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January 2019

Antibiotic Treatment of Nonsevere Pneumonia With Fast Breathing—Is the Pendulum Swinging?

Author Affiliations
  • 1Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
  • 2Department of Pediatrics, University of Maryland School of Medicine, Baltimore
JAMA Pediatr. 2019;173(1):14-16. doi:10.1001/jamapediatrics.2018.3846

Effective case management of childhood pneumonia has formed the cornerstone of global efforts to reduce pneumonia mortality since the World Health Organization (WHO) first developed case identification and treatment guidelines for low-resource settings in 1990. Under these guidelines, children aged 2 months to 59 months with cough or difficulty breathing and an increased respiratory rate in the absence of chest indrawing were classified as having nonsevere pneumonia, with a recommendation for home-based care with oral antibiotics.1 This pragmatic approach prioritized sensitivity over specificity to rapidly identify children who might benefit from antibiotic treatment, and it was based on existing evidence that hospitalized pneumonia in low- and middle-income countries (LMICs) was caused by Haemophilus influenzae type b and Streptococcus pneumoniae.2 Much has changed in the decades since, most notably the widespread use of conjugate vaccines for H. influenzae type b (HCV) and pneumococcus (PCV).3 An increase in the relative proportion of viral and particularly respiratory syncytial virus–associated pneumonia has been observed after the introduction of these vaccines in high-income countries, and the same trend is anticipated in LMICs, as reviewed by Zar and Polack.4