Journal of the Pediatric Infectious Diseases Society

ORIGINAL ARTICLE

The Association of Antibiotic Duration With Successful

Treatment of Community-Acquired Pneumonia in
Children
Rebecca G. Same,1, Joe Amoah,1 Alice J. Hsu,2 Adam L. Hersh,3 Daniel J. Sklansky,4 Sara E. Cosgrove,5 and Pranita D. Tamma1
1
Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; 2Department of Pharmacy, The Johns Hopkins Hospital, Baltimore,
Maryland, USA; 3Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA; 4Department of Pediatrics, University of Wisconsin School of Medicine and Public Health,
Madison, Wisconsin, USA; 5Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Downloaded from https://academic.oup.com/jpids/article/10/3/267/5855956 by guest on 27 September 2023

Background. National guidelines recommend 10 days of antibiotics for children with community-acquired pneumonia
(CAP), acknowledging that the outcomes of children hospitalized with CAP who receive shorter durations of therapy have not been
evaluated.
Methods. We conducted a comparative effectiveness study of children aged ≥6 months hospitalized at The Johns Hopkins
Hospital who received short-course (5–7 days) vs prolonged-course (8–14 days) antibiotic therapy for uncomplicated CAP between
2012 and 2018 using an inverse probability of treatment weighted propensity score analysis. Inclusion was limited to children with
clinical and radiographic criteria consistent with CAP, as adjudicated by 2 infectious diseases physicians. Children with tracheosto-
mies; healthcare-associated, hospital-acquired, or ventilator-associated pneumonia; loculated or moderate to large pleural effusion
or pulmonary abscess; intensive care unit stay >48 hours; cystic fibrosis/bronchiectasis; severe immunosuppression; or unusual
pathogens were excluded. The primary outcome was treatment failure, a composite of unanticipated emergency department visits,
outpatient visits, hospital readmissions, or death (all determined to be likely attributable to bacterial pneumonia) within 30 days after
completing antibiotic therapy.
Results. Four hundred and thirty-nine patients met eligibility criteria; 168 (38%) patients received short-course therapy (me-
dian, 6 days) and 271 (62%) received prolonged-course therapy (median, 10 days). Four percent of children experienced treatment
failure, with no differences observed between patients who received short-course vs prolonged-course antibiotic therapy (odds ratio,
0.48; 95% confidence interval, .18–1.30).
Conclusions. A short course of antibiotic therapy (approximately 5 days) does not increase the odds of 30-day treatment failure
compared with longer courses for hospitalized children with uncomplicated CAP.
Keywords: antibiotics; bacterial pneumonia; duration of therapy; pediatrics.

Community-acquired pneumonia (CAP) is one of the most of research to identify the shortest effective duration of therapy
common reasons children are hospitalized in the United States to minimize patient harms, including the development of anti-
[1]. Children hospitalized for pneumonia receive more days of biotic resistance and drug-related toxicities.
antibiotic therapy than those hospitalized for any other condi- Multiple randomized, controlled trials have demonstrated
tion [2]. The 2011 Infectious Diseases Society of America (IDSA) that clinical outcomes with short-course antibiotic therapy
and Pediatric Infectious Diseases Society (PIDS) guidelines (generally consisting of 5 days) are equivalent to longer courses
state that “treatment courses of 10 days have been best studied for hospitalized adults with CAP [4–10]. Several meta-analyses
[for children with pneumonia], although shorter courses may have corroborated these findings [11–13]. The abundance of ev-
be just as effective (strong recommendation; moderate-quality idence supporting short-course therapy has prompted the IDSA
evidence)” [3]. These guidelines also emphasize the importance and American Thoracic Society to recommend 5 days of anti-
biotics for the treatment of adults hospitalized with uncompli-
cated CAP [14].
There are no data available from randomized, controlled
Received 4 February 2020; editorial decision 4 May 2020; accepted 5 May 2020; Published
online June 11, 2020.
trials or even robust observational studies that evaluate the op-
Correspondence: Rebecca G. Same, Department of Pediatrics, Johns Hopkins University timal duration of therapy for children hospitalized with CAP in
School of Medicine, 200 N. Wolfe St., Room 3150, Baltimore, Maryland, USA (Rebecca.G.Same@
high-resource settings. Children are generally less likely than
jhmi.edu).
Journal of the Pediatric Infectious Diseases Society   2021;10(3):267–73
adults to be smokers, diabetic, have chronic obstructive pul-
© The Author(s) 2020. Published by Oxford University Press on behalf of The Journal of the monary disease, or protracted immobilizing conditions (all of
Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail:
which may contribute to worse clinical outcomes), making it
journals.permissions@oup.com.
DOI: 10.1093/jpids/piaa055 reasonable to hypothesize that 5 days of antibiotic therapy may

Antibiotic Duration for Pediatric CAP • jpids 2021:10 (March) • 267

also be sufficient for children with uncomplicated CAP [15]. If of chemotherapy, hematopoietic stem cell transplant, or solid
shorter courses of therapy are indeed equally effective as pro- organ transplant within the last 6 months or current neutro-
longed courses of therapy for children with CAP, this could penia with absolute neutrophil count ≤500 cells/mm3; receipt
significantly reduce antibiotic use in children across the United of greater than 48 hours of antipseudomonal beta-lactams,
States and the associated downstream consequences of antibi- which may be indicative of other relevant healthcare exposures
otic overuse, including antibiotic resistance, intestinal dysbiosis, or concern for unusual pathogens; or fungal or mycobacterial
and adverse drug events. pneumonia. Children who received fewer than 5 or more than
Based on the available published data and clinical experience 14 days of antibiotic therapy were also excluded as these dur-
in the adult population, local guidelines at the Johns Hopkins ations suggested an alternative diagnosis to uncomplicated CAP.
Hospital have recommended 5 days of antibiotics for children
hospitalized with uncomplicated CAP since 2012 [16]. Because Data Collection
of gradual uptake of these recommendations, variability in pre- Demographic data, preexisting medical conditions, clinical
scribing persists, providing a prime population to compare clin- signs and symptoms, microbiological data, antibiotic regimens,

Downloaded from https://academic.oup.com/jpids/article/10/3/267/5855956 by guest on 27 September 2023

ical outcomes between short and prolonged treatment durations and outcomes data were collected for all eligible patients via
for CAP in children. We sought to determine whether hospital- medical record review and entered into a secure REDCap da-
ized children treated for uncomplicated CAP with short courses tabase. To maximize the comprehensiveness of pre- and post-
of antibiotics are at an increased risk of treatment failure com- discharge clinical data, information was reviewed from the
pared with children who receive longer courses of antibiotics. Epic Care Everywhere Network and the Chesapeake Regional
Information System for Our Patients (CRISP). The Epic Care
Everywhere network includes inpatient and outpatient re-
METHODS
cords from a large number of healthcare facilities in the United
Design, Setting, and Participants States. CRISP includes inpatient, outpatient, and emergency
This was a retrospective cohort study of children hospitalized department information for children in the state of Maryland
with CAP at The Johns Hopkins Hospital from January 2012 and the District of Columbia. The Johns Hopkins University
through December 2018. Specific International Classification of Institutional Review Board approved the study, with a waiver of
Diseases, Ninth Revision and Tenth Revision (ICD-9, ICD-10) informed consent.
codes were used to identify all children aged ≥6 months who
may have had CAP. To optimize sensitivity, records were re- Exposures and Outcomes
viewed for all children with a pneumonia ICD-9/ICD-10 code The primary exposure was duration of antibiotic treatment, di-
anywhere on the discharge diagnosis code list [17]. Study in- chotomized to short-course (5–7 days) and prolonged-course
clusion was then limited to children with the relevant ICD-9/ (8–14 days), with day 1 being the first day antibiotics were ad-
ICD-10 codes as well as both clinical and radiographic criteria ministered in the hospital for the treatment of CAP. Antibiotic
considered to be consistent with CAP based on the adjudica- duration included antibiotics administered in the hospital and
tion of 2 infectious diseases physicians (R. G. S. and P. D. T.). those prescribed after hospital discharge identified through
Diagnostic criteria were similar to those used in prior studies review of inpatient notes, discharge summaries, discharge in-
of pediatric pneumonia [17, 18]. Clinical criteria included the structions, and discharge prescriptions. The primary outcome
combination of fever plus at least 1 of the following symptoms: was treatment failure, a composite of unanticipated outpatient
cough, chest pain, increased work of breathing, or hypoxia. or emergency department visits not necessitating hospital read-
Reports from relevant imaging were reviewed by R. G. S. and mission, new hospitalizations, or death occurring within 30 days
P. D. T. Radiographic criteria required a radiologist’s interpreta- after the discontinuation of antibiotic therapy. Categorization as
tion of chest radiograph or computed tomography scan findings treatment failure required independent agreement by 2 infec-
of an “opacity, density, infiltrate, or consolidation.” tious diseases physicians that the new healthcare encounter was
Exclusion criteria included the following features that may highly likely to be related to underlying bacterial pneumonia.
be consistent with more complex illness for which it is un- Readmissions or outpatient visits not related to pneumonia,
clear whether short-course therapy would be appropriate: the such as for the diagnosis of a new viral illness without prescrip-
presence of a loculated or moderate to large pleural effusion tion of antibiotics, were not included. Treatment failures that
or pulmonary abscess; tracheostomy dependence; healthcare- occurred prior to the completion of the initial prescribed course
associated pneumonia, hospital-acquired pneumonia, or of therapy were also not included because they could not be rea-
ventilator-associated pneumonia; intensive care unit (ICU) stay sonably attributed to the duration of therapy. For example, if a
for greater than 48 hours; sickle cell disease (due to the syn- child was prescribed 10 days of amoxicillin and required read-
dromic overlap with acute chest syndrome); cystic fibrosis or mission on day 3 of therapy, this was not included as the 10 day
bronchiectasis; severe immunosuppression defined as receipt course had not yet been completed.

268 • jpids 2021:10 (March) • Same et al

Statistical Analyses confidence intervals (CIs) for the composite outcome of treat-
Because treatment duration was not assigned at random, pro- ment failure were estimated using weighted regression, adjusting
pensity scores were assigned. Inverse probability of treatment for variables with standardized mean differences greater than
weighting (IPTW) was used to account for possible selection 10%, which indicate suboptimal balance between exposed and
bias regarding the prescribed treatment duration (eg, sicker pa- unexposed groups for that specific variable. A 2-sided P value
tients may have been more likely to receive prolonged courses of <.05 was considered statistically significant for all tests. Statistical
therapy than relatively well-appearing patients). The following analysis was completed using Stata version 13.0.
covariates were included in generating the propensity score:
age, gender, race, asthma, hypoxia, bacteremia due to a respi-
RESULTS
ratory bacterial pathogen, positive respiratory viral test, admis-
sion to the ICU, year of admission, and hospitalization longer There were 3210 pediatric patients hospitalized with ICD-9/
than 7 days. Hospitalization of longer than 7 days was used as ICD-10 codes for pneumonia. After manual chart review, 2771
a surrogate marker for baseline medical complexity as other- patients were excluded, resulting in 439 patients who met eligi-

Downloaded from https://academic.oup.com/jpids/article/10/3/267/5855956 by guest on 27 September 2023

wise healthy patients would not generally require hospitaliza- bility criteria. Among these, 168 (38%) patients received short-
tions longer than 7 days for uncomplicated pneumonia. A new course and 271 (62%) received prolonged-course antibiotic
weighted pseudopopulation was then created in which individ- therapy (Figure 1). The median duration of therapy was 6 days
uals who received a duration of therapy outside of the anticipated (interquartile range [IQR], 5–7) in the short-course group and
range based on the propensity score were given an increased 10 days (IQR, 9–10) in the prolonged-course group (Figure 2).
weight (eg, those who received prolonged-course therapy even At baseline, patients in the short-course group were more likely
though the propensity score suggested a high likelihood of re- to have been admitted to the ICU and to have positive respi-
ceiving short-course therapy) and individuals who received the ratory viral tests (Table 1). They were less likely to have a pro-
expected duration of therapy were given a decreased weight. longed hospitalization or to be admitted during the earlier years
Baseline data were compared using the Pearson χ2 test for of the study. Propensity score weighting yielded 2 well-balanced
categorical variables or the Wilcoxon rank sum test for contin- groups without any residual differences in all measured baseline
uous variables. In the IPTW cohort, odds ratios (ORs) and 95% characteristics (Figure 3).

Figure 1. Design of a study to compare treatment outcomes in hospitalized children receiving short-course vs prolonged-course antibiotic therapy for
uncomplicated CAP. Abbreviations: CAP, community-acquired pneumonia; ICD, International Classification of Diseases, Ninth Revision and Tenth Revision.

Antibiotic Duration for Pediatric CAP • jpids 2021:10 (March) • 269

 between patients who received short-course and prolonged-
course therapy. This estimate is similar to those reported in
prior studies of children hospitalized for CAP [19, 20]. To our
knowledge, this is the first study in the United States to inves-
tigate the clinical outcomes for hospitalized children with un-
complicated CAP receiving short-course antibiotic therapy.
Our findings are consistent with the extensive evidence from
adult trials that indicate that short course therapy is safe and
effective for CAP [4–13]. Limited data in children also support
shorter therapy; a randomized, controlled trial that included
140 children showed no difference in outcomes for ambulatory
children in Israel treated with 5 days compared with 10 days
of high-dose amoxicillin [21]. A multicenter, randomized, pla-

Downloaded from https://academic.oup.com/jpids/article/10/3/267/5855956 by guest on 27 September 2023

cebo controlled clinical trial (SCOUT-CAP) is currently un-
Figure 2. Histogram depicting the duration of antibiotic therapy pre- derway to assess outcomes in pediatric outpatients with mild
scribed for 439 children hospitalized for uncomplicated community- CAP receiving 5 days vs 10 days of oral beta-lactam therapy
acquired pneumonia.
[22]. Both of these studies are limited to otherwise healthy out-
patients; there are no studies evaluating treatment duration for
The most commonly prescribed antibiotic class on day 1 of CAP in hospitalized children in the United States. Although we
therapy was cephalosporins (n = 236, 54%), followed by penicil- did not include ambulatory children with CAP in our study, if
lins (n = 176, 40%). The most common antibiotic class patients a short course of therapy is reasonable for hospitalized children
received to complete their antibiotic course post-discharge was with CAP, this duration should also be sufficient for children
penicillins (n = 309, 70%). with less severe CAP who are treated as outpatients. Trials in
In the propensity-weighted cohort, 20 children (4%) expe- resource-limited settings have suggested that 5 days or fewer of
rienced treatment failure within 30 days of discontinuing anti- antibiotics are effective for the treatment of CAP in both inpa-
biotics (Supplementary Table 1). There was no difference in tient and outpatient settings. However, these studies have used
treatment failure between patients who received short-course clinical rather than radiographic definitions of pneumonia,
(3%) vs prolonged-course (6%) antibiotic therapy (OR, 0.48; which have poor specificity, and the results may not be general-
95% CI, .18–1.30). Three patients (2%) in the short-course izable to children in developed countries [23–25].
group compared with 8 patients (3%) in the prolonged-course The diagnosis of bacterial CAP is challenging. There is var-
group experienced an unplanned emergency department or iability in the interpretation of radiographic images, and a
outpatient visit related to CAP (OR, 0.54; 95% CI, .14–2.07) and definitive microbiologic diagnosis is rare. Children do not re-
2 patients (2%) and 7 patients (3%) in the short- and prolonged- liably produce sputum and blood cultures are only positive in
course groups, respectively, required hospital readmission for around 2% of cases of uncomplicated CAP [26–29]. While the
pneumonia (OR, 0.43; 95% CI, .11–1.74). There were no deaths increased use of multiplex respiratory viral panels has increased
in either group within 30 days of discontinuing therapy. We the number of children with CAP identified with viruses [18],
performed a subgroup analysis excluding all patients with any in practice, it is often unclear whether clinical and radiographic
positive respiratory viral test and repeated the propensity score changes represent a purely viral pneumonia or a concomitant
weighting and subsequent analysis. In this subgroup analysis in- or subsequent bacterial process. We elected to include children
cluding 312 patients, 14 children (4%) experienced treatment with positive respiratory viral tests in our study only if they met
failure. There was no difference in treatment failure between parameters for hospitalization, were febrile, had relevant respi-
those receiving short-course and prolonged-course therapy ratory symptoms and radiographic findings suggestive of bacte-
(OR, 0.45; 95% CI, .05–3.91). rial pneumonia, if the treating clinician diagnosed and treated
bacterial pneumonia, and if 2 infectious diseases physicians in-
dependently agreed that bacterial pneumonia was likely. We be-
DISCUSSION
lieve that, in clinical practice, children with this constellation of
In this observational study of hospitalized children with un- signs and symptoms would generally be treated with antibiotics
complicated CAP, we found no difference in treatment failure because of the limitations in diagnostics for bacterial CAP. To
between children treated with a short course of therapy (median assess the possibility that our results could be biased in favor of
6 days) compared with longer courses of therapy. Pneumonia- shorter courses of therapy due to the inclusion of children with
related revisits and readmissions were rare in our study, viral pneumonia who would have improved without antibiotic
occurring in approximately 4% of patients, and were similar therapy, we performed a subgroup analysis limited to patients

270 • jpids 2021:10 (March) • Same et al

 Table 1. Baseline Characteristics of Pediatric Patients With Uncomplicated Community-Acquired Pneumonia Hospitalized Between 2012 and 2018 at Johns Hopkins Hospital, Before and After Propensity
Score Weighting, by Short-Course (5–7 days) or Prolonged-Course (8–14 days) Antibiotic Therapy

Full Cohort Weighted Cohort

Short Course Prolonged Course Standardized Mean Short Course Prolonged Course Standardized
Characteristic (n = 168) (n = 271) P Value Differences (n = 166.8) (n = 270.0) P Value Mean Differences
Age, median (interquartile range), y 4 (2–8) 4 (2–7) .288 0.103 4 (2–8) 4 (2–8) .897 0.014
Female, n (%) 83 (49.4) 142 (52.4) .542 –0.060 83.0 (49.8) 138.1 (51.1) .794 –0.028
Race, n (%)
White 58 (34.5) 104 (38.4) .416 –0.080 62.6 (37.5) 98.2 (36.4) .822 0.024
Black 77 (45.8) 125 (46.1) .952 –0.006 78.4 (47.0) 126.7 (46.9) .989 0.001
Asian 5 (3.0) 10 (3.7) .689 –0.040 4.5 (2.7) 8.7 (3.2) .761 –0.028
Latino 16 (9.5) 23 (8.5) .711 0.036 13.5 (8.1) 23.7 (8.8) .812 –0.023
Unreported 12 (7.1) 9 (3.3) .068 0.172 7.8 (4.8) 12.8 (4.8) .971 –0.003
Asthma, n (%) 84 (50.0) 138 (50.9) .851 –0.018 87.0 (52.1) 138.0 (51.1) .847 0.020
Hypoxia requiring supplemental oxygen, n (%) 76 (45.2) 135 (49.8) .351 –0.092 81.8 (49.1) 129.7 (48.0) .844 0.021
Bacteremia with a respiratory pathogen, n (%) 2 (1.2) 6 (2.2) .436 –0.079 2.9 (1.7) 5.0 (1.9) .927 –0.010
Intensive care unit, n (%) 59 (35.1) 63 (23.3) .007 0.263 48.9 (29.3) 75.4 (27.9) .770 0.031
Positive respiratory viral panel, n (%) 56 (33.3) 69 (25.5) .076 0.173 47.1 (28.2) 74.3 (27.5) .873 0.016
Influenza 8 (4.8) 5 (1.9) .080 0.163 4.4 (2.6) 6.7 (2.5) .924 0.008
Respiratory syncytial virus 17 (10.1) 21 (7.8) .391 0.083 15.2 (9.1) 22.6 (8.4) .804 0.026
Parainfluenza 1 (0.6) 4 (1.5) .398 –0.087 1.4 (0.8) 3.0 (1.1) .796 –0.028
Rhinovirus/Enterovirus 23 (13.7) 28 (10.3) .286 0.103 19.6 (11.7) 31.8 (11.8) .988 –0.001
Human metapneumovirus 6 (3.6) 11 (4.1) .797 –0.025 6.4 (3.8) 10.5 (3.9) .969 –0.004
Adenovirus 4 (2.4) 2 (0.7) .150 0.133 2.0 (1.2) 2.5 (0.9) .760 0.023
Prolonged hospitalization, n (%) 6 (3.6) 21 (7.8) .077 –0.181 8.7 (5.3) 17.0 (6.3) .703 –0.045
Year of admission, n (%)
2012 13 (7.7) 45 (16.6) .008 –0.273 20.9 (12.5) 35.7 (13.2) .860 –0.021
2013 8 (4.8) 40 (14.8) .001 –0.341 18.0 (11.0) 18.0 (10.8) .956 –0.008
2014 18 (10.7) 32 (11.8) .726 –0.035 18.8 (11.2) 30.8 (11.4) .962 –0.005
2015 27 (16.1) 29 (10.7) .101 0.158 21.4 (12.9) 34.8 (12.9) .989 –0.001
2016 34 (20.2) 47 (17.3) .447 0.074 29.7 (17.8) 49.2 (18.2) .910 –0.011
2017 27 (16.1) 41 (15.1) .791 0.026 27.8 (16.7) 42.6 (15.8) .810 0.025
2018 41 (24.4) 37 (13.7) .004 0.276 30.2 (18.1) 47.3 (17.5) .874 0.016

Antibiotic Duration for Pediatric CAP • jpids 2021:10 (March) • 271

Downloaded from https://academic.oup.com/jpids/article/10/3/267/5855956 by guest on 27 September 2023
 Downloaded from https://academic.oup.com/jpids/article/10/3/267/5855956 by guest on 27 September 2023
Figure 3. Standardized mean differences in baseline characteristics comparing the full unweighted cohort with the inverse probability of treated weighted
cohort incorporating propensity scores.

with negative respiratory viral tests. Treatment failure occurred to reliably verify the duration of antibiotics administered before
in 4% of children (similar to the larger IPTW cohort) and there hospitalization, which may have underestimated treatment du-
was no difference in treatment failure between those who re- ration for some children, though in a subgroup of 294 patients
ceived short- and prolonged-course therapy. in whom this was assessed the majority (over 70%) had not re-
Evidence is mounting across a multitude of bacterial infec- ceived any antibiotics prior to admission. Rigorous review of
tions that “less is more” [11, 30, 31]. For pneumonia specifically, networks of electronic medical records was performed to iden-
a recent study found that each excess day of antibiotic therapy tify inpatient, outpatient, and emergency department encounters
was associated with a 5% increase in patient-reported adverse both within and outside of the Johns Hopkins Health System.
events [32]. Efforts to reduce potentially unnecessary antibiotic However, information from some locations is not included in
use in children are often hindered by the lack of high-quality Epic Care Everywhere or CRISP, for example, records from some
data supporting any specific therapeutic duration for common private practice pediatricians and urgent care centers that do not
pediatric infections and hesitance to extrapolate data from use the Epic electronic health record system. Consequently, if
adults. Absent evidence in children, guidelines often rely on patients sought care at these locations, some healthcare visits
historical regimens, such as the current IDSA/PIDS pediatric would have been missed. Propensity score weighting was per-
CAP guidelines that acknowledge that shorter courses of treat- formed to account for confounding by indication, which may
ment may be safe for CAP but recommend 10 days of therapy have introduced unmeasured bias into the exposure categories
as the “best-studied” duration. CAP accounts for approximately [33]. However, residual confounding may remain as we were
2 million outpatient visits and 124 900 hospitalizations for likely unable to account for all possible factors that may influence
pneumonia in children every year [1]. Reducing the standard the decision to treat with short- or prolonged-course therapy.
duration of therapy from 10 days to 5 could therefore reduce Although a multicenter randomized study would provide
antibiotic exposure in more than 2 million children each year the highest-quality evidence to evaluate the optimal duration
and prevent a substantial number of adverse events. of therapy for CAP in children, we believe that the results of
Our study has several limitations. First, it is a single-center our study, when combined with the abundant randomized,
study at a tertiary care center limited to 439 children and results controlled trial data in adults, suggest that hospitalized children
may not be generalizable to other settings. However, we used with uncomplicated CAP can be safely and effectively treated
stringent clinical and radiographic criteria for CAP. If short- with approximately 5 days of antibiotics. Because CAP is one of
course therapy was safe and effective for our population, many the most common causes of hospitalization and antibiotic pre-
of whom are medically complex, there is no reason to suspect it scription in children, decreasing the duration of therapy could
would be less successful in healthier children. We were unable have an important public health impact.

272 • jpids 2021:10 (March) • Same et al

Supplementary Data 13. Tansarli GS, Mylonakis E. Systematic review and meta-analysis of the efficacy of
short-course antibiotic treatments for community-acquired pneumonia in adults.
Supplementary materials are available at Journal of the Pediatric Infectious
Antimicrob Agents Chemother 2018; 62:e00635–18.
Diseases Society online.
14. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with
community-acquired pneumonia. An official clinical practice guideline of the
American Thoracic Society and Infectious Diseases Society of America. Am J
Notes
Respir Crit Care Med 2019; 200:e45–67.
Financial support. This work was supported by funding from the 15. Tamma PD, Cosgrove SE. Duration of antibiotic therapy for community-acquired
National Institutes of Health (T32-AI052071 to R. G. S. and K23-AI127935 pneumonia in children. Clin Infect Dis 2012; 54:883–4; author reply 5.
to P. D. T.). S. E. C. reports personal fees from Novartis, Theravance, and 16. Hsu AJ, Tamma PD. Johns Hopkins Hospital antibiotic treatment guidelines
Basilea, outside of the submitted work. 2019–2020. Available at: intranet.insidehopkinsmedicine.org/asp/pediatric.html.
Potential conflicts of interest. All authors: No reported conflicts of in- Accessed November 24, 2019.
terest. All authors have submitted the ICMJE Form for Disclosure of 17. Williams DJ, Shah SS, Myers A, et al. Identifying pediatric community-acquired
pneumonia hospitalizations: accuracy of administrative billing codes. JAMA
Potential Conflicts of Interest. Conflicts that the editors consider relevant to
Pediatr 2013; 167:851–8.
the content of the manuscript have been disclosed.
18. Jain S, Williams DJ, Arnold SR, et al.; CDC EPIC Study Team. Community-
acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med
2015; 372:835–45.
References

Downloaded from https://academic.oup.com/jpids/article/10/3/267/5855956 by guest on 27 September 2023

19. Neuman MI, Hall M, Gay JC, et al. Readmissions among children previously hos-
1. Witt WP, Weiss AJ, Elixhauser AA. Overview of Hospital Stays for Children in pitalized with pneumonia. Pediatrics 2014; 134:100–9.
the United States, 2012. HCUP Statistical Brief #187. Rockville, MD: Agency for 20. Ambroggio L, Herman H, Fain E, et al. Clinical risk factors for revisits for children
Healthcare Research and Quality; 2014. with community-acquired pneumonia. Hosp Pediatr 2018; 8:718–23.
2. Gerber JS, Kronman MP, Ross RK, et al. Identifying targets for antimicrobial stew- 21. Greenberg D, Givon-Lavi N, Sadaka Y, et al. Short-course antibiotic treatment for
ardship in children’s hospitals. Infect Control Hosp Epidemiol 2013; 34:1252–8. community-acquired alveolar pneumonia in ambulatory children: a double-blind,
3. Bradley JS, Byington CL, Shah SS, et al.; Pediatric Infectious Diseases Society randomized, placebo-controlled trial. Pediatr Infect Dis J 2014; 33:136–42.
and the Infectious Diseases Society of America. The management of community- 22. Interventional (Clinical Trial Identifier: NCT02891915). A Phase IV Double-Blind,
acquired pneumonia in infants and children older than 3 months of age: clinical Placebo-Controlled, Randomized Trial to Evaluate Short Course vs.Standard
practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Course Outpatient Therapy of Community Acquired Pneumonia in Children
Diseases Society of America. Clin Infect Dis 2011; 53:e25–76. (SCOUT-CAP). 2016. https://clinicaltrials.gov/ct2/show/NCT02891915.
4. Siegel RE, Alicea M, Lee A, Blaiklock R. Comparison of 7 versus 10 days of antibiotic 23. Gupta S, Lodha R, Kabra SK. Antimicrobial therapy in community-acquired
therapy for hospitalized patients with uncomplicated community-acquired pneu- pneumonia in children. Curr Infect Dis Rep 2018; 20:47.
monia: a prospective, randomized, double-blind study. Am J Ther 1999; 6:217–22. 24. Shah SN, Bachur RG, Simel DL, Neuman MI. Does this child have pneumonia?:
5. Léophonte P, Choutet P, Gaillat J, et al. [Efficacy of a ten day course of ceftriaxone The rational clinical examination systematic review. JAMA 2017; 318:462–71.
compared to a shortened five day course in the treatment of community-acquired 25. Rambaud-Althaus C, Althaus F, Genton B, D’Acremont V. Clinical features for
pneumonia in hospitalized adults with risk factors]. Med Mal Infect 2002; diagnosis of pneumonia in children younger than 5 years: a systematic review and
32:369–81. meta-analysis. Lancet Infect Dis 2015; 15:439–50.
6. el Moussaoui R, de Borgie CA, van den Broek P, et al. Effectiveness of discontinuing 26. Elemraid MA, Muller M, Spencer DA, et al.; North East of England Paediatric
antibiotic treatment after three days versus eight days in mild to moderate-severe Respiratory Infection Study Group. Accuracy of the interpretation of chest radio-
community acquired pneumonia: randomised, double blind study. BMJ 2006; graphs for the diagnosis of paediatric pneumonia. PLoS One 2014; 9:e106051.
332:1355. 27. Neuman MI, Hall M, Lipsett SC, et al. Utility of blood culture among chil-
7. Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in dren hospitalized with community-acquired pneumonia. Pediatrics 2017;
community-acquired pneumonia: a multicenter randomized clinical trial. JAMA 140:e20171013.
Intern Med 2016; 176:1257–65. 28. Fritz CQ, Edwards KM, Self WH, et al. Prevalence, risk factors, and outcomes of
8. Dunbar LM, Khashab MM, Kahn JB, et al. Efficacy of 750-mg, 5-day levofloxacin bacteremic pneumonia in children. Pediatrics 2019; 144:e20183090.
in the treatment of community-acquired pneumonia caused by atypical patho- 29. Lipsett SC, Hall M, Ambroggio L, et al. Predictors of bacteremia in children hos-
gens. Curr Med Res Opin 2004; 20:555–63. pitalized with community-acquired pneumonia. Hosp Pediatr 2019; 9:770–8.
9. Dunbar LM, Wunderink RG, Habib MP, et al. High-dose, short-course 30. Spellberg B. The new antibiotic mantra—“shorter is better.” JAMA Intern Med
levofloxacin for community-acquired pneumonia: a new treatment paradigm. 2016; 176:1254–5.
Clin Infect Dis 2003; 37:752–60. 31. Wald-Dickler N, Spellberg B. Short-course antibiotic therapy-replacing
10. File TM Jr, Mandell LA, Tillotson G, et al. Gemifloxacin once daily for 5 days Constantine units with “shorter is better.” Clin Infect Dis 2019; 69:1476–9.
versus 7 days for the treatment of community-acquired pneumonia: a random- 32. Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration
ized, multicentre, double-blind study. J Antimicrob Chemother 2007; 60:112–20. and adverse events in patients hospitalized with pneumonia: a multihospital co-
11. Li JZ, Winston LG, Moore DH, Bent S. Efficacy of short-course antibiotic regi- hort study. Ann Intern Med 2019; 171:153–63.
mens for community-acquired pneumonia: a meta-analysis. Am J Med 2007; 33. Amoah J, Stuart EA, Cosgrove SE, et al. Comparing propensity score methods
120:783–90. versus traditional regression analysis for the evaluation of observational data:
12. Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, et al. Short- versus a case study evaluating the treatment of gram-negative bloodstream infections
long-course antibacterial therapy for community-acquired pneumonia: a meta- [published online ahead of print February 18, 2020]. Clin Infect Dis 2020.
analysis. Drugs 2008; 68:1841–54. doi:10.1093/cid/ciaa169.

Antibiotic Duration for Pediatric CAP • jpids 2021:10 (March) • 273