For hospitalized children with complex medical needs who develop uncomplicated pneumonia, narrow-spectrum antibiotics match broad-spectrum drugs in outcomes such as length of stay and readmission rates, new research in Pediatrics shows.

The findings support ampicillin and amoxicillin as reasonable first-line treatments for community-acquired pneumonia (CAP) in these children when hospitalized — a group currently excluded from guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.

The organizations in 2011 recommended narrow-spectrum aminopenicillins as first-line treatment for otherwise healthy children with nonsevere CAP. But the guidance does not extend to children with medical complexity due to a lack of clinical evidence to guide antibiotic choice for this population. Updated guidelines are available for complicated pneumonia, but not yet for uncomplicated pneumonia.

That lack of evidence can lead clinicians to prescribe broad-spectrum antibiotics because of the perceived high risk when treating children with medical complexity, said Maheswari Ekambaram, MBBS, MSCE, pediatric infectious diseases specialist at Dell Children’s Medical Center in Austin, Texas, who led the study.

“But medical complexity alone should not automatically mean we need to prescribe broad-spectrum antibiotics for nonsevere, uncomplicated pneumonia,” she said.

Children with medical complexity include those with neurologic impairment, genetic disorders, and congenital heart disease. Often, these conditions increase the risk for serious illness, hospitalization, and infections requiring antibiotic treatment.

“Broader-spectrum therapy is not always better,” said Derek Williams, MD, MPH, professor of pediatrics in the Division of Hospital Medicine at Vanderbilt University Medical Center in Nashville, Tennessee.

To investigate whether aminopenicillins showed the same outcomes as broad-spectrum counterparts for CAP, Ekambaram and colleagues conducted an observational trial involving 749 children aged 3 months to 21 years with at least one complex chronic condition who received either broad-spectrum (55%) or narrow-spectrum antibiotics (45%).

All children were treated for nonsevere CAP at Children’s Hospital of Philadelphia in Philadelphia between 2016 and 2024 and were grouped according to the antibiotics they received in the first 12 hours following presentation. Children were excluded if they had severe immunosuppression, sickle cell disease, or a recent pneumonia hospitalization, among others.

Narrow-spectrum antibiotics were defined as receiving ampicillin or amoxicillin. Broad-spectrum treatment included ceftriaxone, amoxicillin-clavulanate, aztreonam, vancomycin, and piperacillin-tazobactam. Ekambaram and colleagues used statistical methods designed to make the two groups more comparable and mimic a randomized trial.

Before adjustment, children given broader drugs were more likely to have required respiratory support, to have been previously hospitalized, to have undergone blood testing, or to have required an ICU stay.

After adjustment, no significant differences in time to discharge were observed. The median hospital stay was 3.8 days among children receiving broad-spectrum antibiotics, half a day longer than among children who received narrow-spectrum versions. No differences were observed between groups in progression to severe pneumonia or related hospital readmissions after adjustment.

Broad-spectrum treatment also showed no statistically significant differences among children with high-intensity neurologic impairment or those dependent on respiratory support.

Ekambaram said more research is needed before incorporating narrow-spectrum treatment for medically complex children in pediatric pneumonia guidelines.

The findings also highlight a larger problem in pediatric research: Medically complex children are frequently left out of studies because they are more difficult to study, said Kathleen Chiotos, MD, MSCE, associate professor of anesthesiology and critical care at the University of Pennsylvania Perelman School of Medicine in Philadelphia and an attending physician at Children’s Hospital of Philadelphia, who helped lead the study.

“That really does them a disservice because they’re not being studied in the same robust way. So we need to understand the best ways to use antibiotics in these kids,” she said.

No disclosures were reported.

Kelley Butler is a freelance writer based in the Washington, DC, area, covering a broad range of healthcare topics.