Beta-lactam or macrolide monotherapy for CAP?

Empiric beta-lactam and macrolide monotherapy are similarly effective in outpatient management of children with community-acquired pneumonia (CAP), according to results of a multicenter retrospective study in 1164 children treated for CAP at primary care pediatric clinics in Pennsylvania. Children whose records investigators analyzed were evenly divided between those who received beta-lactam monotherapy (usually penicillin or aminopenicillin) and those who were prescribed macrolide monotherapy (azithromycin, clarithromycin, or erythromycin) at diagnosis. The 2 treatment groups were matched as to age (ranging from 1 to 18 years) and asthma status.

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Overall, the likelihood of treatment failure (defined as a change in antibiotic prescription within 14 days of the initial pneumonia diagnosis) was the same in children treated with beta-lactam (6%) and those treated with macrolide monotherapy (4%). However, among children aged 6 years and older, those who received macrolide monotherapy had slightly lower odds of experiencing treatment failure than children in this age group who received beta-lactam monotherapy (Ambroggio L, et al. Pediatr Infect Dis J. 2015;34[8]:839-842).

Commentary: Decisions, decisions. The pediatric CAP guideline released by the Infectious Diseases Society of America in 2011 recommends amoxicillin as first-line therapy in immunized, school-aged children who are thought to have pneumococcal pneumonia and a macrolide for therapy of school-aged children, especially those who are older, who have findings consistent with mycoplasma or other atypical organisms. Because the clinical findings of “typical” and “atypical” pneumonias overlap, the choice is yours. Given that this study of antibiotic choice is retrospective, the authors may not have known the prescribing clinicians’ impression of the etiologic agents involved. However, treatment with either category of antibiotics was usually successful, and in some older children macrolide coverage may have been slightly better. I am not sure that treating mycoplasma makes patients feel better any faster, so I will continue to lean toward amoxicillin when I am not confident about which bug is the culprit (Clin Infect Dis. 2011;53[7]:e25-e76). -Michael G Burke, MD

Ms Freedman is a freelance medical editor and writer in New Jersey. Dr Burke, section editor for Journal Club, is chairman of the Department of Pediatrics at Saint Agnes Hospital, Baltimore, Maryland. The editors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.