Antibiotic trials for community-acquired pneumonia

Short-course versus long-course intravenous therapy with the same antibiotic for severe community-acquired pneumonia in children aged two months to 59 months

BACKGROUND

Pneumonia is a leading cause of childhood mortality from infectious disease, responsible for an estimated 1.3 million deaths annually in children under five years of age, many of which are in low-income countries. The World Health Organization recommends intravenous antibiotics for five days as first-line treatment for children with severe pneumonia. Although controversy exists regarding the specific clinical features used to diagnose pneumonia, the criteria for diagnosis of severe pneumonia are better defined and are widely used to triage children for referral and second-line therapy.In 2011 it was estimated that approximately 120 million new cases of pneumonia occur globally each year in children under five years of age, of which 14 million become severe episodes. Hospitalisation for severe pneumonia in children places a significant burden on both patients and their families, including substantial expense, loss of routine, and decrease in quality of life. By reducing the duration of hospital treatment, healthcare burdens could potentially be reduced and treatment compliance may improve.This is an update of a review published in 2015.

OBJECTIVES

To evaluate the efficacy of short-course (two to three days) versus long-course (five days) intravenous therapy (alone or in combination with oral antibiotics) with the same antibiotic for severe community-acquired pneumonia in children aged two months to 59 months.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 12), MEDLINE (1966 to December week 3, 2016), Embase (1974 to 22 December 2016), and four trials registers (23 August 2017), together with reference checking of all relevant trials and reviews.

SELECTION CRITERIA

Randomised controlled trials evaluating the efficacy of short-course (two to three days) versus long-course (five days) intravenous antibiotic therapy (alone or in combination with oral antibiotics) for severe pneumonia in children aged two months to 59 months. We excluded children with any other debilitating disease, including those infected with HIV. We also excluded children who had developed pneumonia during their hospital stay (i.e. with nosocomial infection). There was no restriction on the type of antibiotic used, the dose, or the frequency of dosing.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Our searches identified 4295 records, however no studies met our predefined inclusion criteria.

AUTHORS' CONCLUSIONS

We identified no randomised controlled trials comparing a short course (two to three days) of intravenous antibiotics compared to a long course (five days) for severe pneumonia in children aged two months to 59 months that met our inclusion criteria.

A double blind community-based randomized trial of amoxicillin versus placebo for fast breathing pneumonia in children aged 2-59 months in Karachi, Pakistan (RETAPP)

BACKGROUND

Fast breathing pneumonia is characterized by tachypnoea in the absence of danger signs and is mostly viral in etiology. Current guidelines recommend antibiotic therapy for all children with fast breathing pneumonia in resource limited settings, presuming that most pneumonia is bacterial. High quality clinical trial evidence to challenge or support the continued use of antibiotics, as recommended by the World Health Organization is lacking.

METHODS/DESIGN

This is a randomized double blinded placebo-controlled non-inferiority trial using parallel assignment with 1:1 allocation ratio, to be conducted in low income squatter settlements of urban Karachi, Pakistan. Children 2-59 months old with fast breathing, without any WHO-defined danger signs and seeking care at the primary health care center are randomized to receive either three days of placebo or amoxicillin. From prior studies, a sample size of 2430 children is required over a period of 28 months. Primary outcome is the difference in cumulative treatment failure between the two groups, defined as a new clinical sign based on preset definitions indicating illness progression or mortality and confirmed by two independent primary health care physicians on day 0, 1, 2 or 3 of therapy. Secondary outcomes include relapse measured between days 5-14. Modified per protocol analysis comparing hazards of treatment failure with 95% confidence intervals in the placebo arm with hazards in the amoxicillin arm will be done.

DISCUSSION

This study will provide evidence to support or refute the use of antibiotics for fast breathing pneumonia paving a way for guideline change.

TRIAL REGISTRATION

Clinical Trials (NIH) Register NCT02372461.

Short-course versus long-course intravenous therapy with the same antibiotic for severe community-acquired pneumonia in children aged two months to 59 months

BACKGROUND

Pneumonia remains the single leading cause of childhood mortality, causing an estimated 1.3 million childhood deaths each year in children under the age of five years. The greater burden of disease occurs in low-income countries, where medical resources and hospital-based management are poor. The World Health Organization (WHO) current evidence summaries recommend intravenous antibiotics for five days as first-line treatment for severe pneumonia. Although there is controversy around the specificity of clinical features in the diagnosis of pneumonia, the criteria for the diagnosis of severe pneumonia are better defined and widely used to triage children for referral and second-line therapy.Approximately 120 million new cases of pneumonia occur globally each year in children under five years of age, of which 14 million progress to severe episodes. Hospitalisation for severe pneumonia in children places a significant burden on both patients and their families, including substantial expense, loss of routine and decrease in quality of life. By reducing the duration of treatment in the hospital, this burden could potentially be lessened and possibly lead to better treatment compliance.

OBJECTIVES

To evaluate the efficacy of short-course (two to three days) versus long-course (five days) intravenous therapy with the same antibiotic for severe community-acquired pneumonia (CAP) in children aged two months to 59 months.

SEARCH METHODS

We searched CENTRAL (2015, Issue 1), MEDLINE (1966 to January week 4, 2015) and EMBASE (1974 to February 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating the efficacy of short-course (two to three days) versus long-course (five days) intravenous antibiotic therapy for severe pneumonia in children aged two months to 59 months. We excluded children with any other debilitating disease, including those infected with HIV and we excluded children with signs and symptoms of very severe pneumonia (i.e. unable to drink or breast feed, vomiting, lethargic, unconscious, convulsing, central cyanosis, severe respiratory distress or clinically severe malnutrition). We also excluded children who had developed pneumonia during their hospital stay (i.e. with nosocomial infection). There was no restriction on the type of antibiotic used, the dose or the frequency of dosing.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified 2352 studies, however none fulfilled our pre-defined inclusion criteria.

AUTHORS' CONCLUSIONS

We did not identify any RCTs comparing a short course (two to three days) of intravenous antibiotics compared to a long course (five days) for severe pneumonia in children aged two to 59 months.