Shorter versus longer antibiotic treatment in children with community-acquired pneumonia: A systematic review with meta-analyses

BACKGROUND: Excessive antibiotic use promotes resistance and side effects and increases healthcare costs. Antibiotics are often prescribed to treat community-acquired pneumonia (CAP). The optimal duration of treatment is debated. In this study, we compare the efficacy of shorter and longer antibiotic treatment for CAP in the outpatient setting and evaluate the pertinent economic, environmental, ethical, and societal issues. METHODS: Relevant articles published up until 5 February 2024 were identified by searches in the electronic databases MEDLINE, Embase, and CENTRAL as well as in trial registries and in reference lists of systematic reviews, including health technology assessment (HTA) reports. All randomized controlled trials (RCTs) comparing short- and long-term antibiotic treatment in children with outpatient CAP were included in the benefit assessment. A 10% difference was set as the non-inferiority margin. RESULTS: Seven RCTs that studied a total of 8590 children were included. In young children with clinically diagnosed CAP, a three-day course of amoxicillin was non-inferior to 5-, 7-, or 10-day courses with respect to treatment success (relative risk [RR] 0.99; 95% confidence interval [0.96; 1.02]). Shorter treatment was associated with fewer (non-severe) adverse events (0.87, [0.78; 0.96]). Relapses and deaths were rare overall. Where shorter treatment was equally effective, it also had economic and ecological benefits. CONCLUSION: Three days of antibiotic treatment with amoxicillin may be just as effective as longer treatment, and also better tolerated, in younger children with clinically diagnosed, outpatient, non-severe CAP, and would conserve resources. These findings can be taken into account in the formulation of guideline recommendations.