Pre-Collegiate Global Health Review
Clinical Efficacy of the Length of Antibiotic Treatment for Pediatric Community-Acquired Pneumonia
Ellen Kang, Yorba Linda High School, Yorba Linda, California, USA
Objective: To compare the effectiveness and rates of adverse clinical outcomes between pediatric patients with community-acquired pneumonia prescribed shorter versus longer courses of antibiotics.
Study design: I performed a retrospective literature review using medical search engines, including PubMed and SciHub. The study analyzed children aged 6 months to 18 years diagnosed with non-severe, community-acquired pneumonia (n=125,677).
Results: 11.6% were prescribed the short-duration therapy, and 88.3% were prescribed the long-duration therapy. During the follow up period, 6.2% of the short-treatment cohort experienced relapse, while 5.1% of the long-treatment cohort experienced relapse.
Conclusion: Among pediatric patients with community-acquired pneumonia, no statistically significant differences were found between short- versus long-term antibiotic treatments in general. Specifically, however, prescriptions of 5 days are comparable to that of 10 days, but prescriptions of 3 days may be linked to an increase in adverse clinical outcomes.
Pneumonia is the largest infectious cause of death in children across the globe, causing over fifteen percent of deaths in children under the age of five. Conventionally, the recommended antibiotic durations for pediatric pneumonia patients have been about 10 days; however, there is a lack of research-based evidence justifying these treatment durations (Greenberg, 2014). In the context of rising concern over antimicrobial resistance, it is important that we shift our focus on making judicious decisions on antibiotic duration for children. Previous research has suggested that short-duration treatments for adults with pneumonia may be just as efficient as long-term durations and possibly a more favorable choice considering the fact that long term antibiotic treatment can give rise to more resistant forms of bacteria and kill off beneficial bacteria (Shapiro, 2021). Considering the risks of a longer treatment, it is important to investigate the clinical efficacy of shorter-duration antibiotic treatments for children as well. Thus, the purpose of this literature review is to perform an exploratory evaluation of the adverse clinical outcomes of short- versus long-term antibiotic treatment for pediatric community-acquired pneumonia (CAP) patients.
PubMed and SciHub were used to obtain the studies analyzed. The search parameters included the searches of specific keywords, including pediatric pneumonia, antibiotic treatment of pneumonia, and community-acquired pneumonia. The inclusion criteria was limited to studies published after 2010 that included Amoxicillin as a part of therapy and focused solely on pediatric patients. Furthermore, the researched cases of pneumonia were non-severe pneumonia, which was defined as patients "with a cough or difficulty breathing but no risk of heart, kidneys, or circulatory system failure". The study excluded patients with co-morbid conditions and those diagnosed with hospital-acquired or complicated pneumonia. All research articles were direct sources, meaning no Meta-Analyses or literature reviews were referenced. The studies found varied in categories such as locations, age, and time periods used for short-term versus long-term.
Figure 1. Comparison of the cure rates of short- and long-duration pediatric CAP treatment.
Figure 2. Table containing breakdown of Research
All five studies, collectively analyzing 125,677 patients, revealed no statistically significant differences in the rates of adverse outcomes when comparing short term versus long term treatments of pediatric pneumonia. Upon further investigation of short-term trial lengths, many articles pointed out that prescriptions of 5 days would be comparable to that of 10 days, but prescriptions of 3 days may be linked to an increase in adverse clinical outcomes.
In adults, a retrospective cohort study in Michigan determined that short antibiotic durations of 5 days were not inferior to longer-term treatments (Vaughn, 2019). These results mirror the findings from this meta-analysis: that antibiotic prescriptions of at least 5 days are likely safe in pediatric patients. Accordingly, the findings of this review contribute to existing evidence from clinical adult trials that support shorter antibiotic courses for CAP by confirming that shorter courses of antibiotics are likely effective for pediatric CAP patients as well. Furthermore, these results add to the body of evidence recommending short-duration antibiotic treatments for children by examining a large group of children of all ages across multiple settings and affirming that these results are likely generalizable across people of all age demographics and both developed and developing regions.
The main limitation of this study is that it pulled results confounded from numerous, independent studies. Namely, there may have been baseline differences between treatment groups and differing methods of identifying CAP that could not be accounted for. Second, with most of the research analyzed studying patients in an outpatient setting, I could not reliably verify that antibiotics were consistently administered to the patients.
Nonetheless, the results of this study attest to the clinical efficacy of shorter-term antibiotic treatment by revealing that antibiotic duration is unlikely to be the determinant of treatment failure for most pediatric CAP patients. These results should encourage administrators to prescribe shorter courses of antibiotics for CAP to prevent outcomes of antibiotic resistant bacteria.
In taking these steps, future studies could identify guidelines for when longer-term antibiotic durations should be prescribed. Such indications may include results from x-rays or the progression of respiratory tract infections that assess the severity of the patient’s condition. Moreover, this study focused specifically on the duration of high dose amoxicillin treatment in pediatric CAP. Future studies could investigate the ideal treatment duration for other antimicrobial therapies for CAP such as azithromycin or penicillin.
This study suggests that shorter courses (five days) of antibiotic treatment are not inferior to longer courses in preventing adverse clinical outcomes for pediatric patients diagnosed with non-severe CAP. Considering the risk of antimicrobial resistance associated with a longer treatment, shorter durations of antibiotic treatment are likely the preferable option for children. This solution may lead to an improvement in global health by combating antimicrobial resistance in children of both developed and less-developed countries. Further, curtailing the treatment period may be more cost-effective for both patients and hospitals because drug costs may be cut. By adopting policies that limit the unnecessary use of antibiotics, countries may be able to better allocate limited medications and take a stride towards providing equal healthcare for all patients.
Ginsburg AS, Mvalo T, Nkwopara E, McCollum ED, Phiri M, Schmicker R, Hwang J,
Ndamala CB, Phiri A, Lufesi N, May S. Amoxicillin for 3 or 5 Days for
Chest-Indrawing Pneumonia in Malawian Children. N Engl J Med. 2020 Jul
2;383(1):13-23. doi: 10.1056/NEJMoa1912400. PMID: 32609979; PMCID:
Greenberg, David MD*†; Givon-Lavi, Noga PhD*†; Sadaka, Yair MD*†; Ben-Shimol,
Shalom MD*†; Bar-Ziv, Jacob MD‡; Dagan, Ron MD*† Short-course Antibiotic
Treatment for Community-acquired Alveolar Pneumonia in Ambulatory Children,
The Pediatric Infectious Disease Journal: February 2014 - Volume 33 - Issue 2 -
p 136-142. doi: 10.1097/INF.0000000000000023
Pernica JM, Harman S, Kam AJ, et al. Short-Course Antimicrobial Therapy for Pediatric
Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA
Pediatr. 2021;175(5):475–482. doi:10.1001/jamapediatrics.2020.6735
Same, R. G., Amoah, J., Hsu, A. J., Hersh, A. L., Sklansky, D. J., Cosgrove, S. E.,
Tamma, P. D. (2021). The Association of Antibiotic Duration With Successful
Treatment of Community-Acquired Pneumonia in Children. Journal of the
Pediatric Infectious Diseases Society, 10(3), 267–273.
Shapiro DJ, Hall M, Lipsett SC, Hersh AL, Ambroggio L, Shah SS, Brogan TV, Gerber
JS, Williams DJ, Grijalva CG, Blaschke AJ, Neuman MI. Short- Versus
Prolonged-Duration Antibiotics for Outpatient Pneumonia in Children. J Pediatr.
2021 Jul;234:205-211.e1. doi: 10.1016/j.jpeds.2021.03.017. Epub 2021 Mar 18.
Vaughn VM, Flanders SA, Snyder A, Conlon A, Rogers MAM, Malani AN, McLaughlin E,
Bloemers S, Srinivasan A, Nagel J, Kaatz S, Osterholzer D, Thyagarajan R,
Hsaiky L, Chopra V, Gandhi TN. Excess Antibiotic Treatment Duration and
Adverse Events in Patients Hospitalized With Pneumonia: A Multihospital Cohort
Study. Ann Intern Med. 2019 Aug 6;171(3):153-163. doi: 10.7326/M18-3640.
Epub 2019 Jul 9. PMID: 31284