Short-course versus standard- or longer-course oral antibiotic therapy for pneumonia and lower respiratory tract infection in children: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Reducing unnecessary antibiotic exposure is a major priority in pediatric antimicrobial stewardship. The comparative effectiveness of short-course versus standard- or longer-course oral antibiotic therapy for uncomplicated bacterial infections in children remains uncertain. OBJECTIVE: To evaluate whether short-course oral antibiotic therapy increases clinical treatment failure compared with standard- or longer-course therapy in children with uncomplicated bacterial infections, with a primary focus on same-antibiotic pediatric pneumonia/lower respiratory tract infection (LRTI) trials. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials. MEDLINE/PubMed, Embase, Web of Science, and CENTRAL were searched, supplemented by citation searching and trial registry review. Eligible studies enrolled children aged 0-18 years with uncomplicated bacterial infections treated with oral antibiotics in outpatient or ambulatory settings. The primary outcome was clinical treatment failure; broader pneumonia/LRTI and all-infection analyses were treated as sensitivity or exploratory analyses. Random-effects meta-analysis used risk ratios (RRs) and risk differences (RDs) with 95% confidence intervals (CIs). Risk of bias was assessed with the Cochrane risk-of-bias tool. The review was registered in PROSPERO (CRD420261339263). RESULTS: Fourteen randomized trials were included; nine same-antibiotic pneumonia/LRTI comparisons contributed to the primary pooled analysis. Short-course therapy was not associated with increased treatment failure (RR, 1.01; 95% CI, 0.92-1.11; I2 = 0.0%), and the absolute-effect analysis showed no meaningful difference (RD, 0.001; 95% CI, -0.010 to 0.013; I2 = 10.0%). A broad pneumonia/LRTI sensitivity analysis including different-antibiotic comparisons was also non-significant (RR, 0.94; 95% CI, 0.66-1.33) but heterogeneous. The all-infection exploratory analysis was similarly non-significant (RR, 0.89; 95% CI, 0.63-1.25) and interpreted cautiously given clinical heterogeneity. Of the 14 trials, 5 were at low risk of bias, 2 had some concerns, and 7 were at high risk. CONCLUSION: In same-antibiotic pediatric pneumonia/LRTI trials, short-course therapy was not associated with increased clinical treatment failure compared with standard- or longer-course therapy. Broader analyses across different antibiotic strategies and infection syndromes did not materially change this interpretation but showed substantial heterogeneity. These findings support cautious, infection-specific antibiotic duration reduction rather than broad generalization across all uncomplicated pediatric bacterial infections. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261339263, identifier CRD420261339263.