Treatment of pneumonia in children – is 5 days enough?

An important Canadian multicenter, randomized, controlled, double blind study published online in the JAMA Pediatrics (PMID: 33683325) at 08 March 2021.

We all know that pneumonia is a common and important diagnosis in children, and we all understands that antibiotic treatment is needed in these cases. However, if we could tell that shorter antibiotic course is as effective as the standard 10 day course, than exposure of these children to antibiotic would be minimized. Thus, children will have less adverse effects including rashes, diarrhea, allergic reactions and antimicrobial resistance.

Objective – to determine if 5 days of antibiotic treatment (Amoxicillin) is not inferior to 10 days of treatment is selected cases of pneumonia in children.

The study took place in the emergency department of two academic tertiary children’s’ hospitals in Canada.

Which children were enrolled to the study?

Aged 6 months to 10 years.
Previously healthy children with community acquired pneumonia.
Fever recorded at home or at the hospital.
Signs of respiratory distress including any of the followings; Tachypnea, increased work of breathing or auscultatory findings.
Findings consistent with pneumonia on chest X-ray.
The child was well enough not to be hospitalized, but to be treated as outpatient.
No known penicillin allergy.

All eligible children started 5 days of high dose Amoxicillin treatment (75-100 mg/kg/day). After the first five days, half of the children continue the same treatment for 5 more days and half started 5 days of placebo.

Parents and caregivers will collect data regarding the well-being of the child in designated diaries. In addition, two telephone contact from the study team will be in touch with the family about the clinical state of the child.

Results – 281 participants, median age 2.6 (1.6-4.9) years. Outcome documentation were available for 252 children (140 children– 5 days’ treatment and 141 children – 10 days).

Clinical cure, including no requirement of additional intervention at 14 and 21 days after the enrolment was similar between the groups. Also, care work absenteeism was significantly lower in the study arm of the 5 days treatment. All other outcomes were similar between the groups.

Discussion – an important study which has important implications for our day to day practices. Due to the fact that previous (Israeli) study, with a bit different protocol, reached the same conclusions it is my routine practice to treat pneumonia for 5 days.

Two major points to remember:

I don’t think that all children, even this excellent study, had ‘true’ bacterial pneumonia. Many of the enrolled children had a virus isolation (mainly RSV, read more here), and some had isolation of another bacteria (Mycoplasma pneumonia), that is not sensitive to the treatment which was given. So, if we give 5 days or 10 days of treatment for children with viral bronchiolitis, I assume it does not make any different. This is the study’s major clinical limitation.
We should remember to choose carefully the children who would benefit from this 5 days of treatment instead of 10. The child should be previously healthy, with no severe diseases and good communication should be established with the parent in order to prevent treatment failures. From my clinical experience: when you tell the mother to treat with antibiotic for 10 days – the child gets 7 days at most. So, before prescribing a 5 days course for ‘true’ bacterial pneumonia, make sure the child gets the full 5 days…

So, 5 days of Amoxicillin is as good as 10 days of treatment in selected children with pneumonia. Just, remember to choose the patient carefully…

And If you want to know more of pneumonia in children, a dedicated chapter is waiting for you here.

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