Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2006 Apr 19;2006(2):CD004979.
doi: 10.1002/14651858.CD004979.pub2.

Oral antibiotics versus parenteral antibiotics for severe pneumonia in children

M X Rojas  1 , C Granados
Affiliations

Oral antibiotics versus parenteral antibiotics for severe pneumonia in children

M X Rojas et al. Cochrane Database Syst Rev. .

Abstract

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 Issue 2, 2005); 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Selection criteria: The review included published or unpublished randomised controlled trials (RCTs) and quasi-RCTs comparing any oral antibiotic therapy with any parenteral antibiotic therapy for the treatment of severe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.

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.

PubMed Disclaimer

Conflict of interest statement

Claudia Granados, author of this review, took part as a site co‐investigator in the APPIS Group 2004 trial in Colombia. However, the final analysis and the review writing were done by the contact author María Ximena Rojas. Dr. Granados´s inputs and comments were discussed and agreed with her.

Update of

  • doi: 10.1002/14651858.CD004979

References

References to studies included in this review

APPIS Group 2004 {published data only}
    1. APPIS Group, Addo‐Yobo E, Chisaka N, Hassan M, Hibberd P, Lozano JM, Jeena P, et al. Oral amoxicillin versus injectable penicillin for severe pneumonia in children aged 3 to 59 months: a randomised multicentre equivalency study. Lancet 2004;364(9440):1141‐8. - PubMed
Campbell 1988 {published data only}
    1. Campbell H, Byass P, Forgie IM, O'Neill KP, Lloyd‐Evans N, Greenwood BM. Trial of co‐trimoxazole versus procaine penicillin with ampicillin in treatment of community‐acquired pneumonia in young Gambian children. Lancet 1988;2(8621):1182‐4. - PubMed

References to studies excluded from this review

Al‐Eidan 1999 {published data only}
    1. Al‐Eidan FA, McElnay JC, Scott MG, Kearney MP, Troughton KE, Jenkins J. Sequential antimicrobial therapy:Treatment of severe lower respiratory tract infections in children. Journal of Antimicrobial Chemotherapy 1999;44(5):709‐15. - PubMed
Blokhin 1997 {published data only}
    1. Blokhin BM, Aldonina VV, Kozhukhova TM, Nikulin LA, Rumyantsev AG. Efficacy and tolerance of coamoxiclav in community‐acquired lower respiratory tract infections in children. Antibiotiki i Khimioterapiia 1997;42(10):29‐32. - PubMed
Brambilla 1992 {published data only}
    1. Brambilla C, Escamilla R, Zuck P. Cefuroxime and cefuroxime axetil versus amoxicillin plus clavulanic acid in the treatment of lower respiratory tract infections. European Journal of Clinical Microbiology and Infectious Diseases 1992;11(2):118‐24. - PubMed
Castro 2001 {published data only}
    1. Castro A, Viejo AL, Soler S, Armengou A, Bisbe V, Penarroja G, et al. Efficacy and safety of oral and early‐switch therapy for community‐acquired pneumonia: a randomized controlled trial. American Journal of Medicine 2001;111(5):367‐74. - PubMed
Duke 2002 {published data only}
    1. Duke T, Mgone CS. Chloramphenicol versus benzylpenicillin and gentamicin for the treatment of severe pneumonia in children in Papua New Guinea: A randomised trial. Lancet 2002;359(9305):474‐80. - PubMed
Ehrenkranz 1992 {published data only}
    1. Ehrenkranz NJ, Nerenberg DE, Slater KC, Shultz JM. Intervention to discontinue parenteral antimicrobial therapy in patients hospitalized with pulmonary infections: effect on shortening patient stay. Infection Control and Hospital Epidemiology 1992;13(1):21‐32. - PubMed
Fedorov 1992 {published data only}
    1. Fedorov AM, Tatochenko VK, Khairulin BE. Use of oral antibacterial drugs in the treatment of acute pneumonia in children. Pediatriia 1992;4‐6:38‐42. - PubMed
Friis 1984 {published data only}
    1. Friis B, Andersen P. Antibiotic treatment of pneumonia and bronchiolitis. A prospective randomised study. Archives of Disease in Childhood 1984;59(11):1038‐45. - PMC - PubMed
Fujiki 2003 {published data only}
    1. Fujiki R. Clinical efficacy of oral clarithromycin monotherapy in patients with mild or moderate community‐acquired pneumonia. Japanese Journal of Antibiotics 2003;56(6):712‐8. - PubMed
Galova 1996 {published data only}
    1. Galova K, Sufliarska S. Multicenter randomized study of two once daily regimens in the initial management of community‐acquired respiratory tract infections in 163 children: azithromycin versus ceftibuten. Chemotherapy 1996;42(3):231‐4. - PubMed
Gatzola 1989 {published data only}
    1. Gatzola M. Cefetamet pivoxil in paediatric patients suffering from lower respiratory tract infections. Pharmatherapeutica 1989;5(6):423‐8. - PubMed
Gracheva 1992 {published data only}
    1. Gracheva NM, Petrova MS, Avakov AA, Bobovnikova VT. Augmentin in the clinical picture of infectious diseases. Antibiotiki i Khimioterapiia 1992;37(9):25‐7. - PubMed
Hammerschlag 2000 {published data only}
    1. Hammerschlag MR, Roblin PM. Microbiologic efficacy of moxifloxacin for the treatment of community‐acquired pneumonia due to Chlamydia pneumoniae. International Journal of Antimicrobial Agents 2000;15(2):149‐52. - PubMed
Hernandez 1996 {published data only}
    1. Hernandez JM, Sides GD, Conforti PM, Smietana MG. Clinical efficacy of dirithromycin in patients with bacteremic pneumonia. Clinical Therapeutics 1996;18(6):128‐38. - PubMed
Higuera 1996 {published data only}
    1. Higuera F, Hidalgo H, Feris J, Giguere G, Collins JJ. Comparison of oral cefuroxime axetil and oral amoxycillin/clavulanate in the treatment of community‐acquired pneumonia. Journal of Antimicrobial Chemotherapy 1996;37(3):555‐64. - PubMed
Jibril 1989 {published data only}
    1. Jibril HB, Ifere OA, Odumah DU. An open, comparative evaluation of amoxycillin and amoxycillin plus clavulanic acid ('Augmentin') in the treatment of bacterial pneumonia in children. Current Medical Research and Opinion 1989;11(9):585‐92. - PubMed
Keeley 1996 {published data only}
    1. Keeley DJ, Nkrumah FK, Kapuyanyika C. Randomized trial of sulfametoxazole + trimetripine versus procaine penicillin for the outpatient treatment of childhood pneumonia in Zimbague. Bulletin of the World Health Organization 1990;68(2):185‐92. - PMC - PubMed
Klein 1995 {published data only}
    1. Klein M. Multicenter trial of cefpodoxime proxetil vs. amoxicillin‐clavulanate in acute lower respiratory tract infections in childhood. Pediatic Infectious Disease Journal 1995;14(Suppl 4):19‐22. - PubMed
Krumpe 1999 {published data only}
    1. Krumpe PE, Cohn S, Garreltes J, Ramirez J, Coulter H, Haverstock D, et al. Intravenous and oral mono‐or combination‐therapy in the treatment of severe infections: ciprofloxacin versus standard antibiotic therapy. Journal of Antimicrobial Chemotherapy 1999;43(Suppl A):117‐28. - PubMed
Lode 1999 {published data only}
    1. Lode H, File TM Jr, Mandell L, Ball P, Pypstra R, Thomas M. Oral gemifloxacin versus sequential therapy with intravenous ceftriaxone/oral cefuroxime with or without a macrolide in the treatment of patients hospitalized with community‐acquired pneumonia: a randomized, open‐label, multicenter study of clinical efficacy and tolerability. Clinical Therapeutics 2002;24(11):1915‐36. - PubMed
Mulholland 1995 {published data only}
    1. Mulholland EK, Falade AG, Corrah PT, Omosigho C, N'Jai P, Giadom B, et al. A randomized trial of chloramphenicol vs. trimethoprim‐sulfamethoxazole for the treatment of malnourished children with community‐acquired pneumonia. Pediatic Infectious Disease Journal 1995;14(11):959‐65. - PubMed
Numazaki 2000 {published data only}
    1. Numazaki K, Sakamoto Y, Umetsu M, Agatsuma Y, Yamanaka T Kogasaka R, et al. Therapeutic effect of clarithromycin for respiratory‐tract infections in children caused by Chlamydia pneumoniae. International Journal of Antimicrobial Agents 2000;13(3):219‐22. - PubMed
Portier 1996 {published data only}
    1. Portier H, May T, Proust A. Comparative efficacy of sparfloxacin in comparison with amoxycillin plus ofloxacin in the treatment of community‐acquired pneumonia. Journal of Antimicrobial Chemotherapy 1996;37(Suppl A):83‐91. - PubMed
Prinsloo 1974 {published data only}
    1. Prinsloo JG, Cicoria A, Robinson RG, Laubscher NF. A comparison between oral pivampicillin and ampicillin in children with bronchopneumonia. South African Medical Journal 1974;48(63):2627‐8. - PubMed
Saiman 2003 {published data only}
    1. Saiman L, Goldfarb J, Kaplan SA, Wible K, Edge‐Padbury B, Naberhuis‐Stehouwer S, et al. Safety and tolerability of linezolid in children. Pediatic Infectious Disease Journal 2003;22(Suppl 9):193‐200. - PubMed
Sereda 1994 {published data only}
    1. Sereda EV, Tatochenko VK, Katosova LK. Use of oral macrolide and azalide antibiotics in children with bronchopulmonary diseases. Antibiotiki i Khimioterapiia 1994;39(7):47‐53. - PubMed
Shames 1970 {published data only}
    1. Shames JM, George RB. Comparison of antibiotics in the treatment of mycoplasmal pneumonia. Archives of Internal Medicine 1970;125(4):680‐4. - PubMed
Tatochenko 1999 {published data only}
    1. Tatochenko VK, Katosova LK. Etiology and treatment of pneumonia in children. Antibiotiki i Khimioterapiia 1999;44(1):14‐9. - PubMed
Tsarouhas 1998 {published data only}
    1. Tsarouhas N, Shaw KN, Hodinka RL, Bell LM. Effectiveness of intramuscular penicillin versus oral amoxicillin in the early treatment of outpatient pediatric pneumonia. Pediatric Emergency Care 1998;14(5):338‐41. - PubMed

References to studies awaiting assessment

Alvarez 2003 {published data only}
    1. Alvarez AM. Guidelines for community acquired pneumonia in children and its aplicability [Neumonía adquirida en la comunidad en niños: aplicabilidad de las guías clínicas]. Rev Chil Infectol 2003;20(Suppl 1):59‐62.
Fine 2003 {published data only}
    1. Fine MJ, Stone RA, Lave JR, Hough LJ, Obrosky DS, Mor MK, et al. Implementation of an evidence‐based guideline to reduce duration of intravenous antibiotic therapy and length of stay for patients hospitalized with community‐acquired pneumonia: a randomized controlled trial. American Journal of Medicine 2003;115(5):343‐51. - PubMed
Ministerio 1995 {published data only}
    1. Ministerio de Salud de Chile. Tratamiento de infecciones respiratorias agudas en el niño: bronquitis aguda obstructiva y neumonía. Pediatría (Santiago de Chile) 1995;11(5):285‐8.
Rhew 2001 {published data only}
    1. Rhew DC, Tu GS, Ofman J, Henning JM, Richards MS, Weingarten SR. Early switch and early discharge strategies in patients with community‐acquired pneumonia: A meta‐analysis. Archives of Internal Medicine 2001;12(161):722‐7. - PubMed

References to ongoing studies

PIVOT Trial 2004 {unpublished data only}
    1. Multicentre randomised controlled trial of oral versus intravenous treatment for community acquired pneumonia in children (equivalence study). Ongoing study September 2002.

Additional references

CSG 2002
    1. Catchup Study Group. Clinical efficacy of co‐trimoxazole versus amoxicillin twice daily for treatment of pneumonia: a randomised controlled clinical trial in Pakistan. Archives of Disease in Childhood 2002;86(2):113‐8. - PMC - PubMed
Dickersin 1994
    1. Dickersin K, Scherer R, Lefebvre C. Identifying relevant studies for systematic reviews. BMJ 1994;309:1286‐91. - PMC - PubMed
Fogarty 2002
    1. Fogarty CM, Cyganowski M, Palo WA, Hom RC, Craig WA. A comparison of cefditoren pivoxil and amoxicillin/clavulanate in the treatment of community‐acquired pneumonia: a multicentre, prospective, randomized, investigator‐blinded, parallel‐group study. Clinical Therapeutics 2002;24(11):1854‐70. - PubMed
Garenne 1992
    1. Garenne FE, Ronsmans C, Campbell H. The magnitude of mortality from acute respiratory infections in children under 5 years in developing countries. World Health Statistics Quarterly 1992;45:180‐91. - PubMed
Guyatt 2001
    1. Guyatt G, Rennie D (editors). Users´ Guide to the Medical Literature. Essentials of Evidence‐Based Clinical Practice. JAMA. American Medical Association, 2001.
Harris 1998
    1. Harris JA, Kolokathis A, Campbell M, Cassell GH, Hammerschlag MR. Safety and efficacy of azithromycin in the treatment of community‐acquired pneumonia in children. Pediatric Infectious Disease Journal 1998;17(10):865‐71. - PubMed
Marras 2004
    1. Marras TK, Nopmaneejumruslers C, Chan CK. Efficacy of exclusively oral antibiotic therapy in patients hospitalized with community‐acquired pneumonia: a retrospective study and meta‐analysis. American Journal of Medicine 2004;116(6):385‐93. - PubMed
MASCOT 2002
    1. Pakistan Multicentre Amoxycillin Short Course Therapy (MASCOT) pneumonia study group. Clinical efficacy of 3 days versus 5 days of oral amoxicillin for treatment of childhood pneumonia: a multicentre double‐blind trial. Lancet 2002;360(9336):835‐41. - PubMed
Mulholland 1998
    1. Mulholland K, Agoke G, et al. A randomized trial of cloramphenicol vs trimethoprim sulfamethoxazole for the treatment of malnourished children with community acquired pneumonia. Pediatic Infectious Disease Journal 1998;14:959‐65. - PubMed
WB 1993
    1. The World Bank. World Development Report 1993: Investing in health. Oxford University Press. 1993.
WHO 1991
    1. Programme for the Control of Acute Respiratory Infections. Technical basis for the WHO recommendations on the management of pneumonia in children at first level health facilities. WHO/ARI. Vol. 20, Geneva: World Heath Organisation, 1991.

Publication types

MeSH terms

Substances