An Antibiotic Paradox: What to Do When Children Present with ‘Pneumonia’
Antibiotics can be used to treat a litany of illnesses, but one thing they can’t combat is a viral infection.
“Researchers and physicians have started to recognize that a lot of mild pneumonia in young children is generally viral, but there are not great diagnostics for telling if a child's pneumonia is bacterial or viral, so they all generally get antibiotics ‘just in case,' " says Todd Florin, MD, MSCE, associate professor of Pediatrics in the Division of Emergency Medicine.
That “just in case” approach can bring with it a series of potential side effects, ranging from diarrhea and rashes to antimicrobial resistance and adverse drug reactions resulting in emergency department visits.
A recent cohort study published in JAMA Pediatrics led by Florin, a nationally recognized expert in the field of respiratory infectious diseases in the acute care setting, examined insurance claims of 103,854 children with pneumonia treated in an outpatient setting. The study found that treatment failure was uncommon (1 in 10 or less), and severe outcomes were rare (1 in 100 or less), regardless of whether antibiotics were received.
We were essentially able to emulate a trial of antibiotics vs no antibiotics because we were able to know if an antibiotic was picked up from the pharmacy or not, in addition to knowing if there was subsequent healthcare utilization after the initial pneumonia diagnosis.”
“These findings suggest that future efforts to identify children with pneumonia who can safely be managed without antibiotics are warranted,” says Florin. “I don't think that we were totally surprised by the results. Even though antibiotics have been considered a mainstay of treatment for decades — they were absolutely lifesaving in the pre-vaccine era when bacterial causes predominated — after widespread dissemination of the pneumococcal vaccine, the epidemiology of pneumonia has shifted, and large-scale observational studies have found higher prevalences of viruses compared with bacteria. “
In the United States, community-acquired pneumonia accounts for approximately 2 million pediatric outpatient visits annually and is among the most common causes for hospitalization, with approximately 124,000 pediatric hospitalizations, according to published research.
The study adds to a growing evidence base suggesting that many children with pneumonia can recover well without antibiotics. One innovative piece of the research was the study team’s use of claims data.
“We were essentially able to emulate a trial of antibiotics vs no antibiotics because we were able to know if an antibiotic was picked up from the pharmacy or not, in addition to knowing if there was subsequent healthcare utilization after the initial pneumonia diagnosis, based on if an insurance claim was filed.”
Florin, who is also Associate Division Head for Academic Affairs & Research for the Division of Emergency Medicine at Ann & Robert H. Lurie Children's Hospital of Chicago, believes the research results could be the result of viruses causing most illness (and thus antibiotics don't help) or simply that pneumonia diagnoses are inconsistent.
The lack of reliable diagnostic criteria for pneumonia, especially when making the diagnosis clinically without radiography, leads to many children being labeled as having pneumonia when, in fact, they have a viral lower respiratory tract infection that is not a true pneumonia. “There just are not great clinical features that are sensitive or specific for pneumonia in children,” Florin says.
“If we're giving antibiotics to children who do not need them, we're introducing harm without benefit,” says Florin. “This is why it’s important to improve our diagnostic capabilities and treatment strategies to improve our ability to maximize antibiotic use when they are needed and minimize the use when they are not.”
Written by Roger Anderson
