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Amoxicillin for children with CAP: low-dose for 3 days is noninferior to high-dose for 7 days (CAP-IT)
Clinical Question
What is the optimal dosage of amoxicillin for managing community-acquired pneumonia in children?
Bottom line
Regarding the need for re-treatment of CAP in children discharged from an emergency department or inpatient setting within 48 hours, this study found that lower-dose was noninferior to higher-dose outpatient oral amoxicillin and 3 days was noninferior to 7 days.
This POEM aligns with Choosing Wisely Canada recommendations. The Choosing Wisely Canada Cold Standard toolkit provides tools for reducing unnecessary antibiotics.
1b
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Government
Setting: Emergency department
Synopsis
Although amoxicillin is widely recommended and used for the treatment of community-acquired pneumonia (CAP) in children, the optimal dose and treatment duration remains uncertain. These investigators identified children, 6 months and older, with clinically diagnosed CAP based on standard international guidelines, who were being discharged from either the emergency department or inpatient ward (within 48 hours of admission). Patients randomly received (concealed allocation assignment) 1 of 4 treatments: (1) amoxicillin (35-50 mg/kg/d) for 3 days; (2) amoxicillin (35-50 mg/kg/d) for 7 days; (3) amoxicillin (70-90 mg/kg/d) for 3 days; or (4) amoxicillin (70-90 mg/kg/d) for 7 days. Masking occurred by using matched active or placebo suspension for days 4 through 7. Individuals masked to treatment group assignment assessed the primary outcome of clinically indicated antibiotic re-treatment for respiratory infection within 28 days of randomization. The noninferiority margin was predetermined to be a conservative 8% difference in outcome rates. Complete follow-up data were available for 97% of participants at 28 days. Using intention-to-treat analysis, the primary outcome occurred in 12.6% of the children in the lower-dose groups versus 12.4% in the higher-dose groups, and in 12.5% in the 3-day treatment groups versus 12.5% in the 7-day treatment groups. Both groups demonstrated noninferiority between dose and duration. Similarly, in the subgroup of children with severe CAP, all groups again demonstrated noninferiority.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
Amoxil and Cap
How was the diagnosis of Cap made. Could many of these have been viral ?
Viral pneumonias ?
Given that a specific ethology for pneumonia in children is not commonly determined, ie bacterial vs viral, one could assume that a percentage of these pneumonias (up to 50 % - UpToDate) could be viral. In this scenario the prescribing of any antibiotic would not be expected to affect recovery.
Amoxicillin for children with CAP: low-dose for 3 days is no
This type of research is important in the context of the need for smarter antibiotic stewardship.