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Nearly one in five children with pneumonia managed as outpatients did not receive an oral antibiotic after diagnosis, according to a multistate cohort study of children insured by Medicaid in JAMA Network Open.

“Although not receiving antibiotics was associated with a small increase in the risk of treatment failure, severe outcomes were uncommon regardless of whether antibiotics were received,” Daniel Shapiro, MD, MPH, and colleagues wrote.

Antibiotic treatment in children with pneumonia is common despite a viral etiology in most cases. To investigate whether antibiotic receipt was linked with a lower risk for treatment failure, the researchers looked at outcomes for children seen in ambulatory settings who were and were not treated with an antibiotic for a pneumonia diagnosis from 2017 to 2019 using a Medicaid claims database.

The main outcomes were treatment failure and severe outcomes within 2 to 14 days after the initial visit. Hospitalization or ambulatory revisits for pneumonia, receipt of a new antibiotic with a same-day ambulatory visit, or complicated pneumonia were all considered treatment failures.

The analysis included 103,854 children with pneumonia whose median age was 5 years. Among them, 19.7% did not receive an antibiotic, according to the study findings.

Dr. Shapiro and colleagues used propensity score matching to compare outcomes for 20,227 children who received an antibiotic and 20,227 children who did not.

Outcomes Based on Antibiotic Use

Rates of treatment failure were 10.7% for children who did not receive antibiotics and 8.7% for children who did receive antibiotics, the study found. Rates of severe outcomes, which included hospitalization for pneumonia or complicated pneumonia, were 1.1% in children who did not receive antibiotics and 0.7% for those who did receive antibiotics.

“Antibiotic treatment was associated with an approximately 2–percentage point risk difference for treatment failure and 0.5–percentage point risk difference for severe outcomes,” the researchers wrote. “In sensitivity analyses that considered a longer exposure window for antibiotic treatment or excluded children with asthma and bronchiolitis, risk differences were less than 1 percentage point.”

Given the modest observed differences in treatment failure and the rarity of severe outcomes, future research should investigate which patients can safely go without immediate antibiotic treatment, they continued.

“These results suggest that some children diagnosed with pneumonia can likely be managed without antibiotics and highlight the need for prospective studies to identify these children,” Dr. Shapiro and colleagues wrote.