Credits
Host: Sara Dong
Guest: Michael Cosimini
Producing/Editing/Cover Art: Sara Dong
Our Guest
Michael Cosimini, MD
Michael Cosimini is an assistant professor of pediatrics at the Oregon Health and Science University with clinical interests in pediatric dermatology and infectious diseases. He is the designer of Empiric Game and an associate editor and contributor at Pediatrics Reviews and Perspectives (PedsRAP). His work focuses on educational scholarship in the areas of podcasting and serious games for medical education.
Consult Notes
Empiric Game + more!
You can find the games mentioned on the show at http://www.EmpiricGame.com (for print and play versions). You can also purchase a printed card set at https://www.drivethrucards.com/browse/pub/13729/Empiric?term=empiric.
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Microbiology/Etiologies of pediatric community acquired pneumonia (CAP)
Distinguishing CAP from other LRTI in pediatrics is difficult! There is wide variability between hospitals in diagnosis of CAP vs other lower respiratory tract infections (LRTIs) and poor interrater reliability of auscultation.
- Most kids with CAP will have positive viral testing and proving specific bugs is hard
- Most children have positive viral testing
- For typical bacteria, S.pneumoniae is important
- This is followed by S.aureus, Grp A Strep, Strep viridans and other Strep
- Then C.pneumoniae, H.influenza, and other gram negatives
- M.pneumoniae is more common in older kids (over the age of 5), but the role of treatment is less certain.
- Check out some references here:
- Jain S, Williams DJ, Arnold SR, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med. 2015;372(9):835-845. doi:10.1056/NEJMoa1405870 (S pna 5%)
- DeMuri GP, Gern JE, Eickhoff JC, Lynch SV, Wald ER. Dynamics of Bacterial Colonization With Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis During Symptomatic and Asymptomatic Viral Upper Respiratory Tract Infection. Clin Infect Dis. 2018;66(7):1045-1053. doi:10.1093/cid/cix941
- Florin TA, Ambroggio L, Brokamp C, et al. Reliability of Examination Findings in Suspected Community-Acquired Pneumonia. Pediatrics. 2017;140(3):e20170310. doi:10.1542/peds.2017-0310
- Berg AS, Inchley CS, Aase A, et al. Etiology of Pneumonia in a Pediatric Population with High Pneumococcal Vaccine Coverage: A Prospective Study. Pediatr Infect Dis J. 2016;35(3):e69-e75. doi:10.1097/INF.0000000000001009
- CDC Active Bacterial Core surveillance available here or see Strep pneumo report here
How long do we need to treat children for CAP?
Let’s start with the available guidelines:
- WHO recommendations for 3-5d in low and middle income countries, but historically high-income countries typically used 5-10d
- In the 2011 archived PIDS/IDSA guidelines, authors say 10 days have been best studied but shorter courses for mild cases probably OK
- They also say, “Antimicrobial therapy is not routinely required for preschool-aged children with CAP, because viral pathogens are responsible for the great majority of clinical disease.”
- Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25-e76. doi:10.1093/cid/cir531
- There is also a British Thoracic Society guideline, also from 2011, that says similar
- Children <2yo prob don’t need antibiotics, especially if pneumococcal vaccinated. No specific recommendation on duration
- Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax. 2011;66 Suppl 2:ii1-ii23. doi:10.1136/thoraxjnl-2011-200598
- Recent studies though have indicated that a shorter 3-5 course for nonsevere CAP would be appropriate. Check out the next section for links to some of the key trials
Evidence for shorter courses of antibiotics for pediatric CAP
There are several RCTs for <5 day antibiotic courses for outpatient pediatric CAP pneumonia in LMIC. We didn’t go over these on the podcast, but I wanted to provide some references:
- Haider BA, Saeed MA, Bhutta ZA. Short-course versus long-course antibiotic therapy for non-severe community-acquired pneumonia in children aged 2 months to 59 months. Cochrane Database Syst Rev. 2008;(2):CD005976. Published 2008 Apr 16. doi:10.1002/14651858.CD005976.pub2
- Ginsburg AS, Mvalo T, Nkwopara E, et al. Amoxicillin for 3 or 5 Days for Chest-Indrawing Pneumonia in Malawian Children. N Engl J Med. 2020;383(1):13-23. doi:10.1056/NEJMoa1912400
- Chang AB, Grimwood K. Antibiotics for Childhood Pneumonia – Do We Really Know How Long to Treat?. N Engl J Med. 2020;383(1):77-79. doi:10.1056/NEJMe2016328
Below are some papers looking at shorter courses for uncomplicated CAP in high income countries (suggesting 3-5 d courses)
- The SAFER PCT: Pernica JM, Harman S, Kam AJ, et al. Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatr. 2021;175(5):475-482. doi:10.1001/jamapediatrics.2020.6735
- Greenberg D, Givon-Lavi N, Sadaka Y, Ben-Shimol S, Bar-Ziv J, Dagan R. Short-course antibiotic treatment for community-acquired alveolar pneumonia in ambulatory children: a double-blind, randomized, placebo-controlled trial. Pediatr Infect Dis J. 2014;33(2):136-142. doi:10.1097/INF.0000000000000023
- The SCOUT-CAP RCT: Williams DJ, Creech CB, Walter EB, et al. Short- vs Standard-Course Outpatient Antibiotic Therapy for Community-Acquired Pneumonia in Children: The SCOUT-CAP Randomized Clinical Trial. JAMA Pediatr. 2022;176(3):253-261. doi:10.1001/jamapediatrics.2021.5547
- Just a quick note that the composite primary outcome in this trial was RADAR = response adjusted for duration of antibiotic risk (“composite end point that ranks each child’s clinical response, resolution of symptoms, abx-associated adverse effects in an ordinal desirability of outcome ranking (DOOR)”)
- Using RADAR/DOOR: same clinical response (with same or better adverse effects) using a shorter course of abx therapy, objectively better; yields better RADAR rank. You can read more here: Evans SR, Rubin D, Follmann D, et al. Desirability of Outcome Ranking (DOOR) and Response Adjusted for Duration of Antibiotic Risk (RADAR). Clin Infect Dis. 2015;61(5):800-806. doi:10.1093/cid/civ495
- Analysis from SCOUT-CAP RCT concluded that children receiving 5 days of beta-lactam therapy for CAP had a significantly lower abundance of antibiotic resistance determinants than those receiving standard 10-day treatment >> Pettigrew MM, Kwon J, Gent JF, et al. Comparison of the Respiratory Resistomes and Microbiota in Children Receiving Short versus Standard Course Treatment for Community-Acquired Pneumonia. mBio. 2022;13(2):e0019522. doi:10.1128/mbio.00195-22
- Just a quick note that the composite primary outcome in this trial was RADAR = response adjusted for duration of antibiotic risk (“composite end point that ranks each child’s clinical response, resolution of symptoms, abx-associated adverse effects in an ordinal desirability of outcome ranking (DOOR)”)
- The CAP-IT trial: Bielicki JA, Stöhr W, Barratt S, et al. Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia: The CAP-IT Randomized Clinical Trial [published correction appears in JAMA. 2021 Dec 7;326(21):2208]. JAMA. 2021;326(17):1713-1724. doi:10.1001/jama.2021.17843
- McCallum GB, Fong SM, Grimwood K, et al. Extended Versus Standard Antibiotic Course Duration in Children <5 Years of Age Hospitalized With Community-acquired Pneumonia in High-risk Settings: Four-week Outcomes of a Multicenter, Double-blind, Parallel, Superiority Randomized Controlled Trial [published online ahead of print, 2022 Apr 25]. Pediatr Infect Dis J. 2022;10.1097/INF.0000000000003558. doi:10.1097/INF.0000000000003558
- Ilari Kuitunen, MD, PhD, Johanna Jääskeläinen, BM, Matti Korppi, MD, PhD, Marjo Renko, MD, PhD, Antibiotic treatment duration for community acquired pneumonia in outpatient children in high-income countries – a systematic review and meta-analysis, Clinical Infectious Diseases, 2022;, ciac374, https://doi.org/10.1093/cid/ciac374
Does knowing that a child has a virus with CAP change our practice?
Michael and Sara mentioned this paper, which they both liked. All children with influenza-like illness had a respiratory viral panel done, but providers received results only ½ the time. It showed that rapid viral testing did not decrease antibiotic prescribing.
Disclosures
Our guest Michael Cosimini receives a royalty on sales of Empiric Game. Not related to this podcast or content we discussed, but Michael also receives payment for audio contributions and editorial work for PedsRap.
Febrile podcast and host report no relevant financial disclosures
Citation
Cosimini, M., Dong, S. “#44: Febrile Digest – Gotta CAP ‘Em All”. Febrile: A Cultured Podcast. https://player.captivate.fm/episode/787411f0-f7e4-403a-944b-008bb5b66434