Antibiotics for childhood community-acquired pneumonia in a region with a high prevalence of penicillin non-susceptible Streptococcus pneumoniae

Wai Kin Lee* and Betty Wan Yin Young

Department of Paediatrics and Adolescent Medicine, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong Special Administrative Region, China


* Corresponding author. Tel: +852-25956410; Fax: +852-29045371; E-mail: jleewk{at}hotmail.com

Keywords: antimicrobial therapy , guidelines , prescribing practice

Sir,

Hong Kong has a high prevalence of penicillin non-susceptible Streptococcus pneumoniae and ß-lactamases in Haemophilus influenzae. Their susceptibilities to cefaclor and macrolides are also low.13 Based on this background, we conducted a programme in order to change the prescription habits of the paediatricians in our department for community-acquired pneumonia (CAP).

Baseline data were collected from all patients who were aged from 3 months to 15 years and admitted from August to September 1999 with the diagnosis of pneumonia. Patients who had the onset of symptoms after admission or significant pre-morbid diseases or were admitted to the intensive care unit were excluded. The first lecture was held in March 2000. The message of high antibiotic resistance of common bacterial aetiologies of CAP, the optimal choice of antibiotics and their adequate dosage was conveyed to all paediatricians in our department. For patients above 3 months of age, oral amoxicillin at a dose of 40–50 mg/kg per day in three divided doses (the dose could be doubled if penicillin-resistant S. pneumoniae was suspected) with or without clavulanate was recommended for mild pneumonia. For more severe cases in which intravenous therapy was required, co-amoxiclav or cefuroxime at a dose of 30 mg/kg per dose every 8 h was recommended. For suspected atypical pneumonia, oral erythromycin at a dose of 10 mg/kg per dose every 6 h or clarithromycin at a dose of 7.5 mg/kg per dose every 12 h was recommended. There was no recommendation for cefaclor. The patients admitted from August to September 2000 were recruited and analysed. In addition, a guideline was drafted by a paediatrician and discussed with others in the department as well as microbiologists and pharmacists in the hospital. The final version (with the same principle and recommendation) was endorsed as the departmental guideline and distributed to all paediatricians, paediatric wards, outpatient clinics and the pharmacy as well as posted on the hospital home page in August 2001. The patients admitted from August to September 2001 were recruited and analysed. The results of these three periods were conveyed to the staff in the second lecture in February 2002. The issue of penicillin non-susceptible S. pneumoniae and the value of amoxicillin at adequate dose was emphasized again. On the other hand, the importance of atypical pathogens as the aetiology for CAP in older children was also highlighted. New suggestions were made: amoxicillin with or without clavulanate for patients younger than 5 years and clarithromycin for others. This new recommendation was endorsed in the second departmental guideline in August 2002. The dosages of the medication were also included in a new departmental pocket drug guide, sized 1 x 7 x 10 cm, which was distributed to all medical staff and wards in August 2002. The patients admitted from August to September 2002 were recruited and analysed. The SARS epidemic occurred in 2003. We were interested to know whether there was any impact on our prescription habits and hence identified the patients admitted from August to September 2003 for analysis.

We identified a total of 170 children aged 34.1 ± 55.9 months; 95.9% of them received empirical antibiotics after admission and they were given by the oral route in 82.8% of these 163 patients. The prescription of cefaclor was 58.3% in 1999 but was reduced to 4.3% in 2000 and then 0.0% in 2001–2003. The prescription of amoxicillin ± clavulanate was 8.3% in 1999 but increased to 71.4–78.2% in 2000–2003. The prescriptions of erythromycin and clarithromycin were 0.0–4.5% and 17.4–29.2%, respectively in these periods (Figure 1).



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Figure 1. Programme and results of the change of antibiotic prescription for childhood community-acquired pneumonia over 5 years.

 
Difficulty in pathogen identification existed for CAP. Antibiotics could only be given with a ‘best-guess’ approach and they should ideally be targeted to cover all common causative pathogens. However, we prefer single rather than multiple agents in less severe cases. We therefore recommended amoxicillin ± clavulanate at an appropriate dose but not cefaclor or macrolides for those younger than 5 years because of a higher chance of S. pneumoniae. For patients older than 5 years, we recommended a macrolide because of a greater probability of atypical pathogens. We were quite successful in the change of prescription habits by the physicians, which was persistent after education, publication of guidelines, distribution of the pocket drug guide, re-evaluation and feedback. In 2002, we used more amoxicillin alone without its combination with clavulanate after we emphasized its own value over S. pneumoniae if the dose was adequate. But in 2003, we used more co-amoxiclav again and it was uncertain whether the physicians had changed their attitude towards a broader spectrum antibiotic after the SARS epidemic.

References

1. Felmingham D, Washington J. Trends in the antimicrobial susceptibility of bacterial respiratory tract pathogens—findings of the Alexander Project 1992–1996. J Chemother 1999; 11 Suppl 1: 5–21.[ISI][Medline]

2. Felmingham D, Grüneberg RN. The Alexander Project 1996–1997: latest susceptibility data from this international study of bacterial pathogens from community-acquired lower respiratory tract infections. J Antimicrob Chemother 2000; 45: 191–203.[Abstract/Free Full Text]

3. Jacobs MR, Felmingham D, Appelbaum PC et al. The Alexander Project 1998–2000: susceptibility of pathogens isolated from community-acquired respiratory tract infection to commonly used antimicrobial agents. J Antimicrob Chemother 2003; 52: 229–46.[Abstract/Free Full Text]





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