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Beta-lactams or macrolides for pneumonia?

Macrolide antibiotics such as azithromycin are frequently prescribed as a first-line antibiotic in presumed community-acquired pneumonia (CAP): the usual rationale is that nArrower-spectrum beta-lactam antibiotics would not cover atypical organisms such as Mycoplasma pneumoniae. Indeed, first-line macrolides are officially recommended by some US authorities. The outcome of a large prospective trial challenges this (EPIC study. Williams D et al. JAMA Peds 2017. doi:10.1001/jamapediatrics. 2017.3225). Researchers from Tennessee and Utah identified 1420 previously healthy children, all of whom had been hospitalised for radiologically-proven CAP. Of these, 1020 received beta-lactam monotherapy (mostly cephalosporins, ampicillin, amoxicillin/clavulanate), and 400 received a combination of a beta-lactam and a macrolide (azithro- or clarithromycin). This was not a randomised controlled trial, but using propensity scoring they were able to make a valid comparison of these groups. They found no differences in length-of-stay, rates of intensive care admission, readmissions, or recovery time.

They all had detailed microbiological studies. Using sensitive PCR tests they were able to identify 125 who actually harboured atypical organisms: even within this subgroup there were no outcome differences according to treatment.

These children all required admission: extrapolating the results to less unwell children treated in emergency departments …

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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.