In the JournalsPerspective

Narrow-spectrum agents noninferior to broad-spectrum agents for CAP

Hospitalized patients treated with narrow-spectrum antibiotics for community-acquired pneumonia had similar outcomes to children treated with broad-spectrum agents, according to recent study results published in Pediatrics.

Mary Ann Queen, MD, of the division of pediatric hospital medicine at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and colleagues evaluated medical records of 492 children aged 2 months to 18 years with a discharge diagnosis of community-acquired pneumonia (CAP) to compare the effectiveness of narrow-spectrum therapy and broad-spectrum therapy. Fifty-two percent of patients received a narrow-spectrum antibiotic and the rest received a broad-spectrum antibiotic.

The narrow-spectrum group was more likely to be aged 60 days to 2 years (P=.02) or have an abnormal white blood cell count (P=.03). The broad-spectrum group was more likely to receive antibiotics before going to the hospital (P=.002), receive macrolide antibiotics (P=.001), have a blood culture drawn (P=.001), or have a positive blood culture (P=.02).

The narrow-spectrum group was more likely to have a shorter length of hospital stay (43 hours) compared with the broad-spectrum group (49 hours). No significant differences were found between duration of oxygen, duration of fever, or readmission rate within 7 days between the two groups.

No difference in average daily standardized cost (P=.62) or average daily standardized pharmacy cost (P=.26) was found when modeled for length of stay.

“Comparative effectiveness studies can be used to support consensus recommendations, especially when randomized controlled studies are costly or infeasible,” the researchers wrote. “Our study contributes to a growing body of evidence and consensus that broad-spectrum therapy is not needed in uncomplicated CAP and patients can be safely treated with narrow-spectrum antibiotics.”

These findings support the treatment guidelines released in 2011 by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.

Mary Ann Queen, MD, can be reached at Division of Pediatric Hospital Medicine, Children's Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO 64105; email: mqueen@cmh.edu.

Disclosure: One researcher reports financial ties with the Robert Wood Johnson Foundation Clinical Scholars Fellowship Program.

Hospitalized patients treated with narrow-spectrum antibiotics for community-acquired pneumonia had similar outcomes to children treated with broad-spectrum agents, according to recent study results published in Pediatrics.

Mary Ann Queen, MD, of the division of pediatric hospital medicine at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and colleagues evaluated medical records of 492 children aged 2 months to 18 years with a discharge diagnosis of community-acquired pneumonia (CAP) to compare the effectiveness of narrow-spectrum therapy and broad-spectrum therapy. Fifty-two percent of patients received a narrow-spectrum antibiotic and the rest received a broad-spectrum antibiotic.

The narrow-spectrum group was more likely to be aged 60 days to 2 years (P=.02) or have an abnormal white blood cell count (P=.03). The broad-spectrum group was more likely to receive antibiotics before going to the hospital (P=.002), receive macrolide antibiotics (P=.001), have a blood culture drawn (P=.001), or have a positive blood culture (P=.02).

The narrow-spectrum group was more likely to have a shorter length of hospital stay (43 hours) compared with the broad-spectrum group (49 hours). No significant differences were found between duration of oxygen, duration of fever, or readmission rate within 7 days between the two groups.

No difference in average daily standardized cost (P=.62) or average daily standardized pharmacy cost (P=.26) was found when modeled for length of stay.

“Comparative effectiveness studies can be used to support consensus recommendations, especially when randomized controlled studies are costly or infeasible,” the researchers wrote. “Our study contributes to a growing body of evidence and consensus that broad-spectrum therapy is not needed in uncomplicated CAP and patients can be safely treated with narrow-spectrum antibiotics.”

These findings support the treatment guidelines released in 2011 by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.

Mary Ann Queen, MD, can be reached at Division of Pediatric Hospital Medicine, Children's Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO 64105; email: mqueen@cmh.edu.

Disclosure: One researcher reports financial ties with the Robert Wood Johnson Foundation Clinical Scholars Fellowship Program.

    Perspective
    Jason G. Newland

    Jason G. Newland

    Queen and colleagues have performed an excellent study on the use of narrow-spectrum antibiotics in the treatment of hospitalized children with community acquired pneumonia (CAP) (Pediatrics. 2013;doi:10.1542/peds.2013-1773). In 2011 the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America published a clinical practice guideline recommending the use of penicillin or ampicillin for hospitalized children with CAP. Since the publication of the guideline, this is the first large study comparing the clinical impact of this recommendation on the care of hospitalized children.
    Importantly, this study utilized a sophisticated comparative effectiveness method, propensity score matching, to answer the question on whether children treated with narrow-spectrum antibiotics (eg ampicillin) did as well or better than children treated with broad-spectrum antibiotics (eg. 2nd and 3rd generation cephalosporins). Interestingly, children treated with the narrow-spectrum antibiotics had a 10 hour shorter length of stay and their length of fever, duration of oxygen requirement, or readmission rate was no different.  
    In the era of antibiotic resistance where it has been recently determined that 23,000 Americans die annually and 2 million are infected annually with antibiotic resistant infections, this study is paramount in demonstrating to clinicians that a narrow-spectrum agent like ampicillin can be used to treat hospitalized children with CAP (www.cdc.gov/drugresistance/threat-report-2013). By avoiding broad-spectrum antibiotics in the hospital, patients are also less likely to be going home with these antibiotics. Avoiding broad-spectrum antibiotics decreases the pressure that is put on bacteria by these drugs and in turn decreases the resistance that could develop to these important therapeutic agents.

    • Jason G. Newland, MD, MEd
    • Director, Antimicrobial Stewardship Program, Children’s Mercy Hospital & Clinics

    Disclosures: Newland reports no relevant financial disclosures.