Different antibiotics for community-acquired pneumonia in children younger than 18 years of age in both hospital and ambulatory (outpatient) settings

Kabra SK, Lodha R, Pandey RM

Published Online:

March 17, 2010

Pneumonia is the leading cause of mortality in children under five years of age. Most cases of community-acquired pneumonia (CAP) in low-income countries are caused by bacteria. This systematic review identified 27 randomised controlled trials, enroling 11964 children, comparing antibiotics for treatment of CAP in children; most were single studies only. We found that for outpatient treatment of pneumonia, amoxycillin is an alternative treatment to co-trimoxazole. Oral amoxycillin in hospitalised children with severe pneumonia without hypoxia (decreased level of oxygen) may be effective. However, for outpatient treatment, more studies in community settings are required. For very severe pneumonia, a combination of penicillin or ampicillin and gentamycin is more effective than chloramphenicol alone.

Abstract (click to read)

Background:

Pneumonia caused by bacterial pathogens is the leading cause of mortality in children in low-income countries. Early administration of antibiotics improves outcomes.

Objectives:

To identify effective antibiotics for community acquired pneumonia (CAP) in children by comparing various antibiotics.

Search strategy:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to September 2009); and EMBASE (1990 to September 2009).

Selection criteria:

Randomised controlled trials (RCTs) in children of either sex, comparing at least two antibiotics for CAP within hospital or ambulatory (outpatient) settings.

Data collection and analysis:

Two review authors independently extracted data from full articles of selected studies.

Main results:

There were 27 studies, which enroled 11,928 children, comparing multiple antibiotics. None compared antibiotic with placebo.

For ambulatory treatment of non-severe CAP, amoxycillin compared with co-trimoxazole had similar failure rates (OR 0.92; 95% CI 0.58 to 1.47) and cure rates (OR 1.12; 95% CI 0.61 to 2.03). (Three studies involved 3952 children).

In children hospitalised with severe CAP, oral amoxycillin compared with injectable penicillin or ampicillin had similar failure rates (OR 0.95; 95% CI 0.78 to 1.15). (Three studies involved 3942 children). Relapse rates were similar in the two groups (OR 1.28; 95% CI 0.34 to 4.82).

In very severe CAP, death rates were higher in children receiving chloramphenicol compared to those receiving penicillin/ampicillin plus gentamycin (OR 1.25; 95% CI 0.76 to 2.07). (One study involved 1116 children).

Authors' conclusions:

There were many studies with different methodologies investigating multiple antibiotics. For treatment of ambulatory patients with CAP, amoxycillin is an alternative to co-trimoxazole. With limited data on other antibiotics, co-amoxyclavulanic acid and cefpodoxime may be alternative second-line drugs. For severe pneumonia without hypoxia, oral amoxycillin may be an alternative to injectable penicillin in hospitalised children; however, for ambulatory treatment of such patients with oral antibiotics, more studies in community settings are required. For children hospitalised with severe and very severe CAP, penicillin/ampicillin plus gentamycin is superior to chloramphenicol. The other alternative drugs for such patients are ceftrioxone, levofloxacin, co-amoxyclavulanic acid and cefuroxime. Until more studies are available, these can be used as a second-line therapy.

There is a need for more studies with larger patient populations and similar methodologies to compare newer antibiotics.

This record should be cited as:

Kabra SK, Lodha R, Pandey RM. Antibiotics for community-acquired pneumonia in children. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD004874. DOI: 10.1002/14651858.CD004874.pub3

Assessed as up to date:

September 18, 2009

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Primary Review Group:

Acute Respiratory Infections Group

Health topics:

Infectious disease > Respiratory infections > Pneumonia

Lungs & airways > Respiratory infections > Pneumonia

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Independent high-quality evidence for health care decision making

Different antibiotics for community-acquired pneumonia in children younger than 18 years of age in both hospital and ambulatory (outpatient) settings

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