Short-course antimicrobials for the treatment of paediatric pneumonia

Abstract

Paediatric community-acquired pneumonia (CAP) is common in North America. It is often treated with beta-lactam antimicrobials targeting S. pneumoniae, the most important cause of CAP in young children. Current guidelines recommend 10 days of therapy for paediatric CAP, regardless of severity; in contrast, mild CAP in adults is routinely treated with only 5 days of antimicrobials. There have been no definitive studies of 5-day vs. 10-day therapy for CAP in children. The objective of this thesis was to conduct a pilot RCT comparing 5 to 10 days of amoxicillin for the treatment of mild paediatric CAP and then design the multicentre follow-up trial. Children aged 6 months - 10 years with no significant past medical history presenting to the McMaster Children's Hospital emergency department with mild CAP were eligible for enrollment. All participants were randomized to either 10 days high-dose amoxicillin (90 mg/kg/day divided bid) or 5 days of high-dose amoxicillin + 5 days placebo. The primary outcome was clinical cure at day 14-18 post-enrollment. In total, 61 participants were recruited. The median participant age was 2.64 y. Only 60% of chest radiographs were reported by the radiologist as showing evidence of pneumonia. There were six treatment failures; one participant failed to defervesce on day 4, one participant had recurrent fevers leading to re-presentation to the emergency, and the other four participants did not meet clinical cure criteria but were essentially well at the time of follow-up. Study blinding has been maintained. The majority of previously healthy children with mild CAP who are well enough to be treated as outpatients appear to do well, regardless of duration of antimicrobial treatment. Feasibility and safety of the trial protocol have been demonstrated; the follow-up multicentre trial is slated to begin in mid-2015.