Short-course treatment for outpatient pneumonia-how long should it be?

Are 3, 5, or 10 days of antibiotics best? Israeli investigators set out to answer this question in a group of children aged 6 to 59 months with radiologically confirmed community-acquired alveolar pneumonia (CAAP) that did not require admission.

The children were divided into 3-, 5-, and 10-day treatment groups and given amoxicillin (80 mg/kg/d divided into 3 daily doses). In the first stage of the study, investigators compared outcomes between the 3-day and the 10-day treatment groups. However, because 4 of the 12 patients in the 3-day group experienced treatment failure-defined as need for rescue treatment or hospitalization-investigators temporarily halted the study. They then reinstated it by comparing outcomes in 56 children in a 5-day treatment group and 59 in a 10-day regimen.

No failures were observed in either the 5-day or 10-day treatment groups. Also, the proportion of children without breathing difficulty, restlessness, coughing, loss of appetite, and sleep disturbances was similar in both groups throughout the study. Laboratory values, including white blood cell counts and C-reactive protein concentrations, did not differ between these groups. Investigators therefore concluded that for children aged from 6 to 59 months treated as outpatients for CAAP, a 5-day high-dose oral amoxicillin treatment regimen is just as effective as a 10-day course (Greenberg D, et al. Pediatr Infect Dis J. 2014;33[2]:136-142).

Commentary: Do you prescribe 10 days of antibiotics anticipating that many patients or families will discontinue them after 6 days when the patient feels better or life events get in the way? Will shorter course therapy lead to improved adherence or will the 5-day treatment become 3 days, falling into the range found to be inadequate in the first phase of this study? For both inpatient and outpatient treatment, the duration of therapy will become the next front for the campaign for judicious use of antibiotics. For outpatient therapy, we will need recommendations paired with measures of adherence or a margin for noncompliance.-Michael Burke, MD

Ms Freedman is a freelance medical editor and writer in New Jersey. Dr Burke, section editor for Journal Club, is chairman of the Department of Pediatrics at Saint Agnes Hospital, Baltimore, Maryland. He is a contributing editor for Contemporary Pediatrics. The editors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.