Can children with nonsevere community-acquired pneumonia (CAP) be managed with short-course antibiotics instead of long-course antibiotics? To answer this question, researchers from China, Canada, Colombia, UK and India collaborated on a systematic review and meta-analysis.^1,2

Nine randomized clinical trials that compared a shorter- vs longer-course therapy using the same oral antibiotic in children with children with nonsevere CAP were reviewed after a comprehensive search of Medline, Embase, Web of Science, the Cochrane Library including three Chinese databases. The trials involved 11,143 children with 58% boys and ages ranging from 2 months to 59 months. Treatment failure was the primary study outcome. The secondary outcomes included relapse, adverse events, absenteeism (caregiver and patient) and direct costs of treatment.

Eight out of the 9 studies included in the final analysis reported treatment failure, which, for the purpose of the study was defined as persistence of pneumonia or new danger signs of CAP (such as lethargy, inability to drink, loss of consciousness, seizures), raised body temperature (>38°C) post-treatment, change of antibiotic, hospital admission, death, missing more than 3 doses of the study drug or children who were lost to follow-up.

The incidence of treatment failure among children with nonsevere CAP with a shorter course of antibiotics was 12.8% compared to 12.6% with a longer course of antibiotics showing that a shorter course of oral antibiotics was noninferior to a longer course of antibiotics with risk ratio (RR) of 1.01 and risk difference being 0.00.

The regimens compared were 3 days vs 5-10 days or 5 days vs 7-10 days. A 3-day duration of antibiotic treatment was noninferior to a 5-day duration regarding treatment failure (RR 1.01). Likewise, treatment with antibiotics for 5 days was noninferior to 10 days of antibiotic treatment (RR 0.87). Fewer episodes of gastroenteritis occurred with short-course antibiotics (RR 0.79). Caregiver absenteeism was also less when antibiotics were administered for a shorter duration (5 days vs 10 days) (RR 0.74).  However, the non-inferiority between the two groups was not evident when data for children aged ≥5 years was analysed (RR 2.07).

Six studies reported on relapse, which was the secondary endpoint of the study. Again, short-course antibiotics were non-inferior to long-course antibiotics (RR 1.12). One study reported on the costs of treatment and found that with the 3-day course of antibiotics, the cost of treatment was $1,100 compared to $1,250 with the 5-day course.

This meta-analysis provides evidence that short antibiotic treatment was non-inferior to longer duration treatment in children aged up to 5 years with nonsevere CAP. Hence, clinicians, especially in lower and middle-income countries, can consider a short duration of antibiotics such as 3-5 days when managing such children as outpatients. In view of the growing prevalence of antibiotic resistance, a short course of antibiotics is a step towards antibiotic stewardship. Nevertheless, it is prudent to keep in mind that the optimal duration of antibiotics depends on the clinical situation of the individual patient.

References

1. Qinyuan Li, et al. Short-course vs long-course antibiotic therapy for children with nonsevere community-acquired pneumonia: a systematic review and meta-analysis. JAMA Pediatr. 2022 Dec 1;176(12):1199-1207. doi: 10.1001/jamapediatrics.2022.4123.
2. https://www.healio.com/news/pulmonology/20230104/shortcourse-antibiotic-therapy-appears-effective-for-pediatric-nonsevere-pneumonia. Dated January 04, 2023. Accessed on March 25, 2023.