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Empiric Antibiotic Therapy in 1402 Children With Parapneumonic Effusion/Pleural Empyema in Germany: A Long-term
Johannes Forster1, Giuseppina Piazza2, David Goettler2
1From the Institute for Hygiene and Microbiology, University of Würzburg.
Insights
Pediatric parapneumonic effusion/pleural empyema (PPE/PE) treatment often involves antibiotic overtreatment, with combination therapies showing no improved outcomes. Antibiotic stewardship is crucial for optimizing pediatric PPE/PE management.
Area of Science:
- Pediatric Infectious Diseases
- Antimicrobial Stewardship
- Clinical Microbiology
Background:
- Pediatric parapneumonic effusion/pleural empyema (PPE/PE) is a significant pediatric respiratory condition.
- Empiric antibiotic treatment (EAT) is standard, but optimal strategies require investigation.
Purpose of the Study:
- To investigate empiric antibiotic treatment (EAT), guideline adherence, antibiotic streamlining, and clinical outcomes in hospitalized children with PPE/PE.
- To assess the impact of different antibiotic regimens on clinical severity and outcomes.
Main Methods:
- A nationwide surveillance study in Germany (2010-2018) analyzed data from 1402 children with PPE/PE.
- Data included EAT, clinical course, pathogens, susceptibility testing, and antibiotic streamlining.
- Statistical analyses included chi-squared tests, Fisher exact tests, Mann-Whitney U tests, and linear regression.
Main Results:
- Common EAT included aminopenicillin/beta-lactamase inhibitor and cefuroxime, in monotherapy or combination.
- No clinical outcome differences were observed between EAT regimens.
- Antibiotic streamlining occurred in a low percentage of cases (9.4% for S. pneumoniae, 18.9% for S. pyogenes, 5.2% for S. aureus).
- Reported resistance rates included 4.8% for penicillin in S. pneumoniae and 31.3% for methicillin in S. aureus.
Conclusions:
- Findings suggest potential antibiotic overtreatment in pediatric PPE/PE, particularly with combination therapies.
- Lack of improved outcomes with combination therapy highlights the need for antibiotic stewardship.
- Investigating alternative strategies like anti-inflammatory therapy is warranted.
Objective:
This study investigated empiric antibiotic treatment (EAT), guideline adherence, antibiotic streamlining and clinical outcomes in 1402 hospitalized children with pediatric parapneumonic effusion/pleural empyema (PPE/PE).
Methods:
A nationwide surveillance study collected data on EAT, clinical course/outcome, pathogens, susceptibility testing and antibiotic streamlining of children with PPE/PE in Germany between 2010 and 2018. Subgroups were compared using χ2 test/Fisher exact test, Mann-Whitney U test and linear regression analysis adjusting for patient age where appropriate.
Results:
Complete data on EAT were available for 1402 children. In children with monotherapy (n = 567) and in children with combination therapy of 2 antibiotics (n = 589), the most commonly used antibiotics were aminopenicillin/beta-lactamase inhibitor [138/567 (24.3%) and 102/589 (17.3%)] and cefuroxime [291/567 (51.3%) and 294/589 (49.9%)]. The most common combinations with these beta-lactams were macrolides, aminoglycosides and clindamycin. We observed no difference in clinical severity/outcome between EAT with aminopenicillin/beta-lactamase inhibitor and cefuroxime, neither when used in monotherapy nor when used in combination therapy of 2 antibiotics. Species diagnosis of Streptococcus pneumoniae (n = 192), Streptococcus pyogenes (n = 111) or Staphylococcus aureus (n = 38) in polymerase chain reaction or culture from pleural fluid or blood resulted in a switch to an appropriate narrow-spectrum beta-lactam therapy in 9.4%, 18.9 % and 5.2% of children. In a subset of children with reported bacterial susceptibility testing, penicillin resistance was reported in 3/63 (4.8%) of S. pneumoniae and methicillin resistance in S. aureus was reported in 10/32 (31.3%) of children.
Conclusion:
This study points to antibiotic overtreatment in children with PPE/PE, particularly the frequent use of combinations of antibiotics. Children receiving combinations of antibiotics did not show differences in clinical outcomes. The low rate of children with streamlined antibiotic therapy even upon pathogen detection indicates a necessity for antibiotic stewardship measures in PPE/PE and the need of investigating other potential therapeutic strategies as anti-inflammatory therapy.
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