Community-Acquired Pneumonia in Children – To Treat or Not to Treat (Short Rx Pneumonia) 

Speaker: David Greenberg, Israel

Introduction:

Community-acquired pneumonia (CAP) remains one of the most common infections in pediatric practice. Historically, children diagnosed with CAP are often treated empirically with antibiotics. However, with better understanding of its viral aetiology, this session explored the critical question: Can antibiotics be avoided or shortened in cases of mild pediatric CAP? Dr. David Greenberg presented data challenging traditional approaches, particularly the routine use of prolonged antibiotic therapy in all children with radiologically confirmed pneumonia.

Key Study Insights:

Dr. Greenberg shared results from a randomized controlled trial in Israel that evaluated the efficacy of short-course antibiotic therapy:

1. Study Population: Children aged 6 months to 5 years with radiologically confirmed CAP.
2. Intervention: High-dose amoxicillin for 5 days vs. 10 days.
3. Outcome Measures:
   1. Clinical cure at follow-up
   2. Need for hospitalization
   3. Incidence of complications or recurrence

Key Findings:

• No significant difference in treatment outcomes between the two groups.
• Both 5- and 10-day regimens had similar clinical resolution rates, hospitalization rates, and adverse events.
• This trial supports the growing evidence that 5-day antibiotic therapy is sufficient for uncomplicated CAP in previously healthy children.

Role of Viral Pathogens in Pediatric CAP:

1. Viruses are the most common cause of pneumonia in children under 5 years.
2. Common viruses include:
   1. Respiratory syncytial virus (RSV)
   2. Influenza
   3. Rhinovirus
3. Dr. Greenberg emphasized that in many cases, especially in mildly symptomatic, well-appearing children, the pneumonia is viral and self-limiting, requiring no antibiotic therapy.

Diagnostic Challenges:

• Chest X-ray (CXR) findings are non-specific and cannot reliably distinguish between viral and bacterial pneumonia.
• Reliance on radiology and lab markers often leads to:
  1. Over-diagnosis of bacterial pneumonia
  2. Unnecessary antibiotic prescriptions
• Clinical signs and severity should guide management rather than imaging alone.

Treatment Considerations and Stewardship:

Dr. Greenberg provided a framework for clinical decision-making:

1. When to consider withholding antibiotics:
   1. Child is well-appearing and stable.
   2. Symptoms suggest a viral illness (e.g., wheezing, runny nose).
   3. No hypoxia or respiratory distress.
   4. Close follow-up is possible.
2. When antibiotics are warranted:
   1. Toxic appearance, high fever >38.5°C with focal lung findings.
   2. Underlying comorbidities (e.g., immunosuppression, chronic lung disease).
   3. Poor oral intake, hypoxia, or signs of systemic illness.
3. Antibiotic Stewardship Message:
   1. Avoid blanket treatment with antibiotics.
   2. Tailor treatment based on clinical features and severity, not just radiology.
   3. Shorten duration when treatment is given — 5 days is adequate in most mild to moderate cases.

Conclusion:

The session underscored the importance of reassessing entrenched treatment protocols for pediatric pneumonia. His findings highlight:

• The predominance of viral aetiology in young children with CAP.
• The safety and efficacy of short-course antibiotic therapy.
• The need to base treatment on clinical judgment, not just imaging.
• The critical role of antimicrobial stewardship in pediatric care.

ESPID 2025, 26-30 May, Bucharest