Propensity-Score Matched Comparative Study of Parenteral Penicillin G vs. Cefuroxime/Ceftriaxone for the Treatment of Community-Acquired Pneumonia in Hospitalized Children in the Post-Pneumococcal Conjugate Vaccine Era

Speaker: Liat Ashkenazi-Hoffnung, Tel Aviv

Introduction:

Global guidelines recommend parenteral penicillin for non-severe community-acquired pneumonia (CAP) in children.

Cephalosporins are reserved for:

• Regions with high penicillin resistance
• Unvaccinated children
• Severe pneumonia cases

However, real-world use of penicillin remains low (~10%) due to a lack of strong comparative evidence.

Study Objective:

To compare the effectiveness and safety of parenteral penicillin G vs. cefuroxime/ceftriaxone in hospitalized children with CAP in the post-PCV (pneumococcal conjugate vaccine) era.

Study Design and Methods:

1. Type: Observational, retrospective study (8 years)
2. Inclusion Criteria:

Children were included in the study if they met all of the following criteria:

1. Age: Between 6 months and 10 years
2. Diagnosis: Discharged with an ICD-9 code for pneumonia
3. Fever: Documented fever during admission
4. Radiological confirmation: Presence of infiltrate on chest X-ray, interpreted by a certified pediatric radiologist
5. Minimum hospitalization: Hospital stay of at least 2 days
6. Treatment: Received parenteral penicillin G, ceftriaxone, or cefuroxime during admission

3. Exclusion: Recent admission, chronic illness, complicated/severe pneumonia, low O₂ saturation, blood culture positivity for S. pneumoniae, wheezing or corticosteroid therapy during hospitalization
4. Groups: Penicillin G vs. Ceftriaxone/Cefuroxime
5. Primary and Secondary Outcomes
   1. Effectiveness:
      1. Primary: Length of hospital stay
      2. Secondary: Duration of fever, CRP decline, treatment failure, complications, ICU admissions, 30-day readmission
   2. Safety: Adverse events including phlebitis, allergic reactions, catheter changes, and antibiotic-associated diarrhoea

Results:

Number of Patients post-PSM (Propensity score matching)

• Penicillin G group: 85
• Cephalosporin group: 85

• Both treatment groups were well balanced after matching.
• Length of stay was consistently shorter with penicillin G in both matched analysis and multivariate regression.
• No differences observed in clinical outcomes or adverse events.
• Only 20% of children in the full cohort received penicillin G empirically.

Conclusion:

• Parenteral penicillin G is as clinically effective as cephalosporins for non-severe pediatric CAP.
• Associated with shorter hospital stays, enabling potentially earlier switch to oral antibiotics.
• Findings support increasing penicillin use as part of antimicrobial stewardship, especially in regions with low resistance.

ESPID 2025, 26-30 May, Bucharest