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Outpatient Antibiotic Use and Treatment Failure Among Children With Pneumonia
Daniel J Shapiro1, Matt Hall2, Mark I Neuman3
1Division of Pediatric Emergency Medicine, University of California, San Francisco.
Insights
Nearly 20% of children with pneumonia managed without antibiotics experienced a small increase in treatment failure risk. Severe outcomes were rare in both groups, suggesting some children may not need antibiotics.
Area of Science:
- Pediatric Infectious Diseases
- Clinical Effectiveness Research
- Antibiotic Stewardship
Background:
- Viral infections are a common cause of pediatric pneumonia, yet antibiotic prescriptions remain frequent.
- The efficacy of antibiotics for childhood pneumonia in outpatient settings is not well-established.
Purpose of the Study:
- To compare treatment outcomes in children diagnosed with pneumonia who received oral antibiotics versus those who did not.
Main Methods:
- Retrospective cohort study of Medicaid-insured children (≤17 years) diagnosed with pneumonia.
- Utilized a multistate claims database (2017-2019) with propensity score matching to control for confounding factors.
- Analyzed treatment failure and severe outcomes within 2-14 days post-diagnosis.
Main Results:
- Out of 103,854 children, 19.7% did not receive antibiotics within 1 day of diagnosis.
- In propensity score-matched analysis (40,454 children), treatment failure was slightly higher in the no-antibiotic group (10.7% vs. 8.7%).
- Severe outcomes were uncommon in both groups (1.1% without antibiotics vs. 0.7% with antibiotics).
Conclusions:
- A significant proportion of children with pneumonia receive no antibiotics, with only a small associated increase in treatment failure risk.
- Severe outcomes are rare, irrespective of antibiotic use, suggesting potential for antibiotic de-escalation in select pediatric pneumonia cases.
- Further prospective research is needed to identify children who can be safely managed without antibiotics.
Importance:
Although a viral etiology can be detected in most cases of pediatric pneumonia, antibiotic treatment is common. The effectiveness of antibiotics in the outpatient setting for children diagnosed with pneumonia is not known.
Objective:
To compare outcomes among children diagnosed with pneumonia who were and were not treated with oral antibiotics.
Design, Setting, And Participants:
This retrospective cohort study identified Medicaid-insured children and adolescents 17 years or younger diagnosed with pneumonia and discharged from ambulatory settings in a multistate claims database from January 1, 2017, to December 31, 2019. Propensity score matching was used to mitigate confounding. Data were analyzed from August 31, 2023, to August 16, 2024.
Exposures:
Antibiotic receipt, defined as an oral antibiotic dispensed from a pharmacy on the day of the index visit or on the subsequent day. Children who did not receive antibiotics included those who were not prescribed antibiotics and those who were prescribed antibiotics but did not fill the prescription.
Main Outcomes And Measures:
Treatment failure and severe outcomes within 2 to 14 days after the index visit. Treatment failure included hospitalization or ambulatory revisits for pneumonia, new antibiotic dispensation with a same-day ambulatory visit, or complicated pneumonia. Severe outcomes included hospitalization for pneumonia or complicated pneumonia.
Results:
Among the 103 854 children with pneumonia included in the analysis, the median age was 5 (IQR, 2-9) years, and 54 665 (52.6%) were male. Overall, 20 435 children (19.7%) did not receive an antibiotic within 1 day. The propensity score-matched analysis included 40 454 children (20 227 per group). Treatment failure occurred in 2167 children (10.7%) who did not receive antibiotics and 1766 (8.7%) who received antibiotics (risk difference, 1.98 [95% CI, 1.41-2.56] percentage points). Severe outcomes occurred in 234 of 20 435 children (1.1%) who did not receive antibiotics and in 133 of 83 419 (0.7%) who did (risk difference, 0.46 [95% CI, 0.28-0.64] percentage points).
Conclusions And Relevance:
In this cohort study of children diagnosed with pneumonia in ambulatory settings, almost 20% did not receive antibiotics within a day of diagnosis. Although not receiving antibiotics was associated with a small increase in the risk of treatment failure, severe outcomes were uncommon regardless of whether antibiotics were received. These results suggest that some children diagnosed with pneumonia can likely be managed without antibiotics and highlight the need for prospective studies to identify these children.
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