Antibiotic Use and Outcomes in

Children in the Emergency Department

With Suspected Pneumonia
Matthew J. Lipshaw, MD,a Michelle Eckerle, MD, MPH,a,b Todd A. Florin, MD, MSCE,c Eric J. Crotty, MD,b,d Jessi Lipscomb, BS,e
Judd Jacobs, BS,e Mantosh S. Rattan, MD,b,d Richard M. Ruddy, MD,a,b Samir S. Shah, MD, MSCE,b,f,g Lilliam Ambroggio, PhD, MPHh

Antibiotic therapy is often prescribed for suspected community-

BACKGROUND AND OBJECTIVES: abstract
acquired pneumonia (CAP) in children despite a lack of knowledge of causative pathogen. Our
objective in this study was to investigate the association between antibiotic prescription and
treatment failure in children with suspected CAP who are discharged from the hospital
emergency department (ED).
METHODS: We performed a prospective cohort study of children (ages 3 months–18 years) who
were discharged from the ED with suspected CAP. The primary exposure was antibiotic
receipt or prescription. The primary outcome was treatment failure (ie, hospitalization after
being discharged from the ED, return visit with antibiotic initiation or change, or antibiotic
change within 7–15 days from the ED visit). The secondary outcomes included parent-
reported quality-of-life measures. Propensity score matching was used to limit potential bias
attributable to treatment selection between children who did and did not receive an antibiotic
prescription.
RESULTS: Of337 eligible children, 294 were matched on the basis of propensity score. There was
no statistical difference in treatment failure between children who received antibiotics and
those who did not (odds ratio 1.0; 95% confidence interval 0.45–2.2). There was no difference
in the proportion of children with return visits with hospitalization (3.4% with antibiotics
versus 3.4% without), initiation and/or change of antibiotics (4.8% vs 6.1%), or parent-
reported quality-of-life measures.
CONCLUSIONS: Among children with suspected CAP, the outcomes were not statistically different
between those who did and did not receive an antibiotic prescription.

Divisions of aEmergency Medicine, dRadiology, eBiostatistics and Epidemiology, fHospital Medicine, and gInfectious WHAT’S KNOWN ON THIS SUBJECT: Antibiotics are often
Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; bDepartment of Pediatrics, College of prescribed for pediatric pneumonia in ambulatory children
Medicine, University of Cincinnati, Cincinnati, Ohio; cDepartment of Pediatrics, Feinberg School of Medicine, despite the high prevalence of viral etiology. Studies in the
Northwestern University and Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of developing world have shown low rates of treatment failure
Chicago, Chicago, Illinois; and hDepartment of Pediatrics, University of Colorado Denver and Sections of in children with community-acquired pneumonia treated with
Emergency Medicine and Hospital Medicine, Children’s Hospital Colorado, Denver, Colorado a placebo.
Dr Lipshaw conceptualized and designed the study, drafted the initial manuscript, conducted the WHAT THIS STUDY ADDS: In this propensity score–matched
initial analyses, contributed to the interpretation of the results, and reviewed and revised the analysis of a prospectively enrolled ambulatory cohort
manuscript; Drs Eckerle, Shah, and Ruddy conceptualized and designed the study, contributed to the evaluated for pneumonia and discharged from the emergency
interpretation of the results, and reviewed and revised the manuscript; Dr Florin conceptualized department, antibiotic treatment was not associated with
and designed the study, designed the data collection instruments, coordinated and supervised data lower treatment failure rates or improved quality-of-life
collection, collected data, contributed to the interpretation of the results, and reviewed and revised outcomes after discharge.
the manuscript; Drs Crotty and Rattan conceptualized and designed the study, collected data, and
reviewed and revised the manuscript; Mr Jacobs and Ms Lipscomb coordinated and supervised To cite: Lipshaw MJ, Eckerle M, Florin TA, et al. Antibiotic Use
data collection and critically reviewed the manuscript for important intellectual content; and Outcomes in Children in the Emergency Department With
(Continued) Suspected Pneumonia. Pediatrics. 2020;145(4):e20193138

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PEDIATRICS Volume 145, number 4, April 2020:e20193138 ARTICLE
Community-acquired pneumonia country revealed that 93% of children neuromuscular disease, chronic lung
(CAP) is a common pediatric given a placebo did not experience disease, sickle cell disease, or cystic
infection.1 Although typically treatment failure, this has not been fibrosis); children with asthma were
diagnosed by chest radiographs fully evaluated in outpatients in high- included.23
(CXRs) or examination findings, no resource settings.17 Unnecessary
For this study, our analytic data set
true gold standard for the diagnosis treatment leads to unnecessary
excluded children who were
of CAP exists.2 National guidelines medication side effects, adverse drug
hospitalized at enrollment. In
strongly recommend foregoing CXR to events, and increasing antibiotic
addition, because antibiotic
confirm pneumonia in children with resistance.18,19
exposure was the primary exposure,
suspected CAP who are being
Our objectives in this study were to children on antibiotics at the time of
managed as outpatients. Instead,
(1) determine the association their ED visit were also excluded
the use of clinical suspicion and
between antibiotic prescription and (Fig 1).
physical examination findings
treatment failure in children with
are recommended. However, Study Procedure
suspected CAP who were discharged
traditional clinical signs and
from the emergency department (ED) Clinicians completed a standardized
symptoms of CAP have limited
and (2) determine the association case report form after the CXR was
diagnostic accuracy and interrater
between antibiotic prescription and ordered.20 Clinicians included
reliability.3–5
parent-reported quality-of-life (QoL) pediatric emergency medicine
The lack of practical tools to measures. attending physicians and fellows,
differentiate bacterial from viral pediatricians, and nurse practitioners.
causes of CAP makes treatment In addition, historical information
METHODS
decisions challenging. No clinical, was collected by parents and
radiologic, or laboratory features are Study Design recorded on a separate case
reliable for differentiating bacterial This was a planned secondary report form by research
and viral pneumonia.6–8 Despite the analysis from a prospective cohort coordinators. Data collected from
high prevalence of viral infection in study of children with suspected CAP the clinician included physical
children with CAP, antibiotic presenting to a tertiary-care pediatric examination findings, perceived
treatment is common.9–12 In the ED.20,21 Study approval was obtained severity of illness, and planned
Centers for Disease Control and from our institutional review board. disposition.20,21
Prevention Etiology of Pneumonia Informed consent was obtained from
in the Community cohort, only Exposure Measurements
all legal guardians of subjects at the
15% of hospitalized children with time of study enrollment, and assent The primary exposure was
radiographic pneumonia had was obtained from all children administration of antibiotics and/or
a detectable bacterial etiology; $11 years of age. receipt of an antibiotic prescription
however, 88% received antibiotics.13 during the ED visit. Exposure
In addition, the most common Study Population measurement was abstracted
bacteria identified was Mycoplasma from the electronic health
Children 3 months to 18 years of age
pneumoniae, yet CAP caused by this record and reviewed for
with signs and symptoms of lower
organism has not been definitively accuracy by 2 investigators
respiratory tract infection for whom
shown to improve with antibiotic (T.A.F. and L.A.).
a CXR was obtained for clinical
treatment.14
suspicion of pneumonia were eligible Parents reported age, sex, race,
Viruses cause the majority of CAP in for enrollment. Signs and symptoms history of previous episode of
children; however, most studies of of lower respiratory tract infection wheeze, history of previous episode
pneumonia etiology have occurred in were defined as one or more of the of pneumonia or pneumonia
hospitalized patients.13 The following: cough, sputum production, hospitalization, prematurity, receipt
prevalence of bacterial etiology is chest pain, dyspnea, tachypnea, or of recommended vaccines based on
lower in children with CAP not abnormal lung physical examination age, and receipt of the current
requiring hospitalization, and thus, findings.20,22 Children were excluded season’s influenza vaccine. Parents
empirical antibiotics in this if they had been hospitalized in the were asked about the presence and
population may be unnecessary.15,16 previous 14 days, had a history of duration of specific symptoms
Although a large randomized aspiration pneumonia, or had related to their child’s current
controlled trial of amoxicillin versus chronic complex conditions (eg, illness. These symptoms included
a placebo for children with nonsevere immunodeficiency, chronic total days of current illness,
pneumonia in a low-resource African corticosteroid use, heart disease, days of fever, maximum temperature,

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2 LIPSHAW et al
 definitions of antibiotic effectiveness
used by other studies and adult
guidelines.24–28 Time periods of
follow-up were chosen to capture any
potential event within 30 days while
minimizing the risk of recall bias,
acknowledging that most
revisits were most likely to
occur in the first week after ED
discharge.29
The secondary outcomes included ED
revisits occurring 30 days after
enrollment identified by medical
record review. In addition, parents
reported QoL measures 7 to 15 days
after being discharged from the ED.
QoL measures included days until
return to normal activity, presence
and length of symptoms (eg, fever),
and information regarding scheduled
or unscheduled medical care (ie, from
their primary care physician, revisit
to the ED, or subsequent
FIGURE 1 hospitalizations).
Flow diagram of study enrollment.
Data Analysis
Categorical variables were described
cough, difficulty breathing, apnea, findings on the case report form were
by using counts and percentages and
wheezing, noisy breathing, rapid selected by literature review and
compared between groups (ie, those
breathing, difficulty eating, decreased expert consensus as previously
who received antibiotics and those
oral intake, lack of oral intake for described.20 All CXRs and the
who did not) with the x2 test.
.12 hours, congestion and/or corresponding radiology reports from
Maximum temperature was normally
rhinorrhea, vomiting, diarrhea, the on-call radiologist were manually
distributed and was described by
chest pain, abdominal pain, and reviewed (T.A.F) and confirmed if the
using mean and SD. For this variable,
lethargy. radiologist’s impression of the ED
Student’s t test was used to compare
CXR was consistent with pneumonia
groups. All other continuous and
During their physical examination of or not.
discrete variables were described by
the patient, clinicians documented on
using median and interquartile range
a standardized case form the patient’s
Outcome Measurements (IQR) because of nonnormal
general appearance (ie, well, mildly
distributions. The Kruskal-Wallis
ill, moderately ill, or severely ill), The primary outcome was treatment
test compared continuous
impression of overall illness severity failure, defined as having at least one
nonnormally distributed variables
(mild, moderate, or severe), behavior of the following: (1) a return visit
among groups.
(ie, playing, appropriate; quiet, with hospitalization for pneumonia
appropriate; sleeping, easily within 30 days of discharge, (2) Because of the large number of
arousable; sleeping, not easily return visit with a change in clinical confounders associated with
arousable; fussy, consolable; or antibiotics within 30 days of the decision to prescribe antibiotics,
irritable), oxygen saturation discharge, and (3) parental report of propensity scores were generated to
percentage at the time of physical change in antibiotics by a physician at estimate the probability of receiving
examination, skin color, capillary any time between ED discharge and antibiotic prescription (ie, the
refill time, grunting, head bobbing, the follow-up phone call, which primary exposure) in the ED for each
retractions, and presence of and occurred 7 to 15 days after an ED observation.30 Variables in the
focality of wheeze, decreased breath visit. This primary outcome was propensity score were chosen on the
sounds, crackles, and rhonchi. chosen because of its clinical basis of clinical significance and
Historical and physical examination significance and is consistent with included age, sex, history of

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PEDIATRICS Volume 145, number 4, April 2020 3
pneumonia, history of fever, general TABLE 1 Baseline Characteristics of Unmatched Sample
appearance, and days of illness. In Not Treated With or Treated With or Prescribed P
addition, the presence of wheeze, Prescribed Antibiotics Antibiotics
decreased breath sounds, and N 169 168 —
crackles and the clinician’s Demographics
impression of disease severity were Age, y, median (IQR) 3.3 (1.3–8.5) 3.8 (2.1–7.3) .43
included on the basis of statistical Male sex, n (%) 72 (42.6) 77 (45.8) .63
Past medical history, n (%)
significance (P , .05) in the Wheezing 56 (33.1) 49 (29.2) .43
propensity score model. Although Pneumonia 29 (17.2) 35 (20.8) .27
race has been associated with Receipt of seasonal influenza 83 (50.6) 79 (47.6) .66
antibiotic prescribing, race was well vaccine
Parent-reported symptoms
balanced before and after propensity
Days of current illness, 4 (2–7) 5 (3–7) .054
score matching and not included in median (IQR)
the model.31 Previous studies have Fever, n (%) 136 (80.5) 153 (91.1) ,.01
reported that antibiotic prescribing is Cough, n (%) 155 (91.7) 162 (96.4) .11
not statistically impacted by the Difficulty breathing, n (%) 132 (78.1) 121 (72.0) .24
Wheezing, n (%) 110 (65.1) 83 (49.4) ,.01
radiologist’s impression from the
Difficulty eating, n (%) 47 (27.8) 54 (32.1) .45
CXR.21,32 Therefore, ED CXR results Congestion and/or rhinorrhea, 151 (89.3) 129 (76.8) ,.01
were not included in determining the n (%)
propensity score. A 1:1 nearest- Vomiting, n (%) 68 (40.2) 84 (50.0) .091
neighbor matching without Diarrhea, n (%) 29 (17.2) 28 (16.7) .99
Clinician examination and
replacement based on propensity
assessment, n (%)
score was executed by using the General appearance .19
MatchIt package in the R statistical Well 84 (52.5) 80 (49.4)
program.33 Patients with propensity Mildly ill 72 (45.0) 71 (43.8)
scores outside of the region of Moderately ill 4 (2.5) 11 (6.8)
Wheeze 51 (31.9) 30 (18.5) ,.01
common support were discarded
Crackles 33 (20.6) 60 (37.3) ,.01
before matching.33 To assess Focal crackles 21 (63.6) 49 (81.7) .094
covariate balance after matching, Retractions 46 (28.7) 41 (25.3) .57
standardized mean differences were Rhonchi 51 (31.9) 46 (28.4) .58
compared. The standardized mean Focal rhonchi 9 (17.6) 15 (32.6) .14
Decreased breath sounds 27 (16.9) 46 (28.4) .02
differences were assessed graphically
Focal decreased breath 10 (37.0) 40 (87.0) ,.01
by using a Love plot (Supplemental sounds
Fig 2).34 After matching, all covariates CXR consistent with PNA 1 (0.6) 68 (52.3) ,.01
that had an absolute mean difference Unilateral positive CXR results 7 (4.1) 89 (53.0) ,.01
of ,0.25 were determined to be PNA, pneumonia; —, not applicable.
balanced.35,36

The first model was a logistic cohort. All statistical analyses were did not receive antibiotic prescription
regression model to determine the performed by using the R statistical at the initial ED visit. Children who
association of prescribing antibiotics software (version 3.5.0). received antibiotics or an antibiotic
and treatment failure in the matched prescription in the ED were more
cohort. The results are presented as likely to have fever, crackles, and
odds ratios (ORs) and 95% RESULTS decreased breath sounds (including
confidence intervals (CIs). For count focally decreased breath sounds) and
variable outcomes, which included Study Population
be characterized by the clinician as
QoL measures in days, Poisson Of 1142 children in the parent study, having moderate disease; they were
regression was performed to assess 337 met the inclusion criteria for this also less likely to have wheeze or
the association of prescribing study and 49.9% received antibiotics nasal congestion (on history or
antibiotics and the outcomes. The (Fig 1). The median age was 3.4 years examination; Table 1).
results for these models are (IQR: 1.5–7.3). There were no
presented as risk ratios (RRs) and statistical differences in demographic After matching by propensity scores,
95% CIs. A second logistic regression factors such as age, sex, race, history 294 (87%) remained in the final
model was developed and adjusted of prematurity, or immunization analysis, and covariates were
for CXR impression in the matched status between children who did and appropriately balanced

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4 LIPSHAW et al
(Supplemental Table 4, Supplemental statistically significant after The children in our study may have
Fig 2). adjustment for CXR impression (RR been more likely to have a viral rather
1.1; 95% CI 0.94–1.4; Table 2). There than bacterial pathogen causing
Treatment Failure were no statistical differences infection. A recent cohort of
In the matched cohort, 26 (8.8%) between groups for any other parent- hospitalized children at 3 US
children experienced treatment reported symptoms after discharge. hospitals underwent blood and
failure. There was no statistical Symptoms typically associated with nasopharyngeal polymerase chain
difference between groups in antibiotic side effects such as reaction testing for bacteria and
treatment failure. Additionally, there diarrhea (17.0% with antibiotics viruses, of whom 15% had a bacterial
was no statistical difference in the versus 20.4% without), vomiting pathogen identified and 73% had
individual components of treatment (15.0% vs 8.2%), and abdominal a viral pathogen identified.13 The
failure: return visits with hospital pain (15.0% vs 12.9%) were not relatively low rate of detectable
admission (3.4% with antibiotics statistically different between bacterial infection in pediatric
versus 3.4% without; P = .99), return children who received antibiotics and pneumonia has been replicated in
visits with change in antibiotics (2% those who did not. In addition, time 2 studies of hospitalized children
vs 0.6%; P = .67), or initiation or to resolution for the parent-reported in Japan (49.6%) and the United
change in antibiotics in the 2 weeks symptoms was not statistically Kingdom (30%).37,38 In addition, our
after discharge (4.8% vs 6.1%; P = different (Table 3). cohort was relatively young (median
.61). Both models with and without age of 3.4 years), and viruses tend to
adjustment for CXR impression DISCUSSION predominate in younger children.13,37
demonstrated no statistical difference In this prospective study of children Although true rates of bacterial
in treatment failure between the 2 with suspected CAP managed as infection may be higher because
groups (OR 1.0 [95% CI 0.45–2.2] and outpatients, no association was found bacteria are more difficult to detect
OR 0.66 [95% CI 0.19–2.3], between receipt of antibiotic than viruses, this would have likely
respectively; Table 2). prescription and treatment failure led our results to be farther from the
regardless of whether CXR null because we would have expected
Parent-Reported QoL Measures impression was considered in the improved outcomes in children who
Children who received antibiotics or model. In addition, antibiotic received antibiotics.
an antibiotic prescription had an prescription was not associated with
increased risk of being kept from a difference in QoL measures or Although there have been no trials of
usual activity for more days (RR 1.3; parent-reported symptoms after antibiotics versus a placebo for
95% CI 1.1–1.5); this was not discharge. nonsevere pneumonia in high-

TABLE 2 Clinical Outcomes of Propensity Score–Matched Cohort

Not Treated With or Prescribed Treated With or Prescribed Pa Model 1,a Model 2,b
Antibiotics, n (%) Antibiotics, n (%) OR (95% CI) OR (95% CI)
N 147 147 — — —
Clinical outcomes, n (%)
Treatment failure 13 (8.8) 13 (8.8) .99 1.0 (0.45–2.2) 0.66 (0.19–2.3)
Admission within 30 d 5 (3.4) 5 (3.4) .99 1.1 (0.23–5.7) 0.4 (0.03–4.7)
ED revisit within 30 d 13 (8.8) 12 (8.2) .99 0.92 (0.40–2.1) 0.81 (0.23–2.8)
Parent-reported outcomes
Diagnosis of pneumonia since discharge, n (%) 1 (0.7) 0 (0.0) .99 NA NA
Medical care sought since discharge, n (%) 54 (36.7) 65 (44.2) .24 1.4 (0.86–2.2) 1.1 (0.59–2.1)
Type of medical care sought since discharge, n (%) .52
Unscheduled visit 11 (20.4) 10 (15.4) — —
Scheduled follow-up 33 (61.1) 49 (75.4) — —
Follow-up because of worsening or not improving 6 (11.1) 4 (6.2) — —
Routine visit 2 (3.7) 1 (1.5) — —
Telephone follow-up 2 (3.7) 1 (1.5) — —
Unscheduled visit or visit because of worsening, n (%) 17 (11.6) 14 (9.5) .22 0.60 (0.26–1.4) 0.51 (0.15–1.8)
Addition or change of antibiotic at any follow-up, n (%) 7 (4.8) 9 (6.1) .61 1.3 (0.47–3.6) 0.44 (0.071–2.7)
Days child kept from usual activity, median (IQR) 2 (0–3) 2 (1–4) ,.01 1.3 (1.1–1.5) 1.1 (0.94–1.4)c
Days of parental missed work, median (IQR) 0 (0–1) 0 (0–2) .4 1.3 (1.0–1.6) 1.2 (0.88–1.6)c
NA, not available; —, not applicable.
a Propensity score–matched cohort.
b Propensity score–matched cohort; model additionally adjusted for the presence of radiographic pneumonia.
c Rate ratio.

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PEDIATRICS Volume 145, number 4, April 2020 5
TABLE 3 Symptoms After ED Discharge Based on Phone Follow-up
Not Treated With or Prescribed Antibiotics Treated With or Pa OR (95% CI) OR (95% CI), Adjustedb
Prescribed
Antibiotics
N 147 147 — — —
Parental report of symptoms since
discharge
Presence of fever, n (%) 56 (38.1) 62 (42.2) .552 1.2 (0.74–1.9) 1.2 (0.65–2.2)
Days of fever, median (IQR) 2 (1–3.25) 2 (1–3) .82 0.94 (0.75–1.2)c 1.0 (0.73–1.4)c
Days of cough, median (IQR) 7 (3–7) 7 (4–7) .97 1.0 (0.91–1.1)c 1.0 (0.91–1.2)c
Cough compared with discharge, n (%) .43
Worse 4 (3.7) 3 (2.4) — —
About the same 29 (26.9) 25 (20.2) — —
Better 49 (45.4) 69 (55.6) — —
All better 26 (24.1) 27 (21.8) — —
Presence of difficulty breathing, n (%) 49 (33.3) 38 (25.9) .20 0.70 (0.42–1.2) 0.56 (0.27–1.1)
Presence of wheezing, n (%) 53 (36.1) 42 (28.6) .21 0.71 (0.43–1.2) 0.80 (0.41–1.5)
Presence of rapid breathing, n (%) 37 (25.2) 40 (27.2) .79 1.1 (0.66–1.9) 1.3 (0.33–1.7)
Presence of runny nose, n (%) 103 (70.1) 95 (64.6) .38 0.78 (0.48–1.3) 1.4 (0.71–2.9)
Presence of vomiting, n (%) 23 (15.6) 22 (15.0) .99 0.95 (0.50–1.8) 1.1 (0.46–2.5)
Presence of diarrhea, n (%) 30 (20.4) 25 (17.0) .55 0.80 (0.44–1.4) 1.1 (0.53–2.4)
Presence of abdominal pain, n (%) 19 (12.9) 22 (15.0) .736 1.2 (0.61–2.3) 1.4 (0.58–3.2)
—, not applicable.
a Unadjusted after propensity score matching.
b Adjusted for the presence of radiographic pneumonia.
c Rate ratio.

resource settings, Ginsburg et al17 amoxicillin for the treatment of worsening. Our study results support
performed a randomized, placebo- pneumonia and found high rates the finding that subsequent clinical
controlled trial of amoxicillin for the (40%) of treatment failure in the deteriorations of children with
treatment of World Health children treated for only 3 days suspected CAP managed as
Organization–defined nonsevere fast- compared with 0% in the 10-day outpatients are rare. In addition, our
breathing pneumonia in Malawi. group. Their study inclusion criteria rates of treatment failure were
Treatment failure occurred in 4% of required a CXR with alveolar similar to previously described rates
children given amoxicillin and 7% of pneumonia, a temperature .38.5°C, in children treated in the outpatient
children given a placebo.17 The and a white blood cell count of setting.28,41
placebo was statistically inferior to .15 000, which likely selected
Antibiotic-associated diarrhea is
amoxicillin, although the low rates of children with bacterial pneumonia. In
a common complication of oral
treatment failure in each group and addition, our cohort was composed of
antibiotics in children, occurring in
the high number needed to treat (n = children with clinically suspected CAP
∼11% of children exposed to
33) to prevent 1 case of treatment of any etiology as opposed to alveolar
antibiotics and lasting a mean of 4
failure highlight the need to weigh radiographic pneumonia. Given that
days.42 We did not find a difference in
risks as well as benefits of antibiotic the Infectious Diseases Society of
either the incidence of diarrhea in our
treatment. The low rates of treatment America guideline cautions against
population based on antibiotic
failure are consistent with our the routine use of CXR in outpatients
exposure or length of symptoms of
results; however, the lack of antibiotic and that most outpatient settings do
diarrhea based on parental report.
efficacy in our study is potentially not have readily available CXR, our
attributable to our smaller sample results are more applicable to Although we found no statistical
size. Their study location, a malaria- children with clinically suspected CAP differences in the outcomes examined
endemic region, and the World Health rather than the population assessed in those who did and did not receive
Organization’s definition of by Greenberg et al.3,39 antibiotics, it is not clear if there are
pneumonia make it difficult to specific circumstances in which
translate those results to high- Lipsett et al40 prospectively enrolled antibiotics must be prescribed or may
resource settings. children with suspected CAP, and safely be withheld. Although newer
negative CXR results revealed that biomarkers such as procalcitonin
Greenberg et al39 conducted children observed off of antibiotics have been shown to correspond to
a randomized controlled trial in Israel had only a 1.2% rate of subsequent detection of bacteria in hospitalized
comparing 3, 5, and 10 days of pneumonia diagnoses or clinical children with CAP, there have been no

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6 LIPSHAW et al
biomarkers demonstrated to be sample size because of the analysis to determine an age effect on
useful in children treated as convenience sample of our study; outcomes based on limited sample
outpatients, nor have clinical decision therefore, our study was not powered size. Viral diagnostic testing may
rules been derived or validated to to detect a small treatment effect but influence antibiotic prescribing;
help determine which children may was powered to detect a medium or however, it was infrequently
benefit from antibiotics.43 large effect of antibiotics on the obtained with few positive clinical
This study has several limitations. development of treatment failure. A viral test results (n = 5; ,2%) in
The study was designed to assess proportion (23%) of our cohort was our sample.
outcomes in children suspected of lost to phone follow-up. Seventy-five
pneumonia, with or without percent of the patients lost to follow- CONCLUSIONS
radiographic confirmation, because up were in the group not treated with
antibiotics, which may have led us to We found that in a cohort of children
the most recent Infectious Diseases with suspected CAP discharged from
Society of America guidelines do not overestimate the rate of treatment
failure in this group. Because our the hospital ED, receipt of antibiotics
recommend radiographs in this or an antibiotic prescription did not
cohort for the purpose of making hospital is the pediatric referral
center for a wide catchment area and lead to statistical differences in
treatment decisions. Although 20% treatment failure or parent-reported
had radiographic pneumonia on CXR, admits 99.6% of local pediatric
pneumonia cases, it is unlikely that adverse effects or QoL measures. Our
nearly all of these were in the group results suggest that opportunities
prescribed antibiotics. Although we we missed any potential
hospitalizations.44 In addition, we exist to safely manage more
were able to match on the basis of children with suspected CAP
clinical signs and symptoms, the cannot be sure that parent-reported
changes in antibiotics were treated as outpatients without
unequal distribution of radiographic antibiotics.
pneumonia between the groups may respiratory related.
have led to residual confounding by There is evidence that the
indication. We examined the microbiology of CAP differs between
influence of radiographic findings in younger and older children because ABBREVIATIONS
the final multivariate model, and it Mycoplasma pneumoniae is more CAP: community-acquired
showed similar results. We did not prevalent in children .5 years old.13 pneumonia
use antibiotic type in our analysis; However, rates of treatment failure CI: confidence interval
however, because only 3.9% of did not vary significantly between CXR: chest radiograph
children in our sample were children ,5 years old (7%) and ED: emergency department
prescribed a macrolide, antibiotic children $5 years old (12%; P = .2). IQR: interquartile range
type is unlikely to have been a major Although age was included in the OR: odds ratio
confounder. In addition, the propensity score model and was well QoL: quality of life
possibility of a type II error must be balanced between groups, we were RR: risk ratio
considered. We were limited in our unable to perform an age-stratified

Dr Ambroggio conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection, collected data, assisted
in statistical analysis, contributed to the interpretation of the results, and reviewed and revised the manuscript; and all authors approved the final manuscript as
submitted and agree to be accountable for all aspects of the work.
DOI: https://doi.org/10.1542/peds.2019-3138
Accepted for publication Jan 9, 2020
Address correspondence to Matthew J. Lipshaw, MD, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, ML 2008,
Cincinnati, OH 45229. E-mail: matthew.lipshaw@cchmc.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (grants 1K23 AI121325-01 [Dr Florin] and K01
AI125413–01A1 [Dr Ambroggio]) and a pediatric research grant from The Gerber Foundation (Dr Florin). The funders had no role in the design or conduct of the
study or the collection, management, analysis, or interpretation of the data. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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PEDIATRICS Volume 145, number 4, April 2020 7
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PEDIATRICS Volume 145, number 4, April 2020 9
Antibiotic Use and Outcomes in Children in the Emergency Department With
Suspected Pneumonia
Matthew J. Lipshaw, Michelle Eckerle, Todd A. Florin, Eric J. Crotty, Jessi
Lipscomb, Judd Jacobs, Mantosh S. Rattan, Richard M. Ruddy, Samir S. Shah and
Lilliam Ambroggio
Pediatrics originally published online March 16, 2020;

Updated Information & including high resolution figures, can be found at:
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http://pediatrics.aappublications.org/content/early/2020/03/12/peds.2
019-3138#BIBL
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Antibiotic Use and Outcomes in Children in the Emergency Department With
Suspected Pneumonia
Matthew J. Lipshaw, Michelle Eckerle, Todd A. Florin, Eric J. Crotty, Jessi
Lipscomb, Judd Jacobs, Mantosh S. Rattan, Richard M. Ruddy, Samir S. Shah and
Lilliam Ambroggio
Pediatrics originally published online March 16, 2020;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2020/03/12/peds.2019-3138

Data Supplement at:

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