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%].