Shifting to Shorter Courses of Antibiotic Therapy for Common Pediatric Infections

As antibiotic resistance continues to rise, the need for antimicrobial stewardship to optimize antibiotic selection, dosing, and duration of therapy is critical. Historically, there was limited evidence to guide specific antibiotic durations. Recommended durations ranged from 5-10 or 7-14 days simply out of convenience.¹ A 2017 descriptive study looking at antibiotic duration for common infections in outpatients in the United States indicated that clinicians default to 10 day courses for most infections.² In recent years, the “shorter is better” paradigm has been promoted. In addition to helping slow antibiotic resistance, shorter antibiotic durations are also associated with decreased adverse events.^3,4 There is increasing evidence supporting shorter antibiotic durations for acute otitis media (AOM), community acquired pneumonia (CAP), and urinary tract infection (UTI) for pediatric patients.

AOM is the most common condition for which antibiotics are prescribed for children in the US.⁵ The American Academy of Pediatrics (AAP) AOM clinical practice guideline (CPG) recommends antibiotic durations based on severity of symptoms and patient age. For patients with severe symptoms (moderate-severe otalgia or fever > 39℃) or those of age < 2 years, a standard 10-day antibiotic course is still recommended. However, for non-severe infections in older patients, courses of 7 days for ages 2-5 years and 5-7 days for ages > 5 years are recommended.⁵ In more recently published literature, a report detailing extensive interventions aimed at increasing the percentage of patients > 2 years old receiving an antibiotic duration of 5 days demonstrated similar rates of treatment failure (<2%) and recurrence (<3%) in the pre- and post-intervention groups.⁶ This evidence may allow for promoting the shorter 5-day course in all patients over age 2 with non-severe AOM.

The CAP CPG from the Pediatric Infectious Diseases Society and Infectious Diseases Society of America (PIDS/IDSA) notes that “treatment courses of 10 days have been best studied.”⁷ Studies comparing short and long antibiotic courses have blossomed since the publication of this CPG over 10 years ago. Three studies have compared 5 vs 10 days of antibiotics for CAP in children treated as outpatients. In 2 non-inferiority trials, there was no difference in treatment failure.^8-9 In one superiority trial, the 5-day regimen was associated with a more desirable outcome than the 10-day regimen via desirability of outcome ranking (DOOR) analysis.¹⁰ In the only study to include inpatients with uncomplicated CAP, there was no difference in treatment failure or readmission between 5-7 days and 8-14 days of antibiotics.¹¹

The AAP CPG for UTI in infants and children recommends an antibiotic duration of 7-14 days, recognizing that optimal duration has not been determined.¹² A 2020 study in 791 children aged 6 months to 18 years compared short course treatment (6-9 days) with prolonged treatment (10 or more days) for pyelonephritis. The odds of treatment failure were similar between the groups (11.2% vs. 9.4%).¹³ The results suggest that short course treatment may be as effective as prolonged treatment in children with pyelonephritis.

In summary, there is growing interest in studying shorter antibiotic courses for children with common bacterial infections. Where evidence demonstrates safety and efficacy, widespread adoption of the “shorter is better” paradigm will help to optimize care for our pediatric patients and conserve antibiotics for the future.

References

1. Good A and Olans R. Pediatric Antibiotic Stewardship. AJN 2021;121(11):38-43.

2. King L, Hersh AL, Hicks LA, Fleming-Dutra KE. Duration of Outpatient Antibiotic Therapy for Common Outpatient Infections, 2017. Clin Infect Dis 2020;72(10):e663-6.

3. Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for Acute Otitis Media in Children (Review). Cochrane Database of Systematic Reviews 2015;6:1-3.

4. Vaughn VM, Flanders SA, Snyder A, et al. Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized with Pneumonia: A Multihospital Cohort Study. Ann Intern Med 2019;171:153-63.

5. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics 2013;131:e964-99.

6. Frost HM, Lou YY, Keith A, Byars A, Jenkins TC. Increasing Guideline-Concordant Durations of Antibiotic Therapy for Acute Otitis Media. J Pediatr 2022;24:221-7.

7. Bradley JS, Byington CL, Shah SS, et al. The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011;53(7):e25-76.

8. Greenberg D, Givon-Lavi N, Sadak Y, et al. Short-Course Antibiotic Treatment for Community-Acquired Alveolar Pneumonia in Ambulatory Children: A Double-blind, Randomized, Placebo-controlled Trial. Ped Infect Dis J 2014;33(2):136-42.

9. 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):475-82.

10. Williams DJ, Creech CB, Walter EB, 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):253-261.

11. Same RG, Amoah J, Hsu AJ, et al. The Association of Antibiotic Duration with Successful Treatment of Community-Acquired Pneumonia in Children. J Pediatr Inf Dis Soc 2021;10(3):267-73.

12. Roberts KB, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics 2011;128(3):595–610.

13. Fox MT, Amoah J, Hsu AJ, Herzke CA, Gerber JS, Tamma PD. Comparative Effectiveness of Antibiotic Treatment Duration in Children With Pyelonephritis. JAMA Netw Open 2020;3(5):e203951.