Procalcitonin to Reduce Antibiotic Use in Pediatric Pneumonia

This pilot clinical trial is a 3-site, randomized, placebo-controlled, double-blinded trial assessing the feasibility of comparing amoxicillin to placebo in children 12 months to <6 years of age who present to the ED with Community Acquired Pneumonia (CAP), a procalcitonin (PCT) concentration of <0.25 ng/mL, and who will be treated as outpatients.

Screening and Enrollment This pilot feasibility trial will enroll over a 6-month period and take place at three sites (Ann and Robert H. Lurie Children's Hospital of Chicago, Cincinnati Children's Hospital Medical Center and The Children's Hospital of Philadelphia) that are or were members of the Pediatric Emergency Care Applied Research Network (PECARN). This study aims to enroll 36 patients in total (2 patients per month, per site). Clinical research coordinators (CRCs) at participating EDs will screen potentially eligible patients with respiratory tract symptoms and discuss eligibility with the treating attending physician. If thought to be eligible and a diagnosis of CAP is presumed by the treating physician, the CRC will approach the patient to complete screening procedures. The study will proceed in 2 stages, each with its own informed consent process. During Stage 1, baseline characteristics and serum PCT levels will be ascertained. Stage 2 will consist of a randomized trial of amoxicillin vs. placebo in the subset of patients from Stage 1 that have PCT <0.25 ng/mL.

Randomization After enrollment and confirmation of a PCT <0.25 ng/mL, patients will be randomized to a 10-day course of either amoxicillin (80-100 mg/kg divided BID up to 4,000 mg/day) or placebo. Randomization to amoxicillin or placebo will be at a 1:1 ratio with block sizes of 2 and 4. Patients will be stratified by the clinical site and randomization will be performed through an online system. As a double-blind clinical trial, the study patients and their parents/guardians, investigators and study staff will be blinded to study treatment assignment for the duration of the study.

Study Drug Administration Local investigational drug pharmacies will be provided with active study medication (i.e., amoxicillin) and matching placebo. Site pharmacies at each institution will store study drug and dispense as needed. Study medications will both be liquid reconstituted from powder, and will resemble each other with regards to appearance, favor, consistency and packaging. Study products will be labeled with numerical codes that will maintain allocation concealment. Site investigational pharmacies will be provided with amoxicillin and placebo, in addition to the randomization scheme. The pharmacy will aliquot amoxicillin and placebo into blinded bottles based on randomization scheme.

Follow-up The guardians of participants will be asked to complete a daily symptom diary, using an online data collection form in REDCap, during the first 7 days after the initial Emergency Department study visit. The follow-up will assess patient condition, clinical response, signs or symptoms of clinical deterioration and other adverse effects. The primary outcome will be assessed at day 7 (+/- 2 days), using video chat technology that is standard on most smart phones, tablets, and computers. Video follow-up will be performed by site clinician investigators. In the rare case that a mobile device or computer with video chat technology is not available to the family, the day 7 follow-up will occur by telephone or text through an online system. A final follow-up, performed by site research staff, by telephone call, will occur at Day 21 (+/- 2 days) to assess overall disease course and secondary outcomes.

Data Collection At baseline, demographics, medical history, and history of current illness will be obtained from all participants during stage 1 (pre-randomization). Vital signs will be obtained and a brief physical examination will be performed. After the initial ED visit, patients will record symptoms on daily basis for 6 days via an online data collection form. Follow-up assessments will be completed via telehealth visit or telephone for days 7 and 21. Follow-up visits will collect data regarding symptoms, adverse events and return to medical care, in addition to assessing adherence to study procedures (i.e., medication adherence and daily symptom diary completion). If there is concern for adverse events or deterioration that may warrant medical care, the participant's caregiver will be instructed to contact their primary care physician, emergency department, or call 911, as indicated.