Children with severe pneumonia can leave hospital sooner after switching to oral antibiotics, trial shows

Children hospitalized with severe pneumonia can safely switch from injectable to oral antibiotics once they begin to recover, allowing many to return home sooner and complete treatment outside the hospital. That is according to a major international clinical trial led by researchers from City St George’s, University of London, UCL Innovative Clinical Trials Unit, and partners across Africa and Europe. The results are published in The Lancet.

Pneumonia remains one of the leading infectious killers of children worldwide, particularly in low- and middle-income countries. Current World Health Organization (WHO) guidelines recommend five days of injectable antibiotics for children hospitalized with severe community-acquired pneumonia, often requiring them to stay in the hospital even after they have substantially improved.

Longer hospital stays are more expensive, placing a higher burden on already pressured health care systems and facilities while increasing the risk of hospital-acquired antibiotic-resistant infections and affecting the well-being of children and their families.

A large trial across Africa

The PediCAP trial is one of the largest studies to assess antibiotic treatment for severe childhood pneumonia in Africa. The study enrolled 1,101 children ages 2 months to 6 years with community-acquired pneumonia that developed outside the hospital but was severe enough to require hospital treatment. Thirteen hospitals across South Africa, Uganda, Zambia, Zimbabwe and Mozambique contributed to the study.

All children in the trial began treatment with a WHO-recommended injectable antibiotic. Some were assigned to switch to either oral amoxicillin or oral amoxicillin-clavulanate when their condition improved, as confirmed by a health care worker. Researchers compared these children with those who received the WHO-recommended injectable treatment for the full five days.

Children who switched to oral antibiotics recovered just as well as those who remained on injectable treatment for five days. Rates of hospital readmission or death within 28 days were similar across all groups—6% for oral amoxicillin, 7% for oral amoxicillin-clavulanate and 6% for injectable antibiotics—showing that an early switch to oral treatment is a safe and effective strategy.

Standard amoxicillin performed just as well as the broader-spectrum antibiotic amoxicillin-clavulanate, supporting the use of a treatment that is cheaper and widely available.

Less treatment, same recovery

Researchers also compared how well children recovered with different durations of antibiotic treatment, ranging from four to eight days in total. A total antibiotic course of four to five days was as effective as longer courses of seven or eight days, suggesting many children can be treated successfully with substantially less antibiotic exposure than is often used in practice.

Children who switched to oral antibiotics left the hospital around one day earlier than those who remained on injectable treatment for the full five days.

Julia Bielicki, professor of pediatric infectious diseases at City St George’s, University of London, and co-lead author of the study, said, “Every year millions of children around the world are admitted to the hospital with severe pneumonia. Our study shows that once a child is clinically improving, it is safe to switch from injectable to oral antibiotics and complete treatment at home.

“This simple change could help children get back to their families sooner, reduce pressure on busy hospitals, lower health care costs and avoid sometimes catastrophic financial effects on families from lost caregiver earnings. Because amoxicillin is affordable and widely available, these findings have the potential to change clinical practice and improve care for children around the world.”

An efficient route to evidence

Dr. Michelle Clements, principal statistician at UCL Innovative Clinical Trials Unit and co-lead author, said, “PediCAP is the first large-scale study to use our innovative multiarm trial design to evaluate different antibiotics and treatment durations at the same time. Rather than simply comparing one short course with one longer course, this approach allowed us to establish that the shortest studied treatment strategy was effective and safe, while also helping us understand the relationship between treatment length and effect.

“By generating robust evidence more efficiently, this trial design has helped answer questions that we hope will support changes to global treatment guidelines and improve care for millions of children with pneumonia worldwide.”

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Robert Egan

Bachelor’s in mathematical biology, Master’s in creative writing. Well-traveled with unique perspectives on science and language.

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