Antibiotic overtreatment prevalent in children with PPE/PE

Children with parapneumonic effusion (PPE) or pleural empyema (PE) are often overly treated with antibiotics, particularly the frequent use of antibiotic combination therapy, reports a Germany study.

The findings show no significant difference in clinical outcomes between children receiving monotherapy and those receiving combination or broader spectrum antibiotic therapy (ABT).

“The low rate of children with streamlined ABT even upon pathogen detection indicates a necessity for antibiotic stewardship measures in PPE/PE and the need of investigating other potential therapeutic strategies as anti-inflammatory therapy,” the investigators said.

This nationwide surveillance study obtained data on empiric antibiotic treatment, pathogens, clinical course/outcome, susceptibility testing, and antibiotic streamlining of children with PPE/PE in Germany between 2010 and 2018. The investigators compared subgroups using χ² test/Fisher exact test, Mann–Whitney U test, and linear regression analysis adjusting for patient age where appropriate.

A total of 1,402 children had complete data on empiric antibiotic treatment. Of these, 567 were treated with monotherapy and 589 with combination of two antibiotics. [Pediatr Infec Dis J 2024;43:651-656]

The most common antibiotics used in children with monotherapy and with combination treatment were aminopenicillin/beta-lactamase inhibitor (24.3 percent and 17.3 percent, respectively) and cefuroxime (51.3 percent and 49.9 percent, respectively). Among beta-lactams, the most common combinations were macrolides, aminoglycosides, and clindamycin.

There was no difference seen in clinical severity/outcome between empiric antibiotic treatment with aminopenicillin/beta-lactamase inhibitor and cefuroxime, neither in monotherapy nor in combination therapy of two antibiotics.

Among children with PPE/PE, 9.4 percent, 18.9 percent, and 5.2 percent switched to an appropriate narrow-spectrum beta-lactam therapy following a species diagnosis of Streptococcus pneumoniae (n=192), Streptococcus pyogenes (n=111) or Staphylococcus aureus (n=38) in polymerase chain reaction or culture from pleural fluid or blood, respectively.

Antibiotic resistance

A subset analysis of children with reported bacterial susceptibility testing revealed penicillin resistance in three of 63 (4.8 percent) children with an S pneumonia pathogen and methicillin resistance in 10 of 32 (31.3 percent) with S aureus.

“In children with PPE/PE guideline adherence, proper microbiologic diagnostics and streamlining should be promoted to avoid unnecessary exposure to broad-spectrum ABT and new therapeutic immunomodulating strategies should be investigated in this severe disease,” the investigators said.

From 2010 to 2017, the most prevalent pathogens seen in children with PPE/PE in Germany were S pneumoniae (41 percent), S pyogenes (20 percent), and S aureus (7 percent). [Clin Microbiol Infect 2019;25:857-864]

“Therefore, an extension of antibiotic coverage should only be considered in regions with high rates of methicillin-resistant S aureus or S pneumoniae resistant to penicillin or in children with underlying disease colonized with multidrug-resistant bacilli,” the investigators said.

In the current study, 59.6 percent of children received more than one antibiotic as empiric antibiotic treatment in contrast to the national guideline recommendation.

“The addition of aminoglycosides is especially questionable, as Enterobacterales and nonfermenting Gram-negative rods play a minor role in paediatric PPE/PE,” according to the investigators.

“Aminoglycosides are inactivated in acidic pleural empyema and its use is therefore discouraged in PPE/PE,” they added. [J Thorac Cardiovasc Surg 2017;153:e129-e146; J Infect Dis 1980;142:586-593]