A multistate study of publicly insured children diagnosed as having pneumonia found that one in five did not receive antibiotics, researchers reported yesterday in JAMA Network Open.
But while children who didn’t receive antibiotics had slightly higher rates of treatment failure than those who did, severe outcomes were rare regardless of antibiotic treatment, the researchers found.
The study authors say their findings suggest future research should aim to identify children with pneumonia who can be safely managed without antibiotics.
A key clinical question
Most children with pneumonia are treated with antibiotics, even though pneumonia is in many cases caused by viral pathogens. As the study authors explain, that’s likely because of concerns about bacterial coinfections and a lack of published evidence that could guide clinicians on when to withhold antibiotics. But there have been no large-scale studies in the United States comparing outcomes in children with pneumonia who were treated with and without antibiotics.
To identify the frequency with which children with pneumonia in outpatient settings are treated without antibiotics, a team of US researchers analyzed data from the Merative MarketScan Medicaid database on children aged 17 years and younger who were diagnosed as having pneumonia and discharged from outpatient settings from January 1, 2017, through December 31, 2019. They defined antibiotic receipt as the presence of a claim for an antibiotic dispensation from a pharmacy on the day of the index visit or the next day. They then compared the risk of treatment failure and severe outcomes between those children who received antibiotics and those who did not.
“In this way, this study investigates a key clinical question that has not yet been thoroughly investigated—whether antibiotics are necessary in all children with pneumonia managed in an outpatient setting, in whom viruses are a common cause,” the study authors wrote.
Among the 103,854 children included in the study, the median age was 5 years, and 52.6% were boys. Overall, 83,149 children (80.3%) received antibiotics and 20,435 (19.7%) did not. Children visiting urgent care centers (88.7%) and outpatient clinics (82.7%) received antibiotics more frequently than those treated at emergency departments (74.4%). Non-Hispanic Black children received antibiotics at a lower frequency (79.0%) than non-Hispanic White children (81.7%) and Hispanic children (82.6%).
To compare outcomes between those who didn’t receive antibiotics and those who did, the researchers conducted a propensity score-matched analysis of 40,454 children (20,277 in each treatment group). Treatment failure occurred in 2,167 children (10.7%) who did not receive antibiotics and 1,766 (8.7%) who did (risk difference, 1.98 percentage points; 95% confidence interval [CI], 1.41 to 2.56). Severe outcomes occurred in 230 children (1.1%) who did not receive antibiotics and in 133 (0.7%) who did (risk difference 0.46 percentage points; 95% CI, 0.28 to 0.64).
Modest differences in treatment failure, severe outcomes
A sensitivity analysis found that the risk of treatment failure in children who did not receive antibiotics versus those who did was reduced after excluding children with asthma or bronchiolitis (9.9% vs 9.0%) and after extending the exposure window for receiving antibiotics from 0 to 1 days to 1 to 2 days (7.3% vs 7.1%).
“Together, these results suggest that most children do not experience treatment failure or severe outcomes if they do not receive antibiotics,” the authors wrote.
The authors say the limitations of the study include the fact that it involved only Medicaid-insured children, they could not distinguish visits in which antibiotics were prescribed but not dispensed from those in which antibiotics were not prescribed, and they could not confirm that antibiotics were consumed. Nonetheless, they say the findings emphasize the importance of identifying groups of children who can be safely treated without antibiotics.
“Given that this constitutes a substantial proportion of children with pneumonia, the observed differences in treatment failure were modest, and severe outcomes were rare regardless of antibiotic treatment, future research should determine which children with pneumonia can be safely and effectively treated without immediate antibiotic treatment,” they concluded.
