European Journal of Cardiovascular Medicine

Community-acquired pneumonia (CAP) remains one of the most significant infectious diseases affecting children worldwide, contributing substantially to morbidity, outpatient utilisation, and antimicrobial consumption. Globally, CAP accounts for approximately 14% of all deaths in children under five, equating to more than 700,000 deaths annually, with the greatest burden observed in low- and middle-income countries (LMICs) (1). Although mortality in high-income countries (HICs) is comparatively low, CAP continues to be a leading cause of paediatric emergency department visits and antibiotic prescriptions (2). The aetiological spectrum includes Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, and numerous respiratory viruses such as respiratory syncytial virus (RSV), influenza, and adenovirus, with bacterial–viral co-infections being increasingly recognised (3). Despite widespread vaccination programmes, antibiotic therapy remains central to the management of outpatient paediatric CAP.

Historically, guidelines in North America, the United Kingdom, and Europe have recommended 7–10 days of oral antibiotics—predominantly amoxicillin—for uncomplicated CAP in children (4,5). These guidelines were largely informed by expert consensus rather than robust empirical evidence. Treatment courses were, therefore, a routine procedure even where there was a lack of trial evidence to support the course. These longer regimens have become more and more doubted in light of the emergence of the concept of antimicrobial stewardship as a worldwide priority.

There has been a growing concern about the overexposure of children to antibiotics within the last ten years. The use of long-course therapy is characterized by higher levels of antimicrobial resistance, increased rates of gastrointestinal and dermatological adverse drug reactions, disturbance of the developing gut microbiome, and decreased adherence because of caregiver burden (6). Besides this, the incomplete courses of antibiotics, which are prevalent in the younger age bracket due to issues of palatability of medication or caregiver exhaustion, also contribute to the further invalidity of the argument of regular longer courses of therapy. The rampant use of antibiotics has persistently contributed to increased resistance on routine paediatric pathogens and carries serious consequences on their future treatment (7).

Motivated by these concerns, researchers have increasingly examined whether short-course therapy (3–5 days) yields outcomes comparable to traditional 7–10-day regimens. Several high-quality randomised controlled trials (RCTs) now provide strong evidence in support of shorter durations. The SCOUT-CAP trial (8) demonstrated that 5 days of amoxicillin achieved cure rates equivalent to 10 days while significantly reducing antibiotic-associated adverse events and resistance gene carriage among children aged 6–71 months. Similarly, the SAFER trial (9) showed noninferiority of 5-day versus 10-day high-dose amoxicillin for radiographically confirmed CAP in children aged 6 months to 10 years. The CAP-IT trial (10), conducted across 29 hospitals in the UK, further reported noninferiority of 3-day compared with 7-day amoxicillin for preventing re-treatment after early discharge.

Evidence from LMICs has also strengthened confidence in short-course therapy. Trials conducted in Malawi, Pakistan, and Bangladesh have consistently shown equivalence between 3- and 5-day regimens for non-severe pneumonia diagnosed using WHO clinical criteria (11,12). Although early scepticism existed regarding the applicability of LMIC findings to HIC populations, subsequent HIC RCTs have confirmed the safety and effectiveness of short-course therapy using both radiographic and clinical diagnostic criteria.

In spite of these developments, there is still inconsistency in clinical practice. Though certain guidelines (including NICE in the UK) suggest 5 days of uncomplicated CAP, other guidelines still uphold longer periods, and this leaves clinicians confused (13). Differences in patient characteristics, dosage of antibiotics and the method of diagnosis in studies only add to confusion.

In light of these gaps, a modern systematic review and meta-analysis is needed to consolidate new evidence and combine recent high-quality RCTs like SCOUT-CAP and SAFER, and give clear information on the efficacy and safety of short-course therapy in different contexts. This synthesis can inform the revision of guidelines based on evidence and strengthen the antimicrobial stewardship programs worldwide.

Research Question

Is short-course outpatient antibiotic therapy (3–5 days) as effective and safe as standard-course therapy (7–10 days) for treating community-acquired pneumonia in children?

Objective

To systematically compare the effectiveness and safety of short-course versus standard-course outpatient antibiotic therapy for paediatric community-acquired pneumonia, focusing on clinical cure, treatment failure, relapse, and adverse events.

PECO Framework

The PECO framework was used to organize the review so that the criteria of eligibility and outcome measures could be clearly defined (Table 1). The Population consisted of children between the ages of 1 month to 18 years old with outpatient-diagnosed community-acquired pneumonia (CAP). The Exposure was short-course administration of oral antibiotics therapy of 3-5 days and the Comparator was regular course administration of 7-10 days. Clinical cure, treatment failure, relapse, and adverse drug events were the Outcomes measures that were evaluated in the studies. This hierarchical program helped in study selection, data extraction and synthesis to provide a consistent methodology. The PECO components are summarised visually and the logical flow of the review question illustrated in Figure 1.

Table 1: PECO Framework

Figure 1: PECO Framework

The systematic review and meta-analysis have been carried out according to the guidelines of Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) 2020 (14). To achieve rigour, transparency, and reproducibility, all methodological steps such as searching of databases, selection of study, data extraction, and assessment of risk of bias were carried out systematically and independently by two reviewers. 2.1 Protocol and Registration This meta-analysis and systematic review was performed with the guidance of the PRISMA 2020 principles of systematic review and meta-analysis. Before starting the study, a review protocol was created that outlined the study objectives, eligibility criteria, search strategy, data extraction procedures, and statistical analyses that were intended. The protocol was adhered to as originally specified during the review process and there were no deviations of the prespecified methods. Nevertheless, the protocol was not registered in the PROSPERO database, and it is recognized as one of the methodological limitations. Although prospective registration was not done, methodology transparency and reproducibility were ensured with the PRISMA 2020 reporting standards followed. 2.2 Eligibility Criteria Inclusion Criteria The inclusion criteria were based on the studies that met the methodological and clinical criteria to determine antibiotic duration in community-acquired pneumonia in children. Studies that appeared to be eligible included randomized controlled trials (RCTs), quasi-randomized trials, and high-quality comparative observational researches, which are considered reliable in terms of providing comparative evidence. The population of interest was children with community-acquired pneumonia (CAP) and aged between 1 month and 18 years of age diagnosed with community-acquired pneumonia by the use of clinical evaluation or radiographic diagnosis. It was only researches carried out in outpatient settings or in cases of early discharge where children were given oral antibiotics that were eligible. The intervention of interest was short course antibiotic therapy, which was characterized as 3-5 days treatment. This had to be compared with standard-course therapy, which is 7-10 days. Inclusion criteria required the study to report at least one measurable clinical outcome, which could be clinical cure, treatment failure, relapse, re-treatment, hospitalization or adverse events. In studies, it was also necessary to include extractable quantitative data that would be adequate to generate estimates of the effects. Eligibility criteria for study inclusion shown in (Table 2). Exclusion Criteria The studies were filtered out when they studied hospitalized children on intravenous treatment of pneumonia without an outpatient part or when they studied severe, complicated or nosocomial pneumonia since they are quite different in the management. Studies that included mixed antibiotic regimens, without any distinction as to a short and standard duration were eliminated. These were studies with no extractable outcome data and non-primary research (such as reviews, commentaries, case reports, and conference abstracts) were excluded. Moreover, non-English publications were not considered to introduce methodological assessment consistency. These criteria were used to include only the relevant, similar, and high-quality studies. 2.3 Information Sources and Search Strategy A systematic search of literature was performed using five electronic databases: PubMed/MEDLINE, Cochrane Library, EMBASE, Scopus, and Web of Science. The search covered the period between January 2010 and December 2023 since most of the high-quality randomized controlled trials that assessed the effect of antibiotic duration in treating paediatric community-acquired pneumonia were published within this time. Table 2. Eligibility Criteria for Study Inclusion Category Inclusion Criteria Exclusion Criteria Study Design RCTs, quasi-RCTs, comparative observational studies Reviews, commentaries, case reports, conference abstracts Population Children aged 1 month–18 years with CAP (clinical or radiographic) Severe, complicated, or nosocomial pneumonia Setting Outpatient or early discharge receiving oral antibiotics Exclusively hospitalized children on IV therapy Intervention Short-course (3–5 days) antibiotic therapy Mixed or unclear duration regimens Comparator Standard-course (7–10 days) antibiotic therapy No comparator or non-standard comparison Outcomes Cure, failure, relapse, retreatment, hospitalization, adverse events No extractable outcome data Language English only Non-English publications Data Requirements Sufficient numerical data for effect size calculation Missing or incomplete numerical outcome data Search strategy was based on a combination of Medical Subject Headings (MeSH) and free-text words that were related to disease, population, intervention, and study design. The important search terms were community-acquired pneumonia, paediatric, children, amoxicillin, duration of treatment, short course, 3 days, 5 days, treatment failure and randomized controlled trial. The search sensitivity and specificity were maximized using the Boolean operands (AND/OR) and truncation symbols. Moreover, all included studies and other systematic reviews were screened manually on their reference lists to identify any other eligible articles that were not identified by database searches (8-12). 2.4 Study Selection All the records were introduced into EndNote so that they could be removed as duplicates. Titles and abstracts were also screened by two reviewers to identify potentially eligible studies. The selected articles were then located as full texts and evaluated according to the set inclusion and exclusion criteria. The conflict situations were solved by discussing and reaching a consensus, and in case of necessity, through the consulting of the third reviewer. A PRISMA flow diagram was used to record the process of the study selection and indicate how many records were identified, screened, excluded, and included in the final review. Systematic searching in 5 international databases and other manual searches identified a total of 2,458 records. On elimination of 684 repetitions, there were 1,774 records to go through title and abstract screening. Among them, 1,556 records were filtered out on the basis of irrelevance to the research question. Two hundred and eighty-eight full-text articles were evaluated on the basis of eligibility with 206 articles being eliminated on grounds such as inappropriate population, inability to isolate comparisons of treatments, inappropriate outcome, or improper study design. Lastly 12 quality studies were found to meet all the inclusion criteria, and were included in the qualitative and quantitative synthesis as shown in (Figure 2). 2.5 Data Extraction The data extraction form was designed as a standardized form which was piloted to provide consistency in the included studies. The two reviewers independently identified the pertinent information such as the study characteristics (author, year of publication, country, and study design), sample size, age of participants, diagnostic criteria of community-acquired pneumonia, and the details of the antibiotic regimen (type, dose, and length of administration). The details regarding the follow-up period, major outcomes (clinical cure and treatment failure), and minor outcomes (relapse, re-treatment, hospitalization, and adverse events) were also gathered. Any differences among the reviewers were settled by discussion and consensus. Raw event counts were directly drawn out of study reports or computed as necessary, in the case of dichotomous outcomes. In cases where research has given several definitions of treatment failure, the most narrow (cautious) definition was used to achieve consistency and provide limited bias in outcome measurement. 2.6 Data Synthesis and Statistical Analysis The DerSimonian-Laird random-effects model was used as the meta-analyses tool to allow crucially expectant clinical and methodological heterogeneity between studies. To estimate the effects in the case of dichotomous outcomes, risk ratios (RRs) were estimated with 95% confidence intervals (CIs). Statistical heterogeneity was evaluated using the I² statistic, with values ≥50% indicating substantial heterogeneity, alongside the τ² statistic and Chi-square test (p < 0.10 considered significant). Prespecified subgroup analyses were conducted to explore potential sources of heterogeneity, including age category (<5 years vs ≥5 years), diagnostic method (radiographic vs clinical), country income level (high-income vs low- and middle-income), short-course duration type (3 vs 5 days), and antibiotic agent used (amoxicillin versus others). Sensitivity analyses were undertaken by excluding high-risk studies, non-randomized designs, and trials with unclear diagnostic criteria to assess the stability and robustness of the pooled results. Even though the definitions of clinical cure differed among studies (radiographic resolution in high-income countries, and WHO clinical criteria in low- and middle-income countries), pooled outcomes were based on functional clinical recovery as defined in each trial. Subgroup and interaction analyses indicated no significant effect modification by diagnostic method, which is in favour of validity of pooled estimates.

3.1 Characteristics of Included Studies

12 articles were eligible and included in the meta-analysis. These studies have a wide geographical representation namely North America (n=4), Europe (n=3), Africa (n=2) and Asia (n=3) and this increases the applicability of the findings to the world. The majority were randomized controlled trials, with a smaller number of high-quality comparative studies conducted in community-based settings (Table 3).

Antibiotics most commonly evaluated included amoxicillin (in 10/12 studies), followed by amoxicillin–clavulanate and oral macrolides. Short-course therapy ranged from 3 to 5 days, whereas standard-course therapy ranged from 7 to 10 days. Age ranges of included participants varied widely across trials, covering infants (≥2 months) to older children (up to 10 years). Diagnostic criteria differed across settings; high-income countries generally used radiographic confirmation, whereas low- and middle-income countries used WHO clinical criteria.

Across the 12 studies, primary outcomes included clinical cure and treatment failure, while secondary outcomes included relapse, re-treatment, hospitalization, and adverse events. All included studies provided sufficient quantitative data for effect size calculation.

Table 3. Characteristics of Included Studies (n = 12)

AEs = Adverse Events; WHO = World Health Organization; RCT = Randomized Controlled Trial.

3.2 Risk of Bias Results

Risk of bias was assessed for all 12 included studies using the Cochrane RoB 2 tool for randomized controlled trials and ROBINS-I for the single comparative observational study. Overall, the methodological quality of the evidence was moderate to high (Table 3). Most randomized trials adequately described random sequence generation and allocation concealment, and had low levels of missing outcome data, but several studies had limitations related to lack of blinding and outcome assessment procedures.

Among the large, recent RCTs conducted in high-income settings—SCOUT-CAP, SAFER, CAP-IT, and Le Saux et al. (8–10, 11)—randomization procedures and allocation concealment were clearly reported and judged at low risk of bias. These studies also showed low risk for missing outcome data and selective reporting because follow-up was nearly complete and outcomes were prespecified in trial protocols or registry entries. However, blinding of participants and clinicians was generally not feasible due to differences in treatment duration, which led to “some concerns” in the domain of deviations from intended interventions in open-label trials such as CAP-IT (10).

Trials conducted in community and primary-care settings in Malawi, Pakistan, Kenya, Israel and India (4, 5, 7–9) frequently had some concerns for the randomization and allocation processes because details of sequence generation or concealment were incompletely reported. In addition, most of these studies were unblinded, and outcome assessment relied on caregiver-reported symptoms and clinical examination, which may introduce performance and detection bias. Nevertheless, attrition was low in almost all of these studies, and selective reporting was not evident, resulting in an overall judgment of “some concerns” rather than high risk.

Table 4. Risk of Bias Assessment of Included Studies

RoB 2 = revised Cochrane risk of bias tool for randomized trials; ROBINS-I = Risk Of Bias In Non-randomized Studies of Interventions; RCT = randomized controlled trial.

Two studies were judged at high overall risk of bias. The large community trial by Hazir et al. and the comparative cohort by Harris et al. (6,10) had important limitations related to potential confounding, less rigorous control of co-interventions, and limited description of allocation concealment. The observational design of the Harris study meant that baseline comparability between exposure groups could not be fully assured, and this was reflected as serious risk of bias due to confounding under ROBINS-I.

In summary, 5 of the 12 studies were judged to be at low overall risk of bias, 5 had some concerns, and 2 were at high risk. The principal domains contributing to lower quality were lack of blinding and incomplete reporting of the randomization process in older or community-based trials. Because the largest and most influential trials (SCOUT-CAP, SAFER and CAP-IT) were at low risk of bias (8–10), the overall certainty of evidence for the primary outcome of clinical cure was considered robust. A graphical risk-of-bias summary is presented in Figure 3, and domain-specific judgments for each study are shown in Table 4.

Figure 3: Risk of Bias Assessment

3.3 Primary Outcome – Clinical Cure

The main outcome measure in all the twelve studies included was clinical cure of short-course (3-5 days) and standard-course (7-10 days) outpatient therapy with antibiotics in paediatric patients with community-acquired pneumonia. Non-inferiority of short-course therapy was based on pooled meta-analysis that revealed no statistically significant difference in clinical cure between the treatment durations (RR = 1.01, 95% CI 0.98-1.03). The statistical heterogeneity was small (I²  = 12 percent), which means that there were similar effects across the studies.

Subgroup analyses showed no significant interaction by country income level (high-income vs low- and middle-income countries; p for interaction = 0.64) or diagnostic method (radiographic vs WHO clinical criteria; p for interaction = 0.71). The forest plot (Figure 4) shows that study-level estimates were closely aggregated around the line of no effect. On the whole, the results support the idea that short-course antibiotic therapy has equivalent clinical curative rates as a standard duration of treatment and has a lower total exposure to antibiotics.

Table 5. Clinical Cure Rates across Included Studies

3.4 Secondary Outcomes

The secondary outcomes were treatment failure, relapse, hospitalization, adverse drug reactions, and antibiotic re-treatment in twelve included studies. Strong treatment failure was not statistically different with short-course and standard-course therapy (RR = 0.97, 95% CI 0.85-1.10), with minimal heterogeneity (I²= 18%). The rate of relapse and hospitalization were uncommon and did not differ significantly between the two treatment periods and the frequency of the events was always low in the studies.

Adverse drug reactions and antibiotic re-treatment were not quantitatively pooled and thus were presented narratively due to the high levels of heterogeneity in outcome definitions and reporting formats. The majority of the trials reported comparable or smaller numbers of adverse drug reactions in short course therapy groups and the SCOUT-CAP trial recorded statistically significant decreasing adverse events with 2 -lactam use and a decrease in the number of antimicrobial resistance genes carriage after shorter treatment. The rates of antibiotic re-treatment were low and similar in both high-income and low- and middle-income country setting.

Figure 4. Forest Plot of Clinical Cure (Short vs Standard Therapy)

Table 6. Summary of Secondary Outcomes across Included Studies

Altogether, secondary outcomes suggest that short course antibiotic treatment is equally safe and effective as treatment of usual duration with possible benefits in terms of tolerability and reduced antibiotic exposure. Table 6 shows a summary of secondary outcomes, whereas Figure 5 provides an overview.

3.5 Sensitivity Analyses

The sensitivity analyses were conducted in order to estimate the stability of findings and define whether the quality of studies, design, or statistical modelling had an effect on the findings. Omitting four studies with ambiguous or high risk of bias, mostly non-randomized studies or insufficient blinding (5, 6, 10, 12), yielded practically the same results. The difference in risk ratio to clinical cure changed slightly (from ~1.01 to 1.00), and there were no significant changes in the secondary outcomes including treatment failure, relapse, and hospitalization, meaning that the conclusions were not biased by lower-quality studies shown in (Table 7).

Figure 5. Secondary Outcomes Overview

Limiting the analysis to eight high-quality RCTs (11, 7–9, 1, 4) gave similar results as the overall data, with clinical cure and relapse rates being equal between short- and standard-course therapy.

Using a fixed-effect model to repeat the analyses led to a difference of less than 0.01 in the outcomes with the same direction of difference, as well. Together, these results indicate the high robustness and the uniform non-inferiority of the short-course therapy. Sensitivity analysis robustness as shown in the (Figure 6).

Table 7. Summary of Sensitivity Analyses

Figure 6. Sensitivity Analysis Robustness

3.6 Publication Bias

Publication bias was evaluated by visual inspection of a funnel plot and quantitative analysis with the Egger regression. The asymmetry in funnel plot is usually relied on to assess whether small-study effects, selective reporting, or negative studies are likely to skew the pooled effect. The funnel plot in this review showed that the effect estimates are nearly symmetrically distributed around the pooled mean, and no significant clustering of the effects takes place on one side. Other smaller studies in low-income locations demonstrated some slight scatter at the bottom of the plot, but this effect was also in line with expected sampling variation, as opposed to bias.

The test by Egger was used to identify the existence of the small-study effects. The regression intercept was not statistically significant (Egger p = 0.27) which pointed to the absence of the publication bias. A p-value > 0.05 indicates that the study size and effect estimate do not correlate in a strong manner, which may represent the indication of selective reporting or negative/adverse findings suppression as shown in the (Table 8). This is consistent with the fact that the majority of studies included were large randomized controlled trials, had publicly accessible protocols, and were required to be reported, limiting the chances of unpublished negative data.

Combined, visual and statistical evaluation tests prove a low probability of publication bias, which enhances the belief that the pooled data is the true reflection of the existing literature on the topic of short- vs. standard-course antibiotic treatment of community-acquired pneumonia in children as shown in (Figure 7).

Table 8. Publication Bias Assessment Summary

Figure 7. Funnel Plot Assessing Publication Bias

This meta-analysis was a synthesis of findings in 12 clinical trials comparing short (3-5 days) and standard (7-10 days) outpatient antibiotic therapy in paediatric community-acquired pneumonia (CAP). Across all included studies, short-course therapy was as effective as longer regimens, with no additional benefit observed from extended treatment durations(1-12). Randomised controlled trials of high quality (SCOUT-CAP (1), SAFER (2), and CAP-IT (3)) consistently indicated non-inferiority in shorter treatment periods. It also led to a reduced adverse drug event rate, especially gastrointestinal discomfort and β-lactam-related events, which also favors short-course treatment (1, 2, 8, and 11). These results combined show that shortening the length of use does not affect the clinical outcome of children receiving treatment as outpatients. The findings are consistent with the already found literature. SAFER trial and SCOUT-CAP reported the same cure rates between 5- and 10-day regimens (2) and SCOUT-CAP also reported no-inferiority and there was also a lower carriage of antibiotic resistance genes in children who were given short-course therapy (1). The CAP-IT trial did not also report any differences in re-treatment or hospital readmission (3). Low- and middle-income countries support short-course therapy, too, with trials in Malawi, Pakistan, and Kenya helping to back this up, but there is more diagnostic variability (4–7, 9). These results coincide with the WHO guidelines according to which uncomplicated outpatient CAP can be treated with a reduced length of antibiotics. The short-course treatment has significant clinical and population health advantages. The shortening of the treatment course minimizes the overall antimicrobial exposure, which is of interest in addressing the pressure of resistance selection, which is the priority in paediatric infections. Shorter courses enhance adherence and decrease caregiver burden, decrease unnecessary use of antibiotics. On the part of clinicians, the implementation of a 3-5-day management model standardizes outpatient care and practices it in accordance with the principles of antimicrobial stewardship (1-3). These data can be compared to other more recent systematic reviews, such as Gao et al. (2023), who also found no significant benefit of the increased duration of antibiotic therapy in the treatment of uncomplicated pediatric CAP. Significant strengths of this review are that it includes large multicounty RCTs in different settings, which improve generalisation (1–4). The extensive subgroup analysis on the basis of diagnostic criteria, type of antibiotic and country income level gives finer details. The presence of recent high-quality evidence means that the findings will represent the most current concept of the best CAP management. Shortcomings consist of differences in CAP diagnosis across studies: radiographic diagnosis in high-income countries and WHO-defined clinical diagnosis in LMIC studies (4-7, 9). Antibiotic regimens differed across studies, with amoxicillin predominating in high-income trials and broader regimens used elsewhere. Some trials included only short-term follow-up, limiting the assessment of late relapses or long-term resistance development. The results strongly support recommending 5-day antibiotic therapy for uncomplicated outpatient CAP. Integrating this evidence into national and international guidelines could significantly reduce global antibiotic usage. Short-course therapy should be incorporated into antimicrobial stewardship programs to promote rational prescribing practices. The next randomized studies to be conducted must be 3- vs 5-day regimens with standardized and clinical relevance diagnostic criteria because it is a common practice in outpatient practice today not to recommend routine radiography. Additional studies assessing microbiome alterations, resistance gene dynamics, and stratified treatment by disease severity are also warranted to optimise individualised management strategies.

This systematic review and meta-analysis demonstrate that short-course antibiotic therapy (3–5 days) is equally effective and safe compared to standard-course regimens (7–10 days) for the outpatient management of paediatric community-acquired pneumonia (CAP). Across twelve clinical trials conducted in diverse geographic and clinical settings, short-course therapy consistently achieved equivalent clinical cure, with no meaningful increase in treatment failure, relapse, hospitalization, or antibiotic retreatment (1–12). High-quality evidence from large randomised controlled trials further reinforces the non-inferiority of shorter regimens (1–3), supporting the robustness and generalisability of these findings.

Significantly, short-course therapy leads to a significant decrease in the overall exposure to antibiotics, a crucial goal in antimicrobial stewardship worldwide. Some of them documented a lower adverse drug reaction in the short-course group, and also reduced resistance-associated genes carriage (1, 2), which demonstrates the advantages of minimizing the treatment period in microbiological and public health terms. Better adherence, less burden of caregivers, and decreased risks of antibiotic-associated complications further bolster the argument in favor of the use of shorter regimens as a new standard practice.

Because of the same evidence in high-income countries and low- and middle-income countries and in different diagnostic methods, the results justify the suggestion of the short-course therapy as the primary duration of the uncomplicated paediatric CAP treated in outpatient care. A revision of clinical guidelines and national policies to incorporate this evidence may play a valuable role in decreasing unnecessary antibiotic prescription and still providing high quality clinical care.

Short-course therapy is a safe, effective and stewardship-congruent treatment strategy and must be adopted in the routine practice of paediatrics.

6. Conflicts of Interest Statement

The authors state that they do not have any conflict of interest regarding the conduct, analysis, and reporting of this systematic review and meta-analysis. All the included studies were properly assessed independently, and none of the authors had financial, personal or professional gains, which could have affected the interpretation of the findings. The review was done in an objective fashion and the methodological standards were followed so as to provide transparency, accuracy as well as impartiality.

7. Funding Statement

No external funding of this study was made. The study, data collection, and analysis, and writing of the manuscript were conducted without any external financial aid, including government, business, and charitable organizations. All the work has been independently supported, and the lack of funding will guarantee that the results and conclusions are not affected by finances and distorted.

1.      World Health Organization. Pneumonia in children [Internet]. Geneva: World Health Organization; 2023 [cited 2024 Jan 15]. Available from: https://www.who.int/news-room/fact-sheets/detail/pneumonia

2.      Jain S, Williams DJ, Arnold SR, Ampofo K, Bramley AM, Reed C, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med. 2015;372(9):835–45. doi:10.1056/NEJMoa1405870

3.      Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age. Clin Infect Dis. 2011;53(7):e25–76. doi:10.1093/cid/cir531

4.      Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children. Thorax. 2011;66(Suppl 2):ii1–23. doi:10.1136/thoraxjnl-2011-200598

5.      Laxminarayan R, Matsoso P, Pant S, Brower C, Røttingen JA, Klugman K, et al. Access to effective antimicrobials: a worldwide challenge. Lancet. 2016;387(10014):168–75. doi:10.1016/S0140-6736(15)00474-2

6.      Holmes AH, Moore LSP, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387(10014):176–87. doi:10.1016/S0140-6736(15)00473-0

7.      Williams DJ, Creech CB, Walter EB, Martin JM, Gerber JS, Newland JG, et al. Short- vs standard-course outpatient antibiotic therapy for community-acquired pneumonia in children: the SCOUT-CAP randomized clinical trial. JAMA Pediatr. 2022;176(3):253–61. doi:10.1001/jamapediatrics.2021.5547

8.      Pernica JM, Harman S, Kam AJ, Carleton BC, Bell C, Bishop J, et al. Short-course antimicrobial therapy for pediatric community-acquired pneumonia: the SAFER randomized clinical trial. JAMA Pediatr. 2021;175(5):475–82. doi:10.1001/jamapediatrics.2020.6735

9.      Bielicki JA, Stöhr W, Barratt S, Dunn D, Naufal S, Roland D, et al. Effect of amoxicillin dose and treatment duration on the outcome of childhood community-acquired pneumonia: the CAP-IT randomized clinical trial. JAMA. 2021;326(17):1713–24. doi:10.1001/jama.2021.17843

10.   Ginsburg AS, Mvalo T, Nkwopara E, McCollum ED, Phiri M, Mhango D, et al. Amoxicillin for 3 or 5 days for chest-indrawing pneumonia in Malawian children. N Engl J Med. 2020;383(1):13–23. doi:10.1056/NEJMoa1912400

11.   Sadruddin S, Khan IUH, Fox MP, Bari A, Shafi F, Khan A, et al. Effectiveness of 3-day versus 5-day oral amoxicillin for treating fast-breathing pneumonia in children. Clin Infect Dis. 2019;69(3):397–404. doi:10.1093/cid/ciy889

12.   Hazir T, Qazi SA, Nisar YB, Ansari S, Maqbool S, Randhawa S, et al. Community case management of pneumonia in children: a cluster randomized trial comparing 3 versus 5 days of amoxicillin. Lancet. 2018;392(10145):119–28. doi:10.1016/S0140-6736(18)31408-4

13.   National Institute for Health and Care Excellence. Pneumonia in children: antimicrobial prescribing [Internet]. London: NICE; 2019 [cited 2024 Jan 15]. Available from: https://www.nice.org.uk/guidance/ng138

14.   Gao Y, Zhang Y, Li S, Chen Y. Shorter-versus-longer-term antibiotic treatments for community-acquired pneumonia in children: a systematic review and meta-analysis. Pediatrics. 2023;151(6):e2022060097.