Letters

COMMENT & RESPONSE spectrum antibiotics. Whether antibiotics were appropriate,

we identified a substantial proportion of children who are likely
In Reply We appreciate Weinberger’s letter, which highlights an receiving unnecessary broad-spectrum antibiotics, particu-
important challenge in the treatment of children with com- larly in non-children’s hospitals.
munity-acquired pneumonia (CAP): distinguishing between vi- The crux of Weinberger’s question depends on what one
ral and bacterial infection. Indeed, antibiotics should only be means when using the term community-acquired pneumonia.
prescribed for children with presumed bacterial CAP, and un- We wholeheartedly agree that when making a diagnosis of CAP,
doubtedly, there are children who receive antibiotics for CAP clinicians should attempt to distinguish between viral and bac-
who do not have bacterial pneumonia. terial etiologies and prescribe antibiotics only when a bacte-
As Weinberger noted, younger children are more likely to rial process is strongly suspected. Studies to help distinguish
be overdiagnosed as having bacterial pneumonia. This is par- these 2 entities are sorely needed. At the same time, it is equally
ticularly true in outpatient settings and when using clinical cri- important that when a decision is made to prescribe antibiot-
teria (such as the World Health Organization tachypnea- ics for CAP, clinicians should adhere to national guidelines and
based definition) alone, as observed in the study by Ginsburg prescribe only the narrowest appropriate antibiotic.
et al,1 in which amoxicillin had little benefit over placebo. For
this reason, the 2011 US pediatric CAP guidelines2 state that
in outpatient settings, “antimicrobial therapy is not routinely Alison C. Tribble, MD
required for preschool-aged children with CAP, because viral Rachael K. Ross, MPH
pathogens are responsible for the great majority of clinical Jeffrey S. Gerber, MD, PhD
disease.”2
Author Affiliations: Division of Pediatric Infectious Diseases, C.S. Mott
In contrast, among hospitalized children diagnosed as hav-
Children’s Hospital, University of Michigan, Ann Arbor (Tribble); Department of
ing CAP, there is likely a greater proportion of children with Epidemiology, Gillings School of Global Public Health, University of North
bacterial infection. Jain et al3 provide estimates from 2015, in Carolina at Chapel Hill, Chapel Hill, North Carolina (Ross); Division of Infectious
which a bacterial etiology was identified in 15% of patients with Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
(Gerber).
radiographic and clinical CAP. However, their study was lim-
Corresponding Author: Jeffrey S. Gerber, MD, PhD, University of Pennsylvania
ited by inability to obtain direct lung samples for bacteria. Only School of Medicine, Division of Infectious Diseases, Children's Hospital of
4% of patients had pleural fluid available for analysis, and only Philadelphia, 2716 S St, Room 10364, Philadelphia, PA 19146 (gerberj@email.
1% each had endotracheal tube specimens or bronchoalveo- [Link]).
lar lavage specimens. While viruses were detected in the na- Published Online: June 3, 2019. doi:10.1001/jamapediatrics.2019.1447
sopharynx and/or oropharynx in most patients, this does not Conflict of Interest Disclosures: None reported.
exclude the possibility of bacterial coinfection. Bacterial pneu- 1. Ginsburg AS, Mvalo T, Nkwopara E, et al. Placebo vs amoxicillin for nonsevere
monia is often preceded by viral respiratory tract infection, and fast-breathing pneumonia in malawian children aged 2 to 59 months:
a double-blind, randomized clinical noninferiority trial. JAMA Pediatr. 2018;173
without direct lung samples, it is difficult to determine whether
(1):21-28. doi:10.1001/jamapediatrics.2018.3407
coinfection is present.
2. Bradley JS, Byington CL, Shah SS, et al; Pediatric Infectious Diseases Society
Importantly, our study4 focused on the population of chil- and the Infectious Diseases Society of America. The management of
dren most likely to have bacterial pneumonia. We identified community-acquired pneumonia in infants and children older than 3 months of
patients using a validated algorithm with a specificity of 93% age: clinical practice guidelines by the Pediatric Infectious Diseases Society and
the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25-e76.
for “definite CAP,” defined as clinician diagnosis of CAP and doi:10.1093/cid/cir531
treatment as such within 48 hours of admission, abnormal tem-
3. Jain S, Williams DJ, Arnold SR, et al; CDC EPIC Study Team.
perature or white blood cell count, evidence of respiratory ill- Community-acquired pneumonia requiring hospitalization among U.S. children.
ness, and chest radiograph indicating pneumonia.5 While some N Engl J Med. 2015;372(9):835-845. doi:10.1056/NEJMoa1405870
of these children may not have had bacterial CAP, this is the 4. Tribble AC, Ross RK, Gerber JS. Comparison of antibiotic prescribing for
population most likely to need antibiotics and for whom the pediatric community-acquired pneumonia in children’s and non-children’s
hospitals. JAMA Pediatr. 2019;173(2):190-192. doi:10.1001/jamapediatrics.2018.
guideline recommendation to use narrow-spectrum penicil- 4270
lins is most relevant. Furthermore, for those children who do
5. Williams DJ, Shah SS, Myers A, et al. Identifying pediatric community-
receive unnecessary antibiotics, adherence to national guide- acquired pneumonia hospitalizations: accuracy of administrative billing codes.
lines will at least ensure that they are spared exposure to broad- JAMA Pediatr. 2013;167(9):851-858. doi:10.1001/jamapediatrics.2013.186

[Link] (Reprinted) JAMA Pediatrics Published online June 3, 2019 E1

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