Wise Use of Antibiotics: Shorter Is Better: 3 – 5 Days of Antibiotics for Community-Acquired Pneumonia

Column Author: Josh Herigon, MD, MPH, MBI

Column Editor: Rana El Feghaly, MD, MSCI | Director, Infectious Diseases Clinical Services; Director, Outpatient Antibiotic Stewardship Program; Medical Director, Vaccines for Children (VFC) Program

For years, the standard of care for community-acquired pneumonia (CAP) in children often involved a 10-day course of antibiotics. However, recent studies challenging this approach are highlighting the efficacy of antibiotic regimens as short as three days. This shift toward short-course antibiotic therapy is significant not only for maintaining effective treatment courses while improving patient experience but also for mitigating the growing global problem of antimicrobial resistance. Understanding and implementing these updates is essential in delivering evidence-based care while promoting antibiotic stewardship.

How Short Is “Short-Course Therapy”?

Short-course antibiotic therapy for CAP refers to a treatment duration of three to five days, compared to more conventional seven to 10 day regimens. In recent randomized controlled trials (RCTs), these shorter courses have been shown to be just as effective in children with mild to moderate CAP, provided that the patient responds clinically within the first few days of treatment. Key studies suggest that for uncomplicated cases of CAP, a three- to five-day course of appropriate antibiotics can achieve similar rates of clinical resolution and prevent complications when compared to longer durations.

Key Studies Supporting Shorter Courses

Unfortunately, most antibiotic duration recommendations are based on scant evidence. CAP is the exception to that rule. Owing to its status as a leading cause of pediatric morbidity and mortality worldwide, CAP has been studied extensively recently. Many of these studies have been small and difficult to draw conclusions from. However, two recent meta-analyses with pooled analyses provide more robust evidence.

Gao et al. compared the efficacy and safety of shorter (five days or less) versus longer antibiotic treatments in children with CAP.¹ After data was analyzed from 16 randomized clinical trials involving 12,774 patients, the findings suggested that shorter-duration antibiotics are as effective as longer-duration treatments in terms of clinical cure, treatment failure, and relapse. There was no significant difference in mortality, need for hospitalization, or severe adverse events.

Li et al. evaluated whether a shorter course of antibiotics was as effective as a longer course for treating non-severe childhood CAP.² The meta-analysis included nine randomized clinical trials with 11,143 participants, mostly aged 2 to 59 months. Results showed that a shorter course of antibiotics was noninferior to a longer course in terms of treatment failure, with failure rates of 12.8% for shorter courses and 12.6% for longer courses. Additionally, a three-day course was noninferior to a five-day course, and a five-day course was noninferior to a 10-day course. Shorter courses were associated with fewer adverse effects, such as gastroenteritis, and less caregiver absenteeism.

Benefits of Short-Course Therapy

• Decreased Risk of Adverse Effects: With fewer days of antibiotics, the risk of side effects, such as gastrointestinal disturbances or allergic reactions, decreases. This course of action contributes to an overall better patient experience.
• Cost-Effectiveness: Fewer antibiotics mean lower costs for families and health care systems. In resource-limited settings, this course of action can make a significant difference in access to care.
• Antibiotic Stewardship: Overuse of antibiotics is one of the primary drivers of antimicrobial resistance. By reducing unnecessary antibiotic exposure, short-course therapy helps limit the selection pressure that fosters resistant strains of bacteria.

Practical Considerations

When implementing short-course therapy, it’s crucial to identify appropriate candidates. Children who are mildly to moderately ill, show early clinical improvement, and are otherwise healthy are prime candidates for a shorter regimen. The two meta-analyses cited earlier were conducted primarily with children less than 5 years old, as this is the highest risk group for mortality in resource-poor settings. Some caution should be taken in extrapolating this plan to older children, but there is little evidence to suggest different outcomes. Those with severe illness, underlying chronic conditions, or those who fail to show clinical improvement by day three may still require additional days for their treatment course.

Conclusion

The move toward short-course antibiotic therapy for CAP represents a win for patients, health care providers, and public health. For pediatricians, staying updated on these evolving guidelines is vital to ensure optimal outcomes for young patients while supporting efforts to curb antibiotic resistance. The Children’s Mercy Department of Evidence Based Practice recently reviewed the most up-to-date literature and updated our CAP pathway to include recommendations for shorter antibiotic durations. By embracing this evidence-based approach, pediatricians can help shift the paradigm toward a more judicious use of antibiotics without compromising care quality.

References

1. Gao Y, Liu M, Yang K, et al. Shorter versus longer-term antibiotic treatments for community-acquired pneumonia in children: a meta-analysis. Pediatrics. 2023;151(6):e2022060097. doi:10.1542/peds.2022-060097
2. Li Q, Zhou Q, Florez ID, 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;176(12):1199-1207. doi:10.1001/jamapediatrics.2022.4123