Top Papers Of The Month

3 Top Papers You May Have Missed in March 2021

AUTHOR:
Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA

CITATION:
Vergano ST. 3 top papers you may have missed in March 2021. Consultant360. Published online April 9, 2021.


With so much information to read about the COVID-19 pandemic, I like to keep up with the rest of the pediatric literature and share with you some of the articles that might get overlooked. Here are my choices for the past month, with a focus on community-acquired pneumonia (CAP). They include several issues about which I have more questions than answers. I hope that you and your colleagues will find them useful in your practice. 

Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial1

In this 2-center, blinded, randomized clinical trial, the authors had follow-up data on 223 pediatric patients aged 6 months to 10 years (median age 2.6 years) who presented to the emergency department (ED) with fever, physical examination and chest radiography findings consistent with pneumonia, and a clinical diagnosis of CAP well enough for outpatient therapy. The patients were discharged from the ED with 5 days of high-dose amoxicillin followed by an additional 5 days of a different formulation of high-dose amoxicillin vs 5 days of placebo. Clinical cure rates at 14 to 21 days of follow-up were 85.7% in the 5-day group and 84.1% in the 10-day group. A total of 7 patients were subsequently admitted for treatment of pneumonia, of whom 6 were admitted within the first 5 days of therapy.
 
The authors conclude that 5-day therapy appears equally effective as 10-day therapy in previously well children treated as outpatients for CAP.
 
I am impressed with the design and implementation of the study and concur with the authors’ conclusions. Before changing my own practice, I would like to see similar results replicated in other studies. Ultimately, if the data prove sufficient, perhaps a recommendation will be included in an update to the clinical practice guidelines for CAP published by the Infectious Diseases Society of America (IDSA) and the Pediatric Infectious Diseases Society (PIDS). Until I see changes incorporated into the guidelines, it is likely that I will continue to treat my patients with 10 days of high-dose amoxicillin.


Antibiotic Choice and Clinical Outcomes in Ambulatory Children with Community-Acquired Pneumonia2

The authors of this retrospective cohort study looked at antibiotic selection for all Medicaid-enrolled children from 11 states in the United States who were treated as outpatients for CAP from 2010 to 2016. Patients aged 1 to 18 years (median age 4 years) were seen in both clinic and ED settings. Of the more than 250,000 outpatient pediatric pneumonia visits reported in this study, 43.2% resulted in a prescription for macrolide monotherapy, 26.1% resulted in a prescription for aminopenicillin monotherapy, and 24.7% resulted in a prescription for broad-spectrum antibiotic (amoxicillin-clavulanate or cephalosporin) monotherapy.
 
Compared with children taking narrow-spectrum penicillins, the odds of hospitalization were higher among patients taking broad-spectrum antibiotics and lower in patients taking macrolides alone or with a combination of penicillins and macrolides. Overall, though, hospitalization rates were low in all groups. Only 1488 of 252,177 children were hospitalized (0.59%) and only 117 developed what was characterized as severe pneumonia (0.05%). 
 
The authors conclude that the majority of outpatients with CAP do well, regardless of choice of antibiotic, and that efforts should focus on encouraging antibiotic prescriptions consistent with current IDSA and PIDS guidelines (high-dose amoxicillin for uncomplicated CAP when a bacterial pathogen is suspected and adding a macrolide in school-aged and adolescent patients when an atypical agent is suspected).
 
The overall hospitalization rates for children with CAP are surprisingly low in this large database study. In my opinion, there are 3 possible explanations: 

  1. The vast majority of children with CAP do well, and I can restrict my use of antibiotics to narrow-spectrum agents, as suggested.
  2. Clinicians in this study appropriately chose broader-spectrum agents for sicker children, leading to low rates of hospitalization in all groups. In this case, I should choose broad-spectrum antibiotics for the sickest of my patients with CAP.
  3. Bacterial CAP is being overdiagnosed, and I should be more restrictive about my use of any antibiotics, as many of these children would do well without antibiotics.

I am uncertain which of these explanations is best. After reviewing the data and your own experiences, what do you think?
 
Combating Anti-Asian Sentiment — A Practical Guide for Clinicians3

In addition to documenting the history and pervasiveness of anti-Asian racism in the United States, the author of this editorial published in the New England Journal of Medicine offers several concrete steps that clinicians can take to combat this disturbing phenomenon. He recommends creating a safe environment in our offices and clinics, incorporating questions related to personal responses to racism during the history and screening processes, and providing resources to patients who report evidence of experiencing the effects of racism.
 
I have a personal interest in addressing inequity within our society and am wholeheartedly supportive of efforts to make the opportunities in our country open and accessible to all. Nonetheless, I am uncertain about how best to integrate these recommendations. Would it be appropriate and acceptable for a White physician of privilege in his 50s to open a discussion of racism with pediatric patients and their families during an office visit? How would it be received by patients and their families? I'm not sure. On the other hand, it did not used to be within my purview to talk about gender identity, food and housing insecurity, and other social determinants of health, and now they are an accepted part of the pediatric well visit. What are your thoughts?

I would love to have a dialogue about what you do, what your experiences have been, and what your recommendations would be about how to best to address the racism and inequity that can be overt or subtle within our communities and our offices. Please feel free to share your thoughts with colleagues and with us at editors@hmpglobal.com. 
 
References

  1. Perica JM, Harman S, Kam AJ, et al. Short-course antimicrobial therapy for pediatric community-acquired pneumonia: the SAFER randomized clinical trial. JAMA Pediatr. Published online March 8, 2021. doi:10.1001/jamapediatrics.2020.6735
  2. Lipsett SC, Hall M, Ambroggio L, et al. Antibiotic choice and clinical outcomes in ambulatory children with community-acquired pneumonia. J Pediatr. 2021;229:207-215.e1. https://doi.org/10.1016/j.jpeds.2020.10.005
  3. Lee JH. Combating anti-Asian sentiment — a practical guide for clinicians. N Engl J Med. Published online March 24, 2021. https://doi.org/10.1056/nejmp2102656