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A 7-year-old boy presents to the accident and emergency department with cough, a high temperature and signs of respiratory distress. An x-ray shows pneumonia. Does this child require intravenous antibiotics, or would oral antibiotics be sufficient?
Structured clinical question
In a 7-year-old boy with pneumonia [patient], are oral antibiotics [intervention] as efficacious as intravenous antibiotics [comparison] for resolution of symptoms and avoidance of complications [outcome].
A search of the Cochrane Library using the search term ‘antibiotics AND pneumonia’ revealed 20 reviews, one of which was relevant1 as it referred to two relevant trials.2 3
A search of MEDLINE revealed 98 articles, two of which were relevant.2 4
Of 118 papers retrieved, three were relevant (see table 1).
Pneumonia is an extremely common paediatric illness and around 40% of cases require hospitalisation.4 Those admitted are often initially treated with intravenous antibiotics which, however, carry the risk of pain of cannulation, extravasation, thrombophlebitis and local infection at the site of cannula insertion. If oral antibiotics were deemed to be equivalent in the management of community acquired pneumonia, patients would benefit from painless non-invasive treatment of this widespread disease.
Three randomised controlled trials were relevant. Two studies undertaken in developing countries2 3 both showed that there was no significant difference in treatment failure between the two groups (oral versus intravenous antibiotics). The APPIS trial2 showed no difference in clinical deterioration and no difference in side effects between the two groups. Neither study reported time to recovery or length of hospitalisation. They both used the WHO classification of pneumonia. However, the applicability of these results should be viewed with caution when applied to children in developed countries. Confounding factors such as malnutrition and comorbidity such as HIV and tuberculosis could impact on the external validity of these results.
Clinical bottom line
▶ Oral antibiotics are as efficacious as intravenous antibiotics in the treatment of community acquired pneumonia in children. (Grade B)
▶ Oral antibiotics should be tried in all but the sickest children with pneumonia and observed to ensure they are tolerated and symptoms are resolving. (Grade D)
The PIVOT trial4 was a multicentre randomised trial of children admitted to both tertiary centres and district general hospitals in the UK. The authors compared oral amoxicillin and intravenous penicillin and found no difference in time taken for fever and oxygen requirement to resolve. They also found that length of hospital stay and length of oxygen requirement were reduced in the arm randomised to oral antibiotics. Complications and treatment failure were similar in both groups. In fact, empyema only occurred in three patients who were randomised to the intravenous antibiotic arm.
All three trials agree that oral antibiotics are likely to be equivalent in clinical outcomes to intravenous antibiotics in the treatment of pneumonia in children. Children will benefit from receiving painless non-invasive treatment and will have a shorter hospital stay. This may also confer an economic advantage.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.