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Opportunities for Antibiotic Stewardship for Community-Acquired Pneumonia

July 5, 2022

When you make the diagnosis of pneumonia, how do you decide if the patient should receive antibiotics? Do you use the clinical symptoms? Chest xray (CXR) results? Other criteria?

I suspect that, if I were to ask this question to 10 pediatricians, I would get 10 different answers. That’s because there are no clear criteria.

However, a substantial proportion of children are treated with antibiotics for pneumonia, even if the CXR is normal or not performed. Many of these children probably do not need the antibiotics.

Dr. Jillian Cotter and colleagues from the University of Colorado, Lurie Children’s Hospital, and Cincinnati Children’s Hospital analyzed the prescribing practices for pediatric patients who were evaluated for suspected pneumonia and subsequently hospitalized. Their article, entitled “Factors Associated with Antibiotic Use for Children Hospitalized with Pneumonia,” and the accompanying video abstract, are being early released this week by Pediatrics (10.1542/peds.2021-054677).

The authors analyzed data from healthy children aged 3 months to 18 years who met all of the following criteria:

  • Had signs or symptoms of a lower respiratory tract infection (cough, chest pain, shortness of breath, tachypnea, or abnormal lung findings on physical exam)
  • A CXR was obtained in the emergency department (ED) and
  • Was subsequently hospitalized

Their outcome measure was receipt of antibiotics during the hospitalization (after being transferred from the ED).

For the 477 children who were included in this analysis, the most common physical exam findings were retractions (69%), fever >38.0 degrees Celsius (49%), wheezing (41%), and rhonchi (40%).  29% percent of the CXRs demonstrated radiographic pneumonia, 22% had equivocal findings (“atelectasis vs pneumonia”), and 49% were negative for pneumonia. Half (53%) of the patients received antibiotics in the ED.

During the hospitalization, 60% of patients received at least one dose of antibiotics, and 53% received a full antibiotic course. Of note, of the children with negative CXRs, 29% received at least one dose, and 21% received a full course.

Patients were more likely to receive antibiotics during their hospitalization if they had history of fever, received supplemental oxygen or had received antibiotics in the ED. Antibiotics were continued in 90% of the children who had received antibiotics in the ED.

Again, it is noteworthy that children with negative CXRs were almost 3 times more likely to receive inpatient antibiotics if they had received antibiotics in the ED.

Here is another opportunity for antibiotic stewardship! Almost one-third of children who had negative CXRs still received antibiotics. Prior research has shown that children with negative CXRs are at low risk for developing pneumonia, so these children likely do not need antibiotics.

Take a look at this article, which may change your practice! You may commit to change your default action if that is to continue antibiotics that were started by the ED. You can also work with your ED colleagues on quality improvement projects aimed at decreasing antibiotic use in this group of patients.

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