Antibiotic effectiveness for children with lower respiratory infections: prospective cohort and trial in primary care
Paul Little1, Taeko Becque1, Alastair D Hay2
1Primary Care Population Sciences and Medical Education Unit, University of Southampton, Southampton, UK.
Insights
Antibiotics offer little benefit for children with uncomplicated chest infections. This study found no significant improvement in symptom duration or illness progression, even in sicker children, questioning their routine use.
Area of Science:
- Pediatric infectious diseases
- Clinical trial methodology
- Evidence-based medicine
Background:
- Antibiotic overprescription for pediatric chest infections lacks robust evidence.
- Existing trials often use selected populations, limiting generalizability.
- Effectiveness of antibiotics for uncomplicated pediatric respiratory infections remains uncertain.
Purpose of the Study:
- To evaluate the clinical effectiveness of antibiotics for uncomplicated chest infections in children.
- To provide evidence for antibiotic use in a primary care setting.
- To assess symptom duration and illness progression in children treated with antibiotics versus placebo.
Main Methods:
- Prospective cohort study with a nested randomized controlled trial (RCT) in primary care.
- Included children aged 1-12 years with uncomplicated lower respiratory tract infections.
- Compared amoxicillin versus placebo, with propensity score analysis for observational data.
Main Results:
- 764 children participated; cohort included sicker children than previous studies.
- Antibiotic use showed a non-significant reduction of approximately 1 day in symptom duration.
- No significant effect observed on secondary outcomes like illness progression requiring hospitalization.
Conclusions:
- Antibiotics are unlikely to be clinically effective for uncomplicated chest infections in children.
- Findings suggest caution in prescribing antibiotics, even for more unwell children.
- Evidence supports a conservative approach to antibiotic use in pediatric respiratory infections.
Background:
Antibiotics are commonly prescribed for children with chest infections but there is little randomised evidence and trials commonly recruit selected populations, which undermines their applicability.
Aim:
To document the effectiveness of antibiotics for chest infections in children.
Design And Setting:
This was a prospective cohort study with nested trial in primary care.
Method:
Children aged 1-12 years presenting with uncomplicated lower respiratory tract infections were included in the cohort. Children were either randomised to receive amoxicillin 50 mg/kg per day for 7 days or placebo, or participated in a parallel observational study, where propensity scores controlled for confounding by indication. The outcomes were duration of symptoms rated moderately bad or worse (primary outcome) and illness progression requiring hospital assessment.
Results:
A total of 764 children participated (438 trial, 326 observational), and children were more unwell than in previous cohorts (more sputum, fever, shortness of breath). Children had been unwell for a median of 5-6 days, and symptoms rated moderately bad or worse lasted another 6 days when no antibiotics were given.With antibiotics there was a non-significant reduction of approximately 1 day in duration of symptoms rated moderately bad or worse for the whole cohort (hazard ratio [HR] 1.16, 95% confidence interval [CI] = 0.95 to 1.41), similar to the trial alone (HR 1.13, 95% CI = 0.90 to 1.43). The effect of antibiotic treatment on secondary outcomes was also non-significant.
Conclusion:
Antibiotics for uncomplicated chest infections, even in a sample of more unwell children, are unlikely to be clinically very effective.
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