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Original Investigation
March 8, 2021

Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial

Author Affiliations
  • 1Division of Infectious Diseases, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
  • 2Pediatric Emergency Research Canada, Calgary, Alberta, Canada
  • 3Division of Emergency Medicine, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
  • 4Division of Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
  • 5Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
  • 6Biostiatistics Unit, St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
  • 7Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
  • 8Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Ontario, Canada
  • 9Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
  • 10Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
  • 11Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
JAMA Pediatr. 2021;175(5):475-482. doi:10.1001/jamapediatrics.2020.6735
Key Points

Question  Is short-course antibiotic therapy (5 days of high-dose amoxicillin) inferior to standard care (10 days of high-dose amoxicillin) for the treatment of children aged 6 months to 10 years diagnosed with community-acquired pneumonia in an outpatient setting?

Findings  In this 2-center, blinded randomized clinical trial, children treated with short-course antibiotic therapy had comparable rates of clinical cure at 14 to 21 days after enrollment compared with standard care (85.7% vs 84.1%).

Meaning  Results of this study suggest that short-course therapy for pediatric community-acquired pneumonia not requiring hospitalization offers more benefit than harm and should be considered for inclusion in treatment guidelines.


Importance  Community-acquired pneumonia (CAP) is a common occurrence in childhood; consequently, evidence-based recommendations for its treatment are required.

Objective  To determine whether 5 days of high-dose amoxicillin for CAP was associated with noninferior rates of clinical cure compared with 10 days of high-dose amoxicillin.

Design, Setting, and Participants  The SAFER (Short-Course Antimicrobial Therapy for Pediatric Respiratory Infections) study was a 2-center, parallel-group, noninferiority randomized clinical trial consisting of a single-center pilot study from December 1, 2012, to March 31, 2014, and the follow-up main study from August 1, 2016, to December 31, 2019 at the emergency departments of McMaster Children’s Hospital and the Children’s Hospital of Eastern Ontario. Research staff, participants, and outcome assessors were blinded to treatment allocation. Eligible children were aged 6 months to 10 years and had fever within 48 hours, respiratory symptoms, chest radiography findings consistent with pneumonia as per the emergency department physician, and a primary diagnosis of pneumonia. Children were excluded if they required hospitalization, had comorbidities that would predispose them to severe disease and/or pneumonia of unusual origin, or had previous β-lactam antibiotic therapy. Data were analyzed from March 1 to July 8, 2020.

Interventions  Five days of high-dose amoxicillin therapy followed by 5 days of placebo (intervention group) vs 5 days of high-dose amoxicillin followed by a different formulation of 5 days of high-dose amoxicillin (control group).

Main Outcomes and Measures  Clinical cure at 14 to 21 days.

Results  Among the 281 participants, the median age was 2.6 (interquartile range, 1.6-4.9) years (160 boys [57.7%] of 279 with sex listed). Clinical cure was observed in 101 of 114 children (88.6%) in the intervention group and in 99 of 109 (90.8%) in the control group in per-protocol analysis (risk difference, −0.016; 97.5% confidence limit, −0.087). Clinical cure at 14 to 21 days was observed in 108 of 126 (85.7%) in the intervention group and in 106 of 126 (84.1%) in the control group in the intention-to-treat analysis (risk difference, 0.023; 97.5% confidence limit, −0.061).

Conclusions and Relevance  Short-course antibiotic therapy appeared to be comparable to standard care for the treatment of previously healthy children with CAP not requiring hospitalization. Clinical practice guidelines should consider recommending 5 days of amoxicillin for pediatric pneumonia management in accordance with antimicrobial stewardship principles.

Trial Registration  ClinicalTrials.gov Identifier: NCT02380352

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    1 Comment for this article
    Short Course of antibiotic therapy
    Amarlal Dave, MD | Pediatric Center Rural practice
    I find it ironic that we have not looked into the fact that infections are the end results of body's immune system getting overwhelmed by invaders. The Immune system on an ongoing basis wards off infections. I suspect that in many infections once the patient start feeling better a decision to stop antimicrobials can be undertaken with close follow up, letting body's immune system taking care of any left over infection. I also think that most of the time we are treating inflammation caused by infectious agent with antibiotics rather than infection after initial few hours or few days of treatment with antibiotics. Do we have a way to determine that infection is gone and only inflammation is there in any given clinical circumstance like pneumonia, UTI, Meningitis and many more. The best example in clinical practice is cutaneous abscesses. Once the pus is drained it really does not matter if antibiotics are used, the recovery is as good with or without antibiotics. The same principle applies to all infections, "no infection, no antibiotics"!