Mycoplasma pneumoniae and Chlamydia pneumoniae in pediatric community-acquired pneumonia: comparative efficacy and safety of clarithromycin vs. erythromycin ethylsuccinate

Treatment of Chlamydial Infections

Sexually transmitted infections (STIs) are a major health problem with an estimated burden of disease transmission as high as one million new cases per day globally. Chlamydia trachomatis, a member of the genus Chlamydia, is one of the most common and curable causative agents of STIs. C. trochomatis infections usually affect sexually active young adults and adolescents; and are composed of a broad spectrum of diseases varying from asymptomatic infection to severe genito-urinary infection leading to infertility and acute or chronic ocular infection (trachoma), which may result in blindness and pneumonia. Among the members of the genus Chlamydia, there are also two pathogenic species, Chlamydia pneumoniae and Chlamydia psittaci which are responsible for acute respiratory tract infections and febrile illness in humans. The incidence, pathophysiology, and diagnostic methods are discussed in detail in the previous chapters. The purpose of this chapter is to elucidate the management of infections due to C. trachomatis, C. pneumoniae, and C. psittaci including antibiotic susceptibility and resistance mechanisms, treatment recommendations for ocular infections, genito-urinary and respiratory tract infections, and management of sex partners, pregnant women, neonates, and children according to the latest data.

Erythromycin Formulations—A Journey to Advanced Drug Delivery

Erythromycin (ERY) is a macrolide compound with a broad antimicrobial spectrum which is currently being used to treat a large number of bacterial infections affecting the skin, respiratory tract, intestines, bones and other systems, proving great value from a clinical point of view. It became popular immediately after its discovery in 1952, due to its therapeutic effect against pathogens resistant to other drugs. Despite this major advantage, ERY exhibits several drawbacks, raising serious clinical challenges. Among them, the very low solubility in water and instability under acidic conditions cause a limited efficacy and bioavailability. Apart from this, higher doses promote drug resistance and undesirable effects. In order to overcome these disadvantages, during the past decades, a large variety of ERY formulations, including nanoparticles, have emerged. Despite the interest in ERY-(nano)formulations, a review on them is lacking. Therefore, this work was aimed at reviewing all efforts made to encapsulate ERY in formulations of various chemical compositions, sizes and morphologies. In addition, their preparation/synthesis, physico-chemical properties and performances were carefully analysed. Limitations of these studies, particularly the quantification of ERY, are discussed as well.

Global prevalence of resistance to macrolides in Mycoplasma pneumoniae: a systematic review and meta-analysis

OBJECTIVES

To determine the prevalence of resistance to macrolides in Mycoplasma pneumoniae worldwide.

METHODS

Prior to 12 December 2020, PubMed, Web of Science, Scopus and Embase databases were searched for epidemiological studies of M. pneumoniae resistance. Two reviewers independently extracted data from included studies. The extracted data include sampling population, total sampling number, the number of resistant strains and the molecular subtype of resistant strains. The estimate of resistance prevalence was calculated using the random-effects model.

RESULTS

A total of 17 873 strains were obtained from five continents and reported in 98 investigations between 2000 and 2020, with 8836 strains characterized as macrolide resistant. In summary, macrolide-resistant M. pneumoniae was most common in Asia (63% [95% CI 56, 69]). In Europe, North America, South America and Oceania, the prevalence was 3% [2, 7], 8.6% [6, 11], 0% and 3.3%, respectively. Over the last 20 years, the prevalence of macrolide-resistant M. pneumoniae has remained high in China (81% [73, 87]), with a significant increasing trend in South Korea (4% [1, 9] to 78% [49, 93], P < 0.0001). Furthermore, a point mutation at 2063 from A to G was mostly related to M. pneumoniae macrolide resistance. In terms of clinical outcomes, longer cough (mean difference [MD]: 2.93 [0.26, 5.60]) and febrile days (MD: 1.52 [1.12, 1.92]), and prolonged hospital stays (MD: 0.76 [0.05, 1.46]) might be induced by macrolide-resistant M. pneumoniae pneumonia.

CONCLUSIONS

The incidence of macrolide-resistant M. pneumoniae varies globally, with eastern Asia having a greater degree of resistance. However, attention is also required in other areas, and antibiotic alternatives should be considered for treatment in high-prevalence countries.

Mycoplasma Pneumoniae Infection and Persistent Wheezing in Young Children: A Retrospective Case-Control Study

BACKGROUND

To investigate the clinical characteristics of children with persistent wheezing (PW) with Mycoplasma pneumoniae (MP) DNA in bronchoalveolar lavage fluid (BALF).

METHODS

This retrospective case-control study included consecutive admitted children under 3 years of age who were diagnosed with PW and had MP DNA detected in BALF. Patients with mycoplasma pneumoniae pneumonia (MPP) and foreign-body aspiration (FBA) were enrolled as controls. The clinical characteristics of the groups were compared.

RESULTS

During the study period, there were 89 patients diagnosed with PW without structural anomalies of the conductive airways, and 30 of these patients (33.7%, 30/89) with MP DNA detected in the BALF were selected as the study group. We included 44 patients with MPP and 44 patients with FBA as controls. Patients with MPP were older and had a higher occurrence of fever and C-reactive protein (CRP) than patients with PW (all P < 0.001). The median MP DNA copy number in patients with MPP was higher than that of patients with PW (P = 0.004). The median level of MP IgG in patients with PW was lower than that of patients with MPP and higher than that of patients with FBA (all P < 0.001). MP DNA copy number positively correlated with age (r = 0.392, P = 0.001) and CRP (r = 0.235, P = 0.048).

CONCLUSIONS

Our study reveals that MP was highly detected in the BALF of PW patients. In addition, young patients with a low load of MP infection showed lower amounts of antibody, and a weak inflammatory response might be associated with PW.

Efficacy of different antibiotics in treatment of children with respiratory mycoplasma infection

BACKGROUND

Respiratory infections in children are common pediatric diseases caused by pathogens that invade the respiratory system. Children are considerably susceptible to Mycoplasma pneumoniae infection. There has been widespread clinical attention on treatment strategies for this disease.

AIM

To analyze the clinical efficacy of different antibiotics in treating pediatric respiratory mycoplasma infections.

METHODS

We included 106 children with a confirmed diagnosis of respiratory mycoplasma infection who were admitted to our hospital from April 2017 to July 2019 and grouped them using a random number table. Among them, 53 children each received clarithromycin or erythromycin. The clinical efficacy of both drugs was evaluated and compared. We performed the multiplex polymerase chain reaction (MP-PCR) test and determined the MP-PCR negative rate in children after the end of the treatment course. We compared the incidence of toxic and side effects, including nausea, diarrhea, and abdominal pain; further, we recorded the length of hospitalization, antipyretic time, and drug costs. Additionally, we evaluated and compared the compliance of the children during treatment.

RESULTS

The erythromycin group showed a significantly higher total effective rate of clinical treatment than the clarithromycin group. MP-PCR test results showed that the clarithromycin group had a significantly higher MP-PCR negative rate than the erythromycin group. Moreover, children in the clarithromycin group had shorter fever time, shorter hospital stays, and lower drug costs than those in the erythromycin group. The clarithromycin group had a significantly higher overall drug adherence rate than the erythromycin group. The incidence of toxic and side effects was significantly lower in the clarithromycin group than in the erythromycin group (P < 0.05).

CONCLUSION

Our findings indicate that clarithromycin has various advantages over erythromycin, including higher application safety, stronger mycoplasma clearance, and higher medication compliance in children; therefore, it can be actively promoted.

[Guidelines for the Management of Community Acquired Pneumonia in Children and Adolescents (Pediatric Community Acquired Pneumonia, pCAP) - Issued under the Responsibility of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Pulmonology (GPP)]

The present guideline aims to improve the evidence-based management of children and adolescents with pediatric community-acquired pneumonia (pCAP). Despite a prevalence of approx. 300 cases per 100 000 children per year in Central Europe, mortality is very low. Prevention includes infection control measures and comprehensive immunization. The diagnosis can and should be established clinically by history, physical examination and pulse oximetry, with fever and tachypnea as cardinal features. Additional signs or symptoms such as severely compromised general condition, poor feeding, dehydration, altered consciousness or seizures discriminate subjects with severe pCAP from those with non-severe pCAP. Within an age-dependent spectrum of infectious agents, bacterial etiology cannot be reliably differentiated from viral or mixed infections by currently available biomarkers. Most children and adolescents with non-severe pCAP and oxygen saturation > 92 % can be managed as outpatients without laboratory/microbiology workup or imaging. Anti-infective agents are not generally indicated and can be safely withheld especially in children of young age, with wheeze or other indices suggesting a viral origin. For calculated antibiotic therapy, aminopenicillins are the preferred drug class with comparable efficacy of oral (amoxicillin) and intravenous administration (ampicillin). Follow-up evaluation after 48 - 72 hours is mandatory for the assessment of clinical course, treatment success and potential complications such as parapneumonic pleural effusion or empyema, which may necessitate alternative or add-on therapy.

Polyclonal spread of multiple genotypes of Mycoplasma pneumoniae in semi-closed settings in Yamagata, Japan

PURPOSE

To clarify the spread of Mycoplasma pneumoniae infections in semi-closed settings such as schools and family homes using molecular typing methods.

METHODOLOGY

We retrospectively searched for school- and family-based clusters of M. pneumoniae infections based on information regarding patients from whom M. pneumoniae strains had been isolated between 2011 and 2013 in Yamagata, Japan. The molecular typing profile, including the P1 type and the four-locus (Mpn13, 14, 15 and 16) multiple-locus variable-number tandem-repeat (VNTR) analysis (MLVA) type, was obtained from our previous study.

RESULTS

We identified 11 school-based clusters involving 71 patients and 16 family-based clusters involving 38 patients, including 14 duplications between these types of clusters. A total of 95M. pneumoniae strains isolated from those patients were divided into 4 genotypes: 33 strains of type 4-5-7-2, 1; 31 of type 4-5-7-3, 1; 24 of type 3-5-6-2, 2c; and 7 of type 3-5-6-2, 2a. Of the 11 school-based clusters, 6 clusters (54.5%) consisted of multiple genotypes, and the remaining 5 clusters consisted of a single genotype. Moreover, the presence of multiple genotypes was identified in three classrooms of a school. On the other hand, in 14 (87.5%) of the 16 family-based clusters, the genotypes of the M. pneumoniae strains isolated from each family member were identical.

CONCLUSION

The spread of M. pneumoniae infection in schools is likely polyclonal, since M. pneumoniae strains are brought into schools from various sites, such as family homes, which are important sites of disease transmission.

Recommendations and guidelines for the treatment of pneumonia in Taiwan

Pneumonia is a leading cause of death worldwide, ranking third both globally and in Taiwan. This guideline was prepared by the 2017 Guidelines Recommendations for Evidence-based Antimicrobial agents use in Taiwan (GREAT) working group, formed under the auspices of the Infectious Diseases Society of Taiwan (IDST). A consensus meeting was held jointly by the IDST, Taiwan Society of Pulmonary and Critical Care Medicine (TSPCCM), the Medical Foundation in Memory of Dr. Deh-Lin Cheng, the Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education and CY Lee's Research Foundation for Pediatric Infectious Diseases and Vaccines. The final guideline was endorsed by the IDST and TSPCCM. The major differences between this guideline and the 2007 version include the following: the use of GRADE methodology for the evaluation of available evidence whenever applicable, the specific inclusion of healthcare-associated pneumonia as a category due to the unique medical system in Taiwan and inclusion of recommendations for treatment of pediatric pneumonia. This guideline includes the epidemiology and recommendations of antimicrobial treatment of community-acquired pneumonia, hospital-acquired pneumonia, ventilator-associated pneumonia, healthcare-associated pneumonia in adults and pediatric pneumonia.

Mixed Chlamydia trachomatis Peptide Antigens Provide a Specific and Sensitive Single-Well Colorimetric Enzyme-Linked Immunosorbent Assay for Detection of Human Anti-C. trachomatis Antibodies

For detection of anti-C. trachomatis antibodies by serological assays, use of classical chlamydial antigens results in high cross-reactivity and poor sensitivity. Previously, we discovered 48 strongly reactive peptide antigens of C. trachomatis-specific B-cell epitopes from 21 immunodominant proteins, and individual testing and combined scoring of 5 to 11 peptide antigens provided highly sensitive and specific detection of anti-C. trachomatis antibodies in chemiluminescent ELISAs. To simplify this method, this study established a single-well labor-saving colorimetric ELISA using a mixture of 12 strongly reactive C. trachomatis peptide antigens (Ctr Mix1) for detection of anti-C. trachomatis antibodies. This Ctr Mix1 ELISA (94% sensitivity and 98% specificity) outperformed 4 commercial ELISAs (49% to 79% sensitivity and 98% specificity). This ELISA can be easily implemented and commercialized, with convenient setup for use in nonspecialized laboratories. Thus, this mixed peptide assay with superior specificity and sensitivity will improve serodiagnosis of C. trachomatis infections.

Sensitive and specific detection of anti-Chlamydia trachomatis antibodies in standard enzyme-linked immunosorbent assays (ELISAs) is compromised by cross-reactivity and poor sensitivity of classical C. trachomatis antigens. Previously, we discovered 48 strongly reactive peptide antigens of C. trachomatis-specific B-cell epitopes from 21 immunodominant proteins. By comprehensive individual testing of 11 top-ranked peptide antigens, we found very high sensitivity and specificity for detection of anti-C. trachomatis antibodies in chemiluminescent ELISAs. The current study established a labor-saving colorimetric ELISA by using a mixture of 12 strongly reactive C. trachomatis peptide antigens (Ctr Mix1) in a single well/serum rather than assaying reactivity to each individual peptide. For performance evaluation, we used a simulated population of 212 anti-C. trachomatis antibody-positive and -negative sera from 125 women with NAAT-confirmed active C. trachomatis infection and from 87 healthy women at low risk for C. trachomatis infection. In comparison to a composite reference standard (CRS) for anti-C. trachomatis antibody status, the Ctr Mix1 IgG ELISA achieved 93.9% sensitivity, significantly superior to the 49% to 79% sensitivities of four commercial anti-C. trachomatis IgG ELISAs, and 98% specificity of all tested assays. Compared to the labor-intensive individual peptide testing, this mixed peptide ELISA retained high specificity with only marginal, ∼5% sensitivity loss. By ROC-AUC, likelihood ratio, and predictive value analyses, the Ctr Mix1 ELISA performed satisfactorily at 10% to 75% prevalence range of anti-C. trachomatis antibodies but significantly better than commercial ELISAs. Thus, the labor-saving mixed peptide colorimetric ELISA format provides simultaneously high specificity and sensitivity for detection of anti-C. trachomatis antibodies.

IMPORTANCE For detection of anti-C. trachomatis antibodies by serological assays, use of classical chlamydial antigens results in high cross-reactivity and poor sensitivity. Previously, we discovered 48 strongly reactive peptide antigens of C. trachomatis-specific B-cell epitopes from 21 immunodominant proteins, and individual testing and combined scoring of 5 to 11 peptide antigens provided highly sensitive and specific detection of anti-C. trachomatis antibodies in chemiluminescent ELISAs. To simplify this method, this study established a single-well labor-saving colorimetric ELISA using a mixture of 12 strongly reactive C. trachomatis peptide antigens (Ctr Mix1) for detection of anti-C. trachomatis antibodies. This Ctr Mix1 ELISA (94% sensitivity and 98% specificity) outperformed 4 commercial ELISAs (49% to 79% sensitivity and 98% specificity). This ELISA can be easily implemented and commercialized, with convenient setup for use in nonspecialized laboratories. Thus, this mixed peptide assay with superior specificity and sensitivity will improve serodiagnosis of C. trachomatis infections.

Discovery of Human-Specific Immunodominant Chlamydia trachomatis B Cell Epitopes

Current serological assays for species-specific detection of anti-Chlamydia species antibodies suffer from well-known shortcomings in specificity and ease of use. Due to the high prevalences of both anti-C. trachomatis and anti-C. pneumoniae antibodies in human populations, species-specific serology is unreliable. Therefore, novel specific and simple assays for chlamydial serology are urgently needed. Conventional antigens are problematic due to extensive cross-reactivity within Chlamydia spp. Using accurate B cell epitope prediction and a robust peptide ELISA methodology developed in our laboratory, we identified immunodominant C. trachomatis B cell epitopes by screening performed with sera from C. trachomatis-infected women. We discovered 38 novel human host-dependent antigens from 20 immunodominant C. trachomatis proteins, in addition to confirming 10 host-independent mouse serum peptide antigens that had been identified previously. This extended set of highly specific C. trachomatis peptide antigens can be used in simple ELISA or multiplexed microarray formats and will provide high specificity and sensitivity to human C. trachomatis serodiagnosis.

Chlamydia species-specific serology is compromised by cross-reactivity of the gold standard microimmunofluorescence (MIF) or commercial enzyme-linked immunosorbent assays (ELISAs). This study was conducted to discover novel C. trachomatis-specific peptide antigens that were recognized only by the antibody response of the natural human host. We evaluated a library of 271 peptide antigens from immunodominant C. trachomatis proteins by reactivity with 125 C. trachomatis antibody-positive sera from women with PCR-confirmed C. trachomatis infection and 17 C. trachomatis antibody-negative sera from low-risk women never diagnosed with C. trachomatis infection. These C. trachomatis peptide antigens had been predicted in silico to contain B cell epitopes but had been nonreactive with mouse hyperimmune sera against C. trachomatis. We discovered 38 novel human host-dependent antigens from 20 immunodominant C. trachomatis proteins (PmpD, IncE, IncG, CT529, CT618, CT442, TarP, CT143, CT813, CT795, CT223, PmpC, CT875, CT579, LcrE, IncA, CT226, CT694, Hsp60, and pGP3). Using these human sera, we also confirmed 10 C. trachomatis B cell epitopes from 6 immunodominant C. trachomatis proteins (OmpA, PmpD, IncE, IncG, CT529, and CT618) as host species-independent epitopes that had been previously identified by their reactivity with mouse hyperimmune sera against C. trachomatis. ELISA reactivities against these peptides correlated strongly with the C. trachomatis microimmunofluorescence (MIF) text results (Pearson’s correlation coefficient [R] = 0.80; P < 10⁻⁶). These C. trachomatis peptide antigens do not cross-react with antibodies against other Chlamydia species and are therefore suitable for species-specific detection of antibodies against C. trachomatis. This study identified an extended set of peptide antigens for simple C. trachomatis-specific ELISA serology.

IMPORTANCE Current serological assays for species-specific detection of anti-Chlamydia species antibodies suffer from well-known shortcomings in specificity and ease of use. Due to the high prevalences of both anti-C. trachomatis and anti-C. pneumoniae antibodies in human populations, species-specific serology is unreliable. Therefore, novel specific and simple assays for chlamydial serology are urgently needed. Conventional antigens are problematic due to extensive cross-reactivity within Chlamydia spp. Using accurate B cell epitope prediction and a robust peptide ELISA methodology developed in our laboratory, we identified immunodominant C. trachomatis B cell epitopes by screening performed with sera from C. trachomatis-infected women. We discovered 38 novel human host-dependent antigens from 20 immunodominant C. trachomatis proteins, in addition to confirming 10 host-independent mouse serum peptide antigens that had been identified previously. This extended set of highly specific C. trachomatis peptide antigens can be used in simple ELISA or multiplexed microarray formats and will provide high specificity and sensitivity to human C. trachomatis serodiagnosis.

Comprehensive Molecular Serology of Human Chlamydia trachomatis Infections by Peptide Enzyme-Linked Immunosorbent Assays

For detection of anti-Chlamydia trachomatis antibodies by serological assays, use of classical whole-organism chlamydial antigens results in high cross-reactivity. These antigens bind mainly antibodies against the major outer membrane protein (OmpA) and bind antibodies against other immunodominant non-OmpA proteins to a lesser extent, resulting in poor assay sensitivity. The specificity of C. trachomatis serology is also compromised by the high prevalence of cross-reactive anti-C. pneumoniae antibodies in human populations. We previously identified 48 highly specific C. trachomatis B cell epitope peptide antigens of 21 immunodominant proteins. This study validated peptide antigen-based novel ELISAs that provide highly specific and sensitive detection of anti-C. trachomatis antibodies. Compared to four commercial ELISAs that achieved only poor sensitivities (51.5% to 64.8%), the combined signals of 5 to 11 peptides provided high sensitivity (86.5% to 91.8%) at the same 98% specificity. Thus, by using multiple peptide antigens of immunodominant proteins, we created simple ELISAs with specificity and sensitivity superior to standard C. trachomatis serodiagnosis.

Sensitive species-specific detection of anti-Chlamydia trachomatis antibodies is compromised by cross-reactivity of the C. trachomatis antigens used in standard microimmunofluorescence (MIF) testing and enzyme-linked immunosorbent assays (ELISAs). Previously, we discovered 48 strongly reactive C. trachomatis-specific B cell epitope peptides from 21 immunodominant proteins. Here we comprehensively evaluated the 11 top-ranked C. trachomatis-specific peptide antigens from 8 proteins for use in C. trachomatis serology. Sera from 125 women with nucleic acid amplification test (NAAT)-confirmed active C. trachomatis infection and from 49 healthy women with a low risk of C. trachomatis infection were used as anti-C. trachomatis antibody-positive and -negative sera. Results obtained for detection of IgG1, IgG3, and IgA1 antibodies against the 11 C. trachomatis peptide antigens were compared to results from 4 commercial anti-C. trachomatis IgG ELISAs. Using composite reference standards (CRS) of all assays for anti-C. trachomatis antibody status, commercial ELISAs detected antibodies in antibody-positive women with sensitivities of 51.5% to 64.8%. In contrast, a combination of the results of all 11 peptides detected IgG (IgG1 and IgG3) antibodies with 91.8% sensitivity, and a labor-saving combination of the 5 optimal peptides still detected antibodies in antibody-positive women with 86.5% sensitivity (all at 98% specificity). The superior performance of the combined peptide ELISAs was confirmed by area under the receiver operating characteristic curve (ROC-AUC), likelihood ratio, and predictive value analyses. The higher sensitivity of the peptide assays results from using multiple B cell epitopes of several C. trachomatis immunodominant proteins, including OmpA, compared to exclusively using the OmpA antigens used in commercial ELISAs. Thus, ELISAs with combined use of synthetic peptide antigens for C. trachomatis antibody detection have the advantage of simultaneous high sensitivity and high specificity.

IMPORTANCE For detection of anti-Chlamydia trachomatis antibodies by serological assays, use of classical whole-organism chlamydial antigens results in high cross-reactivity. These antigens bind mainly antibodies against the major outer membrane protein (OmpA) and bind antibodies against other immunodominant non-OmpA proteins to a lesser extent, resulting in poor assay sensitivity. The specificity of C. trachomatis serology is also compromised by the high prevalence of cross-reactive anti-C. pneumoniae antibodies in human populations. We previously identified 48 highly specific C. trachomatis B cell epitope peptide antigens of 21 immunodominant proteins. This study validated peptide antigen-based novel ELISAs that provide highly specific and sensitive detection of anti-C. trachomatis antibodies. Compared to four commercial ELISAs that achieved only poor sensitivities (51.5% to 64.8%), the combined signals of 5 to 11 peptides provided high sensitivity (86.5% to 91.8%) at the same 98% specificity. Thus, by using multiple peptide antigens of immunodominant proteins, we created simple ELISAs with specificity and sensitivity superior to standard C. trachomatis serodiagnosis.

Multiple-Locus Variable-Number Tandem-Repeat Analysis of Mycoplasma pneumoniae Isolates between 2004 and 2014 in Yamagata, Japan: Change in Molecular Characteristics during an 11-year Period

Multiple-locus variable-number tandem-repeat analysis (MLVA) typing was performed for Mycoplasma pneumoniae strains isolated between 2004 and 2014 in Yamagata, Japan. The results were examined by considering the combination of the P1 type and prevalence of macrolide resistance-associated mutations. Four-locus (Mpn13-16) MLVA classified 347 strains into 9 MLVA types, including 3 major types: 3-5-6-2, 4-5-7-2, and 4-5-7-3. All type 3-5-6-2 strains (77 strains) were P1 type 2 variants (2a or 2c), while types 4-5-7-2 (181 strains) and 4-5-7-3 (75 strains) were P1 type 1. MLVA type 4-5-7-2 strains circulated and were dominant until 2010, accounting for 88.4% of the 121 strains isolated between 2004 and 2010. The prevalence of types 4-5-7-3 and 3-5-6-2 strains increased rapidly in 2011 and 2012, respectively, resulting in cocirculation of 3 MLVA types, including type 4-5-7-2, between 2011 and 2013. The prevalence of macrolide resistance-associated mutations in MLVA types 4-5-7-2, 4-5-7-3, and 3-5-6-2 strains was 59.7% (108/181), 25.3% (19/75), and 0% (0/77), respectively. Because the prevalence of macrolide resistance-associated mutations differed by current MLVA types in Yamagata, continued surveillance combined with molecular typing and identification of macrolide resistance-associated mutations is necessary.

Clarithromycin Plus Intravenous Immunoglobulin Therapy Can Reduce the Relapse Rate of Kawasaki Disease: A Phase 2, Open-Label, Randomized Control Study

Background

We previously reported that biofilms and innate immunity contribute to the pathogenesis of Kawasaki disease. Therefore, we aimed to assess the efficacy of clarithromycin, an antibiofilm agent, in patients with Kawasaki disease.

Methods and Results

We conducted an open‐label, multicenter, randomized, phase 2 trial at 8 hospitals in Japan. Eligible patients included children aged between 4 months and 5 years who were enrolled between days 4 and 8 of illness. Participants were randomly allocated to receive either intravenous immunoglobulin (IVIG) or IVIG plus clarithromycin. The primary end point was the duration of fever after the initiation of IVIG treatment. Eighty‐one eligible patients were randomized. The duration of the fever did not differ between the 2 groups (mean±SD, 34.3±32.4 and 31.1±31.1 hours in the IVIG plus clarithromycin group and the IVIG group, respectively [P=0.66]). The relapse rate of patients in the IVIG plus clarithromycin group was significantly lower than that in the IVIG group (12.5% versus 30.8%, P=0.046). No serious adverse events occurred during the study period. In a post hoc analysis, the patients in the IVIG plus clarithromycin group required significantly shorter mean lengths of hospital stays than those in the IVIG group (8.9 days versus 10.3 days, P=0.049).

Conclusions

Although IVIG plus clarithromycin therapy failed to shorten the duration of fever, it reduced the relapse rate and shortened the duration of hospitalization in patients with Kawasaki disease.

Clinical Trial Registration

URL: http://www.umin.ac.jp/ctr/index.htm. Unique identifier: UMIN000015437.

Antimicrobial therapy in childhood asthma and wheezing

There is an increasing number of viral and bacterial pathogens suspected of contributing to asthma pathogenesis in childhood, making it more difficult for the practitioner to make specific therapy decisions. This review discusses the role of viruses, e.g. respiratory syncytial virus, human metapneumovirus, influenza viruses and rhinoviruses, as well as the role of the atypical bacteria Chlamydophila pneumoniae and Mycoplasma pneumoniae, as contributors to childhood asthma. Diagnosis, prevention, and therapy are discussed, including a summary of drugs, i.e. macrolide antibacterials, antivirals, and vaccine regimens already available, or at least in clinical trials. For the practitioner dealing with patients every day, drug regimens are assigned to the individual pathogens and an algorithm for the management of atypical infections in patients with asthma or recurrent wheezing is presented.

An update on antimicrobial options for childhood community-acquired pneumonia: a critical appraisal of available evidence

INTRODUCTION

Community-acquired pneumonia (CAP) is a leading cause of death and a major cause of morbidity in children under the age of 5. Appropriate antimicrobial use is one crucial tool in controlling childhood CAP mortality and suffering.

AREAS COVERED

Structured search of current literature. PubMed was consulted for published trials conducted in children with CAP. We aimed to provide a comprehensive evaluation of antimicrobials used to treat childhood CAP, including a critical appraisal of the methodological aspects of these clinical trials.

EXPERT OPINION

Amoxicillin is the preferred option to treat non-severe non-complicated CAP among children aged ≥2 months. Amoxicillin may be used to treat children in this age group with severe CAP if they do not require hospital assistance. If the patient warrants hospitalization, intravenous penicillin is the chosen option. Heterogeneity was high in the included trials, in regard to clinical inclusion criteria, use of radiological inclusion criteria, placebo use and masking. Higher quality evidence was found in the studies which included amoxicillin. There is a clear dearth of randomized, placebo-controlled, well-performed clinical trials evaluating children with CAP aged under 2 months, or aged 2 months and above with very severe or complicated CAP, or in specific age groups like teenagers.

Role of Atypical Pathogens and the Antibiotic Prescription Pattern in Acute Bronchitis: A Multicenter Study in Korea

The role of atypical bacteria and the effect of antibiotic treatments in acute bronchitis are still not clear. This study was conducted at 22 hospitals (17 primary care clinics and 5 university hospitals) in Korea. Outpatients (aged ≥ 18 yr) who had an acute illness with a new cough and sputum (≤ 30 days) were enrolled in 2013. Multiplex real-time polymerase chain reaction (RT-PCR) was used to detect five atypical bacteria. A total of 435 patients were diagnosed as having acute bronchitis (vs. probable pneumonia, n = 75), and 1.8% (n = 8) were positive for atypical pathogens (Bordetella pertussis, n = 3; B. parapertussis, n = 0; Mycoplasma pneumoniae, n = 1; Chlamydophila pneumoniae, n = 3; Legionella pneumophila, n = 1). Among clinical symptoms and signs, only post-tussive vomiting was more frequent in patients with atypical pathogens than those without (P = 0.024). In all, 72.2% of the enrolled patients received antibiotic treatment at their first visits, and β-lactams (29.4%) and quinolones (20.5%) were the most commonly prescribed agents. In conclusion, our study demonstrates that the incidence of atypical pathogens is low in patients with acute bronchitis, and the rate of antibiotic prescriptions is high.

Enrofloxacin and macrolides alone or in combination with rifampicin as antimicrobial treatment in a bovine model of acute Chlamydia psittaci infection

Chlamydia psittaci is a zoonotic bacterium with a wide host range that can cause respiratory disease in humans and cattle. In the present study, effects of treatment with macrolides and quinolones applied alone or in combination with rifampicin were tested in a previously established bovine model of respiratory C. psittaci infection. Fifty animals were inoculated intrabronchially at the age of 6-8 weeks. Seven served as untreated controls, the others were assigned to seven treatment groups: (i) rifampicin, (ii) enrofloxacin, (iii) enrofloxacin + rifampicin, (iv) azithromycin, (v) azithromycin + rifampicin, (vi) erythromycin, and (vii) erythromycin + rifampicin. Treatment started 30 hours after inoculation and continued until 14 days after inoculation (dpi), when all animals were necropsied. The infection was successful in all animals and sufficient antibiotic levels were detected in blood plasma and tissue of the treated animals. Reisolation of the pathogen was achieved more often from untreated animals than from other groups. Nevertheless, pathogen detection by PCR was possible to the same extent in all animals and there were no significant differences between treated and untreated animals in terms of local (i.e., cell count and differentiation of BALF-cells) and systemic inflammation (i.e. white blood cells and concentration of acute phase protein LBP), clinical signs, and pathological findings at necropsy. Regardless of the reduced reisolation rate in treated animals, the treatment of experimentally induced respiratory C. psittaci infection with enrofloxacin, azithromycin or erythromycin alone or in combination with rifampicin was without obvious benefit for the host, since no significant differences in clinical and pathological findings or inflammatory parameters were detected and all animals recovered clinically within two weeks.

Evaluation of antimicrobial treatment in a bovine model of acute Chlamydia psittaci infection: tetracycline versus tetracycline plus rifampicin

Antimicrobial treatment of chlamydial infections is known to be of limited efficacy. In this study, effects of doxycycline (D), usually the drug of choice, were compared with the combined therapy of doxycycline and rifampicin (R) in a bovine model of respiratory Chlamydia psittaci infection. After intrabronchial inoculation of the pathogen, 30 animals were assigned to five groups (n = 6 per group): untreated controls, monotherapy with D (5 mg kg(-1)day(-1) or 10 mg kg(-1)day(-1)), and combination therapy of D and R (600 mg day(-1)). Treatment continued until day 14 post inoculation (d.p.i.). Clinical signs, inflammatory markers, and pathological findings confirmed successful infection in all animals. Reisolation of the pathogen was possible in 4/6 untreated animals and in 4/12 animals treated with D alone until 4 d.p.i., but in none of the calves of the two D + R groups. Pathogen detection was possible in all animals without significant differences among groups. Severity of disease and time course of its resolution, assessed by clinical and pathological findings as well as inflammatory parameters, were not significantly different between untreated controls and calves receiving D alone or in combination with R. Regardless of the treatment regimen, all groups recovered clinically and cleared the infection within 2 weeks.

Antibiotics for community-acquired lower respiratory tract infections secondary to Mycoplasma pneumoniae in children

Background. Mycoplasma pneumoniae (M. pneumoniae) is widely recognised as an important cause of community-acquired lower respiratory tract infection (LRTI) in children. Pulmonary manifestations are typically tracheobronchitis or pneumonia but M. pneumoniae is also implicated in wheezing episodes in both asthmatic and non-asthmatic individuals. Although antibiotics are used to treat LRTIs, are view of several major textbooks offers conflicting advice for using antibiotics in the management of M. pneumoniae LRTI in children.Objectives To determine whether antibiotics are effective in the treatment of childhood LRTI secondary to M. pneumoniae infections acquired in the community.Search methods We searched CENTRAL (2014, Issue 3), MEDLINE (1966 to July week 4, 2014), EMBASE (1980 to July, 2014), and both WHOICTRP and ClinicalTrials.gov (13 August 2014).Selection criteria Randomised controlled trials (RCTs) comparing antibiotics commonly used for treating M. pneumoniae (i.e. macrolide, tetracycline or quinolone classes) versus placebo, or antibiotics from any other class in the treatment of children under 18 years of age with community acquired LRTI secondary to M. pneumoniae.Data collection and analysis The review authors independently selected trials for inclusion and assessed methodological quality. We extracted and analysed relevant data separately and resolved disagreements by consensus.Main results A total of 1912 children were enrolled from seven studies. Data interpretation was limited by the inability to extract data that referred to children with M. pneumoniae. In most studies, clinical response did not differ between children randomised to a macrolide antibiotic and children randomised to a non-macrolide antibiotic. In one controlled study (of children with recurrent respiratory infections, whose acute LRTI was associated with Mycoplasma, Chlamydia or both, by polymerase chain reaction and/or paired sera) 100% of children treated with azithromycin had clinical resolution of their illness compared to 77% not treated with azithromycin at one month. Authors' conclusions There is insufficient evidence to draw any specific conclusions about the efficacy of antibiotics for this condition in children (although one trial suggests macrolides may be efficacious in some children with LRTI secondary to Mycoplasma). The use of antibiotics has to be balanced with possible adverse events. There is still a need for high quality, double-blinded RCTs to assess the efficacy and safety of antibiotics for LRTI secondary to M. pneumoniae in children.

In vitro activity of AZD0914, a novel DNA gyrase inhibitor, against Chlamydia trachomatis and Chlamydia pneumoniae

The in vitro activities of AZD0914, levofloxacin, azithromycin, and doxycycline against 10 isolates each of Chlamydia trachomatis and Chlamydia pneumoniae were tested. For AZD0914, the MIC90s for C. trachomatis and C. pneumoniae were 0.25 μg/ml (range, 0.06 to 0.5 μg/ml) and 1 μg/ml (range, 0.25 to 1 μg/ml), respectively, and the minimal bactericidal concentrations at which 90% of the isolates were killed (MBC90s) were 0.5 μg/ml for C. trachomatis (range, 0.125 to 1 μg/ml) and 2 μg/ml for C. pneumoniae (range, 0.5 to 2 μg/ml).

Systematic review on antibiotic therapy for pneumonia in children between 2 and 59 months of age

Community-acquired pneumonia (CAP) remains a force to reckon with, as it accounts for 1.1 million of all deaths in children less than 5 years of age globally, with disproportionately higher mortality occurring in the low and middle income-countries (LMICs) of Southeast Asia and Africa. Existing strategies to curb pneumonia-related morbidity and mortality have not effectively translated into meaningful control of pneumonia-related burden. In the present systematic review, we conducted a meta-analysis of trials conducted in LMICs to determine the most suitable antibiotic therapy for treating pneumonia (very severe, severe and non-severe). While previous reviews, including the most recent review by Lodha et al, have focused either on single modality of antibiotic therapy (such as choice of antibiotic) or children under the age of 16 years, the current review updates evidence on the choice of drug, duration, route and combination of antibiotics in children specifically between 2 and 59 months of age. We included randomised controlled trials (RCTs) and quasi-RCTs that assessed the route, dose, combination and duration of antibiotics in the management of WHO-defined very severe/severe/non-severe CAP. Study participants included children between 2 and 59 months of age with CAP. All available titles and abstracts were screened for inclusion by two review authors independently. All data was entered and analysed using Review Manager 5 software. The review identified 8122 studies on initial search, of which 22 studies which enrolled 20,593 children were included in meta-analyses. Evidence from these trials showed a combination of penicillin/ampicillin and gentamicin to be effective for managing very severe pneumonia in children between 2 and 59 months of age, and oral amoxicillin to be equally efficacious, as other parenteral antibiotics for managing severe pneumonia in children of this particular age group. Oral amoxicillin was also found to be effective in non-severe pneumonia as well. The review further found a short 3 day course of antibiotics to be equally beneficial as 5 day course for managing non-severe pneumonia in children between 2 and 59 months of age. This review updates evidence on the general spectrum of antibiotic recommendation for CAP in children between 2 and 59 months of age, which is an age group that warrants special focus owing to its high disease and mortality burden. Evidence derived from the review found oral amoxicillin to be equally effective as parenteral antibiotics for severe pneumonia in the 2-59 month age group, which holds important implications for LMICs where parenteral drug administration is an issue. Also, the review's finding that 3 day course of antibiotic is equally effective as 5 day course for non-severe pneumonia for 2-59 months of age is again beneficial for LMICs, as a shorter therapy will be associated with a lower cost. The review addresses some research gaps in antibiotic treatment for CAP as well, and this crucial information is presented with the aim of providing a targeted cure for the middle and low income setting.

Antibiotics for community-acquired pneumonia in children

BACKGROUND

Pneumonia caused by bacterial pathogens is the leading cause of mortality in children in low-income countries. Early administration of antibiotics improves outcomes.

OBJECTIVES

To identify effective antibiotic drug therapies for community-acquired pneumonia (CAP) of varying severity in children by comparing various antibiotics.

SEARCH METHODS

We searched CENTRAL 2012, Issue 10; MEDLINE (1966 to October week 4, 2012); EMBASE (1990 to November 2012); CINAHL (2009 to November 2012); Web of Science (2009 to November 2012) and LILACS (2009 to November 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in children of either sex, comparing at least two antibiotics for CAP within hospital or ambulatory (outpatient) settings.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the full articles of selected studies.

MAIN RESULTS

We included 29 trials, which enrolled 14,188 children, comparing multiple antibiotics. None compared antibiotics with placebo.Assessment of quality of study revealed that 5 out of 29 studies were double-blind and allocation concealment was adequate. Another 12 studies were unblinded but had adequate allocation concealment, classifying them as good quality studies. There was more than one study comparing co-trimoxazole with amoxycillin, oral amoxycillin with injectable penicillin/ampicillin and chloramphenicol with ampicillin/penicillin and studies were of good quality, suggesting the evidence for these comparisons was of high quality compared to other comparisons.In ambulatory settings, for treatment of World Health Organization (WHO) defined non-severe CAP, amoxycillin compared with co-trimoxazole had similar failure rates (odds ratio (OR) 1.18, 95% confidence interval (CI) 0.91 to 1.51) and cure rates (OR 1.03, 95% CI 0.56 to 1.89). Three studies involved 3952 children.In children with severe pneumonia without hypoxaemia, oral antibiotics (amoxycillin/co-trimoxazole) compared with injectable penicillin had similar failure rates (OR 0.84, 95% CI 0.56 to 1.24), hospitalisation rates (OR 1.13, 95% CI 0.38 to 3.34) and relapse rates (OR 1.28, 95% CI 0.34 to 4.82). Six studies involved 4331 children below 18 years of age.In very severe CAP, death rates were higher in children receiving chloramphenicol compared to those receiving penicillin/ampicillin plus gentamicin (OR 1.25, 95% CI 0.76 to 2.07). One study involved 1116 children.

AUTHORS' CONCLUSIONS

For treatment of patients with CAP in ambulatory settings, amoxycillin is an alternative to co-trimoxazole. With limited data on other antibiotics, co-amoxyclavulanic acid and cefpodoxime may be alternative second-line drugs. Children with severe pneumonia without hypoxaemia can be treated with oral amoxycillin in an ambulatory setting. For children hospitalised with severe and very severe CAP, penicillin/ampicillin plus gentamycin is superior to chloramphenicol. The other alternative drugs for such patients are co-amoxyclavulanic acid and cefuroxime. Until more studies are available, these can be used as second-line therapies.There is a need for more studies with radiographically confirmed pneumonia in larger patient populations and similar methodologies to compare newer antibiotics. Recommendations in this review are applicable to countries with high case fatalities due to pneumonia in children without underlying morbidities and where point of care tests for identification of aetiological agents for pneumonia are not available.

Community outbreak of macrolide-resistant Mycoplasma pneumoniae in Yamagata, Japan in 2009

BACKGROUND

We detected a community outbreak of macrolide-resistant Mycoplasma pneumoniae infection that occurred predominantly among students at 2 schools in Yamagata, Japan.

METHODS

Throat swab specimens were collected from patients who were clinically suspected to have M. pneumoniae infection after testing negative for influenza virus by a nasopharyngeal swab rapid antigen test. We performed cultures for M. pneumoniae, and all isolates were sequenced for the presence of a mutation of the 23S rRNA gene.

RESULTS

Of 96 specimens collected between July 2009 and January 2010, 83 were from students attending junior high school A and primary schools B, C and D. A total of 47 M. pneumoniae isolates were obtained; among them, 25, 15 and 4 were isolated from students attending schools A, B and D, respectively, and M. pneumoniae could not be isolated from students who attended school C. An A2063T mutation in domain V of the 23S rRNA gene, which is associated with macrolide resistance, was identified in 39 (83.0%) isolates. The rates of macrolide resistance at schools A, B and D were 96.0%, 86.7% and 0%, respectively. The minimum inhibitory concentrations for isolates with an A2063T transversion showed high resistance to clarithromycin (minimum inhibitory concentration, 16-64 mg/L), and clarithromycin prescribed initially was clinically ineffective.

CONCLUSIONS

This school-based cluster of macrolide-resistant M. pneumoniae infections, which was identified in 2 geographically close schools, indicates that the transmission principally occurred by close contact between students at school. Monitoring the spread of macrolide-resistant M. pneumoniae and clinical guidelines for the appropriate medication against such infections would be needed to control outbreaks of M. pneumoniae.

Mycoplasma pneumoniae in children with acute and refractory asthma

BACKGROUND

The presence of Mycoplasma pneumoniae has been associated with worsening asthma in children. Sensitive assays have been developed to detect M pneumoniae-derived community-acquired respiratory distress syndrome (CARDS) toxin.

OBJECTIVES

To identify the frequency and persistence of M pneumoniae detection in respiratory secretions of children with and without asthma and to evaluate antibody responses to M pneumoniae and the impact of M pneumoniae on biological markers, asthma control, and quality of life.

METHODS

We enrolled 143 pediatric patients (53 patients with acute asthma, 26 patients with refractory asthma, and 64 healthy controls; age range, 5-17 years) during a 20-month period with 2 to 5 follow-up visits. We detected M pneumoniae using CARDS toxin antigen capture and polymerase chain reaction and P1 adhesin polymerase chain reaction. Immune responses to M pneumoniae were determined by IgG and IgM levels directed against CARDS toxin and P1 adhesin. pH was measured in exhaled breath condensates, and asthma control and quality of life were assessed using the Asthma Control Test and Pediatric Asthma Quality of Life Questionnaire.

RESULTS

M pneumoniae was detected in 64% of patients with acute asthma, 65% with refractory asthma, and 56% of healthy controls. Children with asthma had lower antibody levels to M pneumoniae compared with healthy controls. Exhaled breath condensate pHs and asthma control and quality of life scores were lower in M pneumoniae-positive patients with asthma.

CONCLUSION

The results suggest that M pneumoniae detection is common in children, M pneumoniae detection is associated with worsening asthma, and children with asthma may have poor humoral immune responses to M pneumoniae.

Clinical symptoms and signs for the diagnosis of Mycoplasma pneumoniae in children and adolescents with community-acquired pneumonia

BACKGROUND

Mycoplasma pneumoniae (M. pneumoniae) is a significant cause of community-acquired pneumonia in children and adolescents. Treatment with macrolide antibiotics is recommended. However, M. pneumoniae is difficult to diagnose based on clinical symptoms and signs. Diagnostic uncertainty can lead to inappropriate antibiotic prescribing, which may worsen clinical prognosis and increase antibiotic resistance.

OBJECTIVES

The objectives of this review are (i) to assess the diagnostic accuracy of symptoms and signs in the clinical recognition of M. pneumoniae in children and adolescents with community-acquired pneumonia; and (ii) to assess the influence of potential sources of heterogeneity on the diagnostic accuracy of symptoms and signs in the clinical recognition of M. pneumoniae.

SEARCH METHODS

We searched MEDLINE (January 1950 to 26 June 2012) and EMBASE (January 1980 to 26 June 2012). We identified additional references by handsearching the reference lists of included articles and snowballing. We searched the reference lists of relevant systematic reviews identified by searching the Medion database, Database of Reviews of Effects 2012, Issue 6 (25 June 2012) and the Cochrane Register of Diagnostic Test Accuracy studies (2 July 2012). Experts in the field reviewed our list of included studies for any obvious omissions.

SELECTION CRITERIA

We included peer-reviewed published studies which prospectively and consecutively recruited children with community-acquired pneumonia from any healthcare setting, confirmed the presence of M. pneumoniae using serology with or without other laboratory methods and reported data on clinical symptoms and signs in sufficient detail to construct 2 x 2 tables.

DATA COLLECTION AND ANALYSIS

One review author scanned titles to exclude obviously irrelevant articles. Two review authors independently scanned the remaining titles and abstracts, reviewed full-text versions of potentially relevant articles, assessed the quality of included articles and extracted data on study characteristics and the following clinical features: cough, wheeze, coryza, crepitations, fever, rhonchi, shortness of breath, chest pain, diarrhea, myalgia and headache.We calculated study-specific values for sensitivity, specificity and positive and negative likelihood ratios with 95% confidence intervals (CIs). We estimated the post-test probability of M. pneumoniae based on the absence or presence of symptoms and signs.We calculated pooled sensitivities, specificities, positive and negative likelihood ratios with 95% CIs for symptoms and signs where data were reported by at least four included studies by fitting a bivariate normal model for the logit transforms of sensitivity and specificity. We explored potential sources of heterogeneity by fitting bivariate models with covariates using multi-level mixed-effects logistic regression. We performed sensitivity analyses excluding data from studies for which we were concerned about the representativeness of the study population and/or the acceptability of the reference standard.

MAIN RESULTS

Our search identified 8299 articles (excluding duplicates). We examined the titles and abstracts of 1125 articles and the full-text versions of 97 articles. We included seven studies in our review, which reported data from 1491 children; all were conducted in hospital settings. Overall, study quality was moderate. In two studies the presence of chest pain more than doubled the probability of M. pneumoniae. Wheeze was 12% more likely to be absent in children with M. pneumoniae (pooled positive likelihood ratio (LR+) 0.76, 95% CI 0.60 to 0.97; pooled negative likelihood ratio (LR-) 1.12, 95% CI 1.02 to 1.23). Our sensitivity analysis showed that the presence of crepitations was associated with M. pneumoniae, but this finding was of borderline statistical significance (pooled LR+ 1.10, 95% CI 0.99 to 1.23; pooled LR- 0.66, 95% CI 0.46 to 0.96).

AUTHORS' CONCLUSIONS

M. pneumoniae cannot be reliably diagnosed in children and adolescents with community-acquired pneumonia based on clinical symptoms and signs. Although the absence of wheeze is a statistically significant diagnostic indicator, it does not have sufficient diagnostic value to guide empirical macrolide treatment. Data from two studies suggest that the presence of chest pain more than doubles the probability of M. pneumoniae. However, further research is needed to substantiate this finding. More high quality large-scale studies in primary care settings are needed to help develop prediction rules based on epidemiological data as well as clinical and baseline patient characteristics.

Antibiotics for community-acquired lower respiratory tract infections secondary to Mycoplasma pneumoniae in children

BACKGROUND

Mycoplasma pneumoniae (M. pneumoniae) is widely recognised as an important cause of community-acquired lower respiratory tract infection (LRTI) in children. Pulmonary manifestations are typically tracheobronchitis or pneumonia but M. pneumoniae is also implicated in wheezing episodes in both asthmatic and non-asthmatic individuals. Although antibiotics are used to treat LRTIs, a review of several major textbooks offers conflicting advice for using antibiotics in the management of M. pneumoniae LRTI in children.

OBJECTIVES

To determine whether antibiotics are effective in the treatment of childhood LRTI secondary to M. pneumoniae infections acquired in the community.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 2), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to February week 5, 2012) and EMBASE (1980 to March 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotics commonly used for treating M. pneumoniae (i.e. macrolide, tetracycline or quinolone classes) versus placebo, or antibiotics from any other class in the treatment of children under 18 years of age with community-acquired LRTI secondary to M. pneumoniae.

DATA COLLECTION AND ANALYSIS

The review authors independently selected trials for inclusion and assessed methodological quality. We extracted and analysed relevant data separately. We resolved disagreements by consensus.

MAIN RESULTS

A total of 1912 children were enrolled from seven studies. Data interpretation was limited by the inability to extract data that referred to children with M. pneumoniae. In most studies, clinical response did not differ between children randomised to a macrolide antibiotic and children randomised to a non-macrolide antibiotic. In one controlled study (of children with recurrent respiratory infections, whose acute LRTI was associated with Mycoplasma, Chlamydia or both by polymerase chain reaction, and/or paired sera) 100% of children treated with azithromycin had clinical resolution of their illness compared to 77% not treated with azithromycin at one month.

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw any specific conclusions about the efficacy of antibiotics for this condition in children (although one trial suggests macrolides may be efficacious in some children with LRTI secondary to Mycoplasma). The use of antibiotics has to be balanced with possible adverse events. There is still a need for high quality, double-blinded RCTs to assess the efficacy and safety of antibiotics for LRTI secondary to M. pneumoniae in children.

Antibiotic therapy for pediatric community-acquired pneumonia: do we know when, what and for how long to treat?

Community-acquired pneumonia (CAP) is a common cause of morbidity among children in developed countries and accounts for an incidence of 10-40 cases per 1000 children in the first 5 years of life. Given the clinical, social and economic importance of CAP, there is general agreement that prompt and adequate therapy is essential to reduce the impact of the disease. The aim of this discussion paper is to consider critically the available data concerning the treatment of uncomplicated pediatric CAP and to consider when, how and for how long it should be treated. This review has identified the various reasons that make it difficult to establish a rational approach to the treatment of pediatric CAP, including the definition of CAP, the absence of a pediatric CAP severity score, the difficulty of identifying the etiology, limited pharmacokinetic (PK)/pharmacodynamic (PD) studies, the high resistance of the most frequent respiratory pathogens to the most widely used anti-infectious agents and the lack of information concerning the changes in CAP epidemiology following the introduction of new vaccines against respiratory pathogens. More research is clearly required in various areas, such as the etiology of CAP and the reasons for its complications, the better definition of first- and second-line antibiotic therapies (including the doses and duration of parenteral and oral antibiotic treatment), the role of antiviral treatment and on how to follow-up patients with CAP. Finally, further efforts are needed to increase vaccination coverage against respiratory pathogens and to conduct prospective studies of their impact.

Protective efficacy of a Mycoplasma pneumoniae P1C DNA vaccine fused with the B subunit of Escherichia coli heat-labile enterotoxin

In the present study, we investigated the immunomodulatory responses of a DNA vaccine constructed by fusing Mycoplasma pneumoniae P1 protein carboxy terminal region (P1C) with the Escherichia coli heat-labile toxin B subunit (LTB). BALB/c mice were immunized by intranasal inoculation with control DNAs, the P1C DNA vaccine or the LTB–P1C fusion DNA vaccine. Levels of the anti-M. pneumoniae antibodies and levels of interferon-γ and IL-4 in mice were increased significantly upon inoculation of the LTB–P1C fusion DNA vaccine when compared with the inoculation with P1C DNA vaccine. The LTB–P1C fusion DNA vaccine efficiently enhanced the M. pneumoniae-specific IgA and IgG levels. The IgG2a/IgG1 ratio was significantly higher in bronchoalveolar lavages fluid and sera from mice fusion with LTB and P1C than mice receiving P1C alone. When the mice were challenged intranasally with 107 CFU M. pneumoniae strain (M129), the LTB–P1C fusion DNA vaccine conferred significantly better protection than P1C DNA vaccine (P < 0.05), as suggested by the results, such as less inflammation, lower histopathological score values, lower detectable number of M. pneumoniae strain, and lower mortality of challenging from 5 × 108 CFU M. pneumoniae. These results indicated that the LTB–P1C fusion DNA vaccine efficiently improved protective efficacy against M. pneumoniae infection and effectively attenuated development of M. pneumoniae in mice.

Rising rates of macrolide-resistant Mycoplasma pneumoniae in the central United States

Macrolide-resistant Mycoplasma pneumoniae is widespread in Asia, and severe cases of pneumonia have been described in children. Little information is available about the resistance pattern in the United States. We collected respiratory samples from 49 patients with Mycoplasma infection in the central United States between 2007 and 2010. We found a macrolide resistance rate of 8.2%. Resistance should be considered when patients with M. pneumoniae infection do not have a satisfactory response to macrolides. Alternative antibiotics include tetracyclines or fluoroquinolones.

Impact of a guideline on management of children hospitalized with community-acquired pneumonia

OBJECTIVES

We sought to describe the impact a clinical practice guideline (CPG) had on antibiotic management of children hospitalized with community-acquired pneumonia (CAP).

PATIENTS AND METHODS

We conducted a retrospective study of discharged patients from a children's hospital with an ICD-9-CM code for pneumonia (480-486). Eligible patients were admitted from July 8, 2007, through July 9, 2009, 12 months before and after the CAP CPG was introduced. Three-stage least squares regression analyses were performed to examine hypothesized simultaneous relationships, including the impact of our institution\x{2019}s antimicrobial stewardship program (ASP).

RESULTS

The final analysis included 1033 patients: 530 (51%) before the CPG (pre-CPG) and 503 (49%) after the CPG (post-CPG). Pre-CPG, ceftriaxone (72%) was the most commonly prescribed antibiotic, followed by ampicillin (13%). Post-CPG, the most common antibiotic was ampicillin (63%). The effect of the CPG was associated with a 34% increase in ampicillin use (P < .001). Discharge antibiotics also changed post-CPG, showing a significant increase in amoxicillin use (P < .001) and a significant decrease in cefdinir and amoxicillin/clavulanate (P < .001), with the combined effect of the CPG and ASP leading to 12% (P < 0.001) and 16% (P < .001) reduction, respectively. Overall, treatment failure was infrequent (1.5% vs 1%).

CONCLUSIONS

A CPG and ASP led to the increase in use of ampicillin for children hospitalized with CAP. In addition, less broad-spectrum discharge antibiotics were used. Patient adverse outcomes were low, indicating that ampicillin is appropriate first-line therapy for otherwise healthy children admitted with uncomplicated CAP.

Treatment of chlamydial infections

INTRODUCTION

Chlamydiae are obligate intracellular bacterial pathogens whose entry into mucosal epithelial cells is required for intracellular survival and subsequent growth. The life cycle of Chlamydia spp. and the ability to cause persistent, often subclinical infection, has major ramifications for diagnosis and treatment of C. trachomatis and C. pneumoniae infections in humans.

AREAS COVERED

This up-to-date review describes the current state of knowledge of antimicrobial susceptibilities and treatment of genital infections due to C. trachomatis and respiratory infections due to C. pneumoniae.

EXPERT OPINION

Chlamydiae are susceptible to antibiotics that interfere with DNA and protein synthesis, including tetracyclines, macrolides and quinolones, which are the compounds that have been most extensively studied and used for treatment of human infection. Treatment of individuals with C. trachomatis genital infection prevents sexual transmission and complications, including pelvic inflammatory disease. Treatment of pregnant women will prevent the transmission of infection to infants during delivery. The benefits of treatment of respiratory infections due to C. pneumoniae are more difficult to assess, primarily because of the lack of FDA-approved, specific diagnostic tests for detection of the organism in clinical samples. The majority of published studies have relied on serology for diagnosis, making it difficult to assess microbiologic efficacy.

The validity of the criteria for primary infection of Chlamydophila pneumoniae in children by measuring ELISA IgM antibodies

As IgM antibody measurement by enzyme-linked immunosorbent assay (ELISA) has become possible for the serological diagnosis of Chlamydophila pneumoniae (C. pn) infection, the HITAZYME-ELISA method has become widely employed in Japan. However, in children, when the diagnostic criterion of primary infection is set at ID ≥1.1, the positive rate is higher than expected, and the potential for inaccurate reflection of the prevalence has been raised. In this study, we performed ROC analysis involving 136 pediatric patients with acute airway symptoms (0-14 years of age), considering a 32-fold or higher micro-immunofluorescence IgM antibody titer against C. pn as positive. Setting the cut-off value for ELISA C. pn IgM antibody ID at 2.0, the specificity was 100%, with no false positivity. The maximum (sensitivity + specificity)/2 was obtained when the cut-off value was set at 1.5. Therefore, IgM ID ≥2.0 was regarded as definitely positive and an IgM ID between 1.5 and 2.0 was regarded as indeterminate as diagnostic criteria for the primary infection. When the prevalence was investigated in 3,108 children (0-15 years of age) with airway symptoms based on these criteria, 542 cases (17.4%) were positive, and the median duration of IgM antibody positivity was five months. Long-term positivity (ten cases) for more than 12 months and recurrent positivity (eight cases) were also observed, but it may be appropriate to set a new criterion of IgM antibody ID ≥2.0 for the diagnosis of primary Chlamydophila pneumoniae infection in children.

The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

Persistence of community-acquired respiratory distress syndrome toxin-producing Mycoplasma pneumoniae in refractory asthma

BACKGROUND

The role of Mycoplasma pneumoniae (Mp) in the initiation and persistence of asthma remains elusive. Mp community-acquired respiratory distress syndrome toxin (CARDS Tx) is a unique virulence factor that induces an intense lymphocytic response and exacerbates asthma in animal models. We sought to determine the incidence of Mp infection and the presence of CARDS Tx in subjects with refractory asthma (RA).

METHODS

We conducted a prospective observational study in 64 subjects with RA. Respiratory secretions (sputum, nasal lavage, and throat swab) and blood were analyzed for the presence of CARDS Tx and P1 adhesin (P1) DNA by polymerase chain reaction (PCR), and CARDS Tx by antigen capture. Serum IgM and IgG antibodies to CARDS Tx were determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Thirty-three of 64 subjects (52%) tested positive for Mp: 29 of 33 by CARDS Tx vs 10 of 33 by P1 assays. Ten subjects followed longitudinally for up to 633 days tested persistently positive for Mp. There were no significant differences in Mp-specific IgG responses between Mp-positive and Mp-negative groups. Eight of 10 subjects who tested persistently positive failed to mount a substantial IgG response to CARDS Tx, and up to 8 weeks of clarithromycin failed to eradicate Mp in five subjects.

CONCLUSIONS

Subjects with RA may be chronically infected with Mp. PCR for CARDS Tx appears to be the most sensitive method of identifying Mp infection. Despite the persistence of Mp in subjects with RA, some subjects failed to mount an IgG response, and macrolide therapy was insufficient to eradicate Mp.

Pneumonia caused by Mycoplasma pneumoniae and Chlamydophila pneumoniae in children - comparative analysis of clinical picture

PURPOSE

The aim of the study was comparative analysis of clinical picture and prevalence of pneumonia caused by Mycoplasma pneumoniae and Chlamydophila pneumoniae in children.

MATERIAL AND METHODS

The study involved 332 children hospitalized in the 3rd Department of Paediatric, Polish Mother's Memorial Hospital - Research Institute, due to pneumonia caused by Mycoplasma pneumoniae - group I or Chlamydophila pneumonia - group II.

RESULTS

Over 2003-2009 period there were 1870 children hospitalized due to pneumonia, of which in 332 (17.8%) the Mycoplasma pneumoniae and/or Chlamydophila pneumoniae etiology was confirmed. Mycoplasma pneumoniae, Chlamydophila pneumoniae, and mixed infection was diagnosed in 198 (10.6%), 102 (5.5%), and 32 (1.7%) children, respectively. The dominant clinical feature in both groups was cough, observed in 186 (93.9%) and 88 (86.3%) children, respectively. Further, reddening of the throat, rhinitis, shortness of breath, fever, enlarged lymph nodes, skin lesions and dyspepsia were also observed. The frequency of specific clinical features in both groups was similar. Statistical relationship (p≤0.05) was observed only in case of skin lesions. In chest x-ray there was no statistical link as for analyzed changes. Interstitial inflammatory changes were most frequently observed.

CONCLUSIONS

Mycoplasma pneumoniae and Chlamydophila pneumoniae are significant etiological factors in pneumonia in children, and as such they should be taken into consideration in differential diagnosis of pneumonia in children. The clinical picture of pneumonia caused by Mycoplasma pneumoniae and Chlamydophila pneumoniae is hardly specific, with basic labs and chest x-ray of little help in differentiation of infection etiology.

Pneumonia in the developed world

In this paper, we review the literature on the management of pneumonia in the developed world setting. Pneumonia is usually diagnosed on the basis of a cough, respiratory distress, a fever, and chest X-ray changes. Pneumonia affects all paediatric age groups, though the highest incidence is in the under 5s. There is a significant burden of primary and secondary care illness, although mortality is low. Inpatient admission rates for pneumonia may have increased in recent years in some regions. Pneumonia is unlikely if a child presents with solely wheeze. In routine clinical practice, a microbiological diagnosis is often not made, because current tests are insensitive. Aetiology varies with geographical location, but approximately half of cases are viral. The mainstay of management of moderate pneumonia (the commonest group presenting to secondary care) is careful assessment, and oral antibiotics, followed by early discharge when the patient shows signs of improvement. We summarise the available clinical trial data from the developed world; most of these trials are not adequately powered. Patients with moderately severe pneumonia do not require invasive investigation, but clinical judgement should be used to identify and investigate more complex cases. We discuss several pathogens that have gained importance as causal agents, including non-vaccinated strains of S. pneumoniae, Panton Valentine leucocidin S. aureus, H1N1 Influenza A and Human Bocavirus. The importance of antimicrobial resistance is considered, and we review recent data on long term effects of pneumonia in childhood. By reviewing the available literature, we demonstrate that there are clear evidence gaps, and we suggest future areas for clinical research.

[Epidemiology and morbidity of mycoplasma as causative agent for community-acquired pneumonia in hospitalized children in a Community Hospital in Vienna]

BACKGROUND

Epidemiology and morbidity of mycoplasma-associated pneumonia in youths and children in Vienna are not known. The first objective was to elucidate the incidence and the second was to evaluate a standard antibiotic regimen with addition of a macrolid in children over 5 years.

METHODS

Hospitalized patients were evaluated prospectively during 3 winter seasons. In a clinical routine setting microbiologic tests were performed, nasal secretions were tested for viruses, Chlamydia pneumoniae and Mycoplasma pneumoniae, and clinical parameters were documented.

RESULTS

Mycoplasma pneumoniae was identified in 12 patients out of 279 (4.3%). All were 5 years and older. The mean number of days in hospital was 4.6, the number of days with fever > 38.5 degrees was 1.2, the maximal value of C-reactive protein was 48 mg/L, no complications occurred, and all children recovered completely.

CONCLUSION

Mycoplasma pneumoniae was identified in 4.3% of children and youths. The antibiotic regimen is appropriate as initial therapy.

Antibiotics for community-acquired lower respiratory tract infections secondary to Mycoplasma pneumoniae in children

BACKGROUND

Mycoplasma pneumoniae (M. pneumoniae) is widely recognised as an important cause of community-acquired lower respiratory tract infection (LRTI) in children. Pulmonary manifestations are typically tracheobronchitis or pneumonia but M. pneumoniae is also implicated in wheezing episodes in both asthmatic and non-asthmatic individuals. Although antibiotics are used to treat LRTI, a review of several major textbooks offers conflicting advice for using antibiotics in the management of M. pneumoniae LRTI in children.

OBJECTIVES

To determine whether antibiotics are effective in the treatment of childhood LRTI secondary to M. pneumoniae infections acquired in the community.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, issue 1), which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to February 2010) and EMBASE (1980 to February 2010).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotics commonly used for treating M. pneumoniae (i.e. macrolide, tetracycline or quinolone classes) versus placebo, or antibiotics from any other class in the treatment of children under 18 years of age with community-acquired LRTI secondary to M. pneumoniae.

DATA COLLECTION AND ANALYSIS

The review authors independently selected trials for inclusion and assessed methodological quality. We extracted and analysed relevant data separately. Disagreements were resolved by consensus.

MAIN RESULTS

A total of 1912 children were enrolled from seven studies. Data interpretation was limited by the inability to extract data that referred to children with M. pneumoniae. In most studies, clinical response did not differ between children randomised to a macrolide antibiotic and children randomised to a non-macrolide antibiotic. In one controlled study (of children with recurrent respiratory infections, whose acute LRTI was associated with Mycoplasma, Chlamydia or both by polymerase chain reaction, and/or paired sera) 100% of children treated with azithromycin had clinical resolution of their illness compared to 77% not treated with azithromycin at one month.

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw any specific conclusions about the efficacy of antibiotics for this condition in children (although one trial suggests macrolides may be efficacious in some children with LRTI secondary to Mycoplasma). The use of antibiotics has to be balanced with possible adverse events. There is still a need for high quality, double-blinded RCTs to assess the efficacy and safety of antibiotics for LRTI secondary to M. pneumoniae in children.

The role of Mycoplasma in upper respiratory infections

Mycoplasma pneumoniae is a common cause of upper and lower respiratory tract infections. Pneumonia is the most clinically important manifestation, but tracheobronchitis and various nonspecific upper respiratory tract symptoms are more typically seen in clinical settings. M. pneumoniae can cause pharyngitis with or without concomitant lower respiratory tract involvement, but it is less commonly detected in other upper respiratory conditions such as otitis media, sinusitis, and the common cold. A variety of methods exist for laboratory diagnosis of M. pneumoniae infection, including culture, serology, and the polymerase chain reaction assay, but each has limitations. This article provides a summary of recent studies that have evaluated the role of M. pneumoniae in upper respiratory tract infections; a brief discussion of its cell biology, pathogenic mechanisms, and epidemiology; and recommendations for laboratory diagnosis and management.

Variation in colonization, ADP-ribosylating and vacuolating cytotoxin, and pulmonary disease severity among mycoplasma pneumoniae strains

RATIONALE

Mycoplasma pneumoniae was recently discovered to produce an ADP-ribosylating and vacuolating cytotoxin, designated CARDS toxin, which is hypothesized to be a primary pathogenic mechanism responsible for M. pneumoniae-induced pulmonary inflammation. It is unknown if cytotoxin production varies with M. pneumoniae strain or if variation in cytotoxin production affects pulmonary disease severity.

OBJECTIVES

To examine the production of CARDS toxin by various strains of M. pneumoniae and compare the disease manifestations elicited by these strains in an experimental model of M. pneumoniae respiratory infection.

METHODS

BALB/c mice were inoculated once intranasally with SP4 broth (negative control) or three different M. pneumoniae strains: M129-B7, M129-B9, or S1. Mice were assessed at 1, 2, 4, 7, 10, and 14 days after inoculation. Outcome variables included comparisons among M. pneumoniae strains relative to bronchoalveolar lavage (BAL) M. pneumoniae quantitative culture, CARDS toxin-based PCR, and CARDS toxin protein determinations, as well as cytokine and chemokine concentrations. Graded lung histopathologic score (HPS) was also assessed.

MEASUREMENTS AND MAIN RESULTS

CARDS toxin concentrations were significantly increased in mice inoculated with strain S1 compared with mice inoculated with M129-B7 or M129-B9 strains. Quantitative M. pneumoniae culture and polymerase chain reaction were also significantly greater in mice infected with S1 strain compared with the other two strains, as were lung HPS and concentrations of IFN-γ, IL-12, IL-1α, macrophage inflammatory protein-1α, and keratinocyte-derived chemokine. In addition, a significant positive correlation was found between CARDS toxin concentration and lung HPS.

CONCLUSIONS

CARDS toxin concentrations in BAL are directly linked to the ability of specific M. pneumoniae strains to colonize, replicate, and persist, and elicit lung histopathology. This variation among strains may predict the range in severity of pulmonary disease observed among patients.

Chlamydophila pneumoniae

Chlamydophila pneumoniae is estimated to cause about 10% of community-acquired pneumonia (CAP) cases and 5% of bronchitis cases, although most patients with C pneumoniae infection are asymptomatic, and the course of respiratory illness is relatively mild. The incubation period of C pneumoniae infection is around 21 days, and such symptoms as cough and malaise show a gradual onset, yet may persist for several weeks or months despite appropriate antibiotic therapy. Diagnosis by nasopharyngeal specimen culture, serum antibody titers, or molecular techniques is usually delayed with respect to the onset of symptoms, antibiotic treatment, or disease resolution and there is no accurate, standardized, commercial US Food and Drug Administration-cleared diagnostic method available. Erythromycin, tetracycline, and doxycycline are used as first-line therapy, although some investigators report no clinical or survival benefits from treating CAP caused by atypical pathogens. Meanwhile, adequate prospective studies have met with ethical and logistic barriers. Despite these limitations, North American guidelines recommend the antimicrobial treatment of patients with acute C pneumoniae respiratory infection.

Antibiotics for community-acquired pneumonia in children

BACKGROUND

Pneumonia caused by bacterial pathogens is the leading cause of mortality in children in low-income countries. Early administration of antibiotics improves outcomes.

OBJECTIVES

To identify effective antibiotics for community acquired pneumonia (CAP) in children by comparing various antibiotics.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to September 2009); and EMBASE (1990 to September 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in children of either sex, comparing at least two antibiotics for CAP within hospital or ambulatory (outpatient) settings.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from full articles of selected studies.

MAIN RESULTS

There were 27 studies, which enroled 11,928 children, comparing multiple antibiotics. None compared antibiotic with placebo.For ambulatory treatment of non-severe CAP, amoxycillin compared with co-trimoxazole had similar failure rates (OR 0.92; 95% CI 0.58 to 1.47) and cure rates (OR 1.12; 95% CI 0.61 to 2.03). (Three studies involved 3952 children).In children hospitalised with severe CAP, oral amoxycillin compared with injectable penicillin or ampicillin had similar failure rates (OR 0.95; 95% CI 0.78 to 1.15). (Three studies involved 3942 children). Relapse rates were similar in the two groups (OR 1.28; 95% CI 0.34 to 4.82).In very severe CAP, death rates were higher in children receiving chloramphenicol compared to those receiving penicillin/ampicillin plus gentamycin (OR 1.25; 95% CI 0.76 to 2.07). (One study involved 1116 children).

AUTHORS' CONCLUSIONS

There were many studies with different methodologies investigating multiple antibiotics. For treatment of ambulatory patients with CAP, amoxycillin is an alternative to co-trimoxazole. With limited data on other antibiotics, co-amoxyclavulanic acid and cefpodoxime may be alternative second-line drugs. For severe pneumonia without hypoxia, oral amoxycillin may be an alternative to injectable penicillin in hospitalised children; however, for ambulatory treatment of such patients with oral antibiotics, more studies in community settings are required. For children hospitalised with severe and very severe CAP, penicillin/ampicillin plus gentamycin is superior to chloramphenicol. The other alternative drugs for such patients are ceftrioxone, levofloxacin, co-amoxyclavulanic acid and cefuroxime. Until more studies are available, these can be used as a second-line therapy.There is a need for more studies with larger patient populations and similar methodologies to compare newer antibiotics.