Oral antibiotics appear to be as effective as parenteral antibiotics in the treatment of severe pneumonia in children

Acute respiratory infection (including pneumonia) is one of the leading causes of morbidity and mortality in children under five years of age in developing countries. Antibiotics are needed when a bacterial infection is suspected. When children are hospitalised they often receive injectable antibiotics. This has disadvantages: pain, risk of other infections and cost. There are studies that show that oral antibiotics are effective when children are treated as outpatients. The objective of this review was to determine the effectiveness and safety of oral antibiotics compared to parenteral antibiotics in the treatment of pneumonia in children less than five years old. Oral therapy appears to be an effective and safe alternative to parenteral antibiotics in hospitalised children with severe pneumonia who do not have any serious signs or symptoms. There is currently insufficient evidence to determine the relative benefits and harms of oral antibiotics in children with severe pneumonia if serious signs and symptoms are present or in children with severe pneumonia associated with bacterial confirmation or lobar consolidation on chest X-ray.

Authors' conclusions: 

Oral therapy appears to be an effective and safe alternative to parenteral antibiotics in hospitalised children with severe pneumonia who do not have any serious signs or symptoms.

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Background: 

Acute respiratory infection (ARI) is one of the leading causes of morbidity and mortality in children under five years of age in developing countries. When hospitalisation is required, the usual practice includes administering parenteral antibiotics if a bacterial infection is suspected. This has disadvantages as it causes pain and discomfort to the children, which may lead to treatment refusal or reduced compliance. It is also associated with needle-related complications. In some settings this equipment is in short supply or unavailable necessitating transfer of the child, which increases risks and healthcare costs.

Objectives: 

To determine the equivalence in effectiveness and safety of oral antibiotic compared to parenteral antibiotic therapies in the treatment of severe pneumonia in children between three months and five years of age.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2005, issue 2) which contains the Acute Respiratory Infections Group's specialized register; MEDLINE (January 1966 to July 2005); EMBASE (January 1990 to July 2005) and LILACS (February 2005).

Selection criteria: 

The review included published or unpublished randomised controlled trials (RCTs) and quasi-RCTs comparing any oral antibiotic therapy with any parenteral antibiotic therapy for the treatment of severe pneumonia in children from three months to five years of age.

Data collection and analysis: 

The search yielded more than 1300 titles. Only three studies met all criteria for eligibility. One of the identified trials is yet to publish its results. We did not perform a meta-analysis because of clinical heterogeneity of therapies compared in the included trials.

Main results: 

Campbell 1988 compared oral co-trimoxazole versus intramuscular procaine penicillin followed by oral ampicillin in 134 children. At the seventh day of follow up, treatment failure occurred in 6/66 (9.1%) in the oral co-trimoxazole group and 7/68 (10.2%) in the combined-treatment group. The risk difference was -0.01% (95% confidence interval (CI) -0.11 to 0.09). The APPIS Group 2004 evaluated 1702 patients comparing oral amoxicillin versus intravenous penicillin for two days followed by oral amoxicillin. After 48 hours, treatment failure occurred in 161/845 (19%) in the amoxicillin group and 167/857 (19%) in the parenteral penicillin group. The risk difference was -0.4% (95% CI -4.2 to 3.3). The authors reported similar recovery in both groups at 5 and 14 days.

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