Antibiotics for community-acquired pneumonia in children.
Author(s): Lodha R(1), Kabra SK, Pandey RM.
Affiliation(s): Author information:
(1)Department of Pediatrics, All India Institute ofMedical Sciences, Ansari Nagar,
India.
Publication date & source: 2013, Cochrane Database Syst Rev. , 6:CD004874
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 antibiotic drug therapies for
community-acquired pneumonia (CAP) of varying severity in children by comparing
various antibiotics.
SEARCH METHODS: We searched CENTRAL 2012, Issue 10; MEDLINE (1966 to October week
4, 2012); EMBASE (1990 to November 2012); CINAHL (2009 to November 2012); Web of
Science (2009 to November 2012) and LILACS (2009 to November 2012).
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 the full articles of selected studies.
MAIN RESULTS: We included 29 trials, which enrolled 14,188 children, comparing
multiple antibiotics. None compared antibiotics with placebo.Assessment of
quality of study revealed that 5 out of 29 studies were double-blind and
allocation concealment was adequate. Another 12 studies were unblinded but had
adequate allocation concealment, classifying them as good quality studies. There
was more than one study comparing co-trimoxazole with amoxycillin, oral
amoxycillin with injectable penicillin/ampicillin and chloramphenicol with
ampicillin/penicillin and studies were of good quality, suggesting the evidence
for these comparisons was of high quality compared to other comparisons.In
ambulatory settings, for treatment of World Health Organization (WHO) defined
non-severe CAP, amoxycillin compared with co-trimoxazole had similar failure
rates (odds ratio (OR) 1.18, 95% confidence interval (CI) 0.91 to 1.51) and cure
rates (OR 1.03, 95% CI 0.56 to 1.89). Three studies involved 3952 children.In
children with severe pneumonia without hypoxaemia, oral antibiotics
(amoxycillin/co-trimoxazole) compared with injectable penicillin had similar
failure rates (OR 0.84, 95% CI 0.56 to 1.24), hospitalisation rates (OR 1.13, 95%
CI 0.38 to 3.34) and relapse rates (OR 1.28, 95% CI 0.34 to 4.82). Six studies
involved 4331 children below 18 years of age.In very severe CAP, death rates were
higher in children receiving chloramphenicol compared to those receiving
penicillin/ampicillin plus gentamicin (OR 1.25, 95% CI 0.76 to 2.07). One study
involved 1116 children.
AUTHORS' CONCLUSIONS: For treatment of patients with CAP in ambulatory settings,
amoxycillin is an alternative to co-trimoxazole. With limited data on other
antibiotics, co-amoxyclavulanic acid and cefpodoxime may be alternative
second-line drugs. Children with severe pneumonia without hypoxaemia can be
treated with oral amoxycillin in an ambulatory setting. 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
co-amoxyclavulanic acid and cefuroxime. Until more studies are available, these
can be used as second-line therapies.There is a need for more studies with
radiographically confirmed pneumonia in larger patient populations and similar
methodologies to compare newer antibiotics. Recommendations in this review are
applicable to countries with high case fatalities due to pneumonia in children
without underlying morbidities and where point of care tests for identification
of aetiological agents for pneumonia are not available.
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