.
Queen and colleagues conclude that the narrow-spectrum approach to treating CAP is not inferior to broad-spectrum coverage. They comment that only 33% of the children overall received narrow-spectrum antibiotics, suggesting that many more children are eligible to receive narrow-spectrum therapy.
Viewpoint
The investigators are correct that this study is unique in its comparison of 2 groups of children with CAP who receive very different antibiotic regimens. These findings support the 2011 guideline recommendations to use narrow-spectrum antibiotics for CAP, but I suspect that many clinicians would still rather see randomized data. Queen and colleagues admit that there are probably many unmeasured factors that go into the initial antibiotic selection, so it is unlikely that they were able to remove all selection bias from the group assignment. Nevertheless, the data do suggest that significant numbers of patients with CAP can be safely and effectively treated with narrow-spectrum regimens. The secret for implementing this approach is very careful selection of children so as not to improperly treat children with chronic conditions or other scenarios that would warrant broad-spectrum coverage.
Abstract