Short- versus long-course antibiotic therapy in non-severe CAP in children: a systematic review and meta-analysis

Optimizing antibiotic duration for pediatric community-acquired pneumonia (CAP) may reduce treatment burden and support antimicrobial stewardship. Although recent randomized trials and evidence syntheses have reported similar clinical outcomes with shorter antibiotic courses, the effect of treatment duration on adherence-an especially relevant consideration in children-has received comparatively limited systematic evaluation. We therefore aimed to compare treatment effectiveness, medication adherence, and antibiotic-related adverse events between short-course and conventional-duration antibiotic therapy for non-severe CAP in immunocompetent children. PubMed, Cochrane Library, Scopus, ClinicalTrials.gov, and WHO Global Index Medicus were sought through April 25, 2025. Only randomized clinical trials that included immunocompetent children < 18 years with non-severe CAP and compared short-course (≤ 5 days) with longer therapy (> 5 days) were considered. Data extraction and risk of bias (ROB 2) assessment were performed by two independent reviewers. Summary data were extracted by published reports. The principal outcomes were treatment effectiveness, assessed through treatment failure and relapse according to the definitions prespecified by each trial, and medication non-adherence to the active (non-placebo) study drug. Antibiotic-related adverse events were assessed as a secondary outcome. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using random-effects models. Two hundred thirty studies were originally screened, after removal of duplicates and 10 trials (n = 8970) met inclusion criteria. No significant differences were found in treatment failure [RR = 1.07 (95% CI, 0.93-1.24), I² = 3%] or relapse [RR = 1.04 (95% CI, 0.72-1.49), I² = 0%]. Shorter regimens markedly reduced non-adherence [RR = 0.35 (95% CI, 0.24-0.50), I² = 54%], the most consistent and clinically meaningful difference. Adverse events were comparable [RR = 0.71 (95% CI, 0.36-1.40), I² = 81%].

Short-course therapy was not associated with significantly different treatment failure or relapse rates compared with longer regimens and was associated with substantially lower non-adherence. These findings support shorter antibiotic courses as a reasonable treatment option for non-severe pediatric CAP, while acknowledging that the present meta-analysis was not designed to formally establish non-inferiority or equivalence.

• Short-course antibiotic therapy may achieve similar clinical outcomes to conventional longer courses in children with non-severe community-acquired pneumonia. • Medication adherence remains an important challenge in pediatric antibiotic therapy.

• This meta-analysis found no significant difference in treatment failure or relapse between short- and long-course therapy. • Short-course therapy was associated with substantially lower non-adherence, highlighting an important practical advantage of shorter regimens.