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Short-Course Antimicrobial Therapy for Pediatric Community-Acquired PneumoniaThe SAFER Randomized Clinical Trial

Educational Objective
To determine whether 5 days of high-dose amoxicillin for community-acquired pneumonia was associated with noninferior rates of clinical cure compared with 10 days of high-dose amoxicillin.
1 Credit CME
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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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: October 22, 2020.

Published Online: March 8, 2021. doi:10.1001/jamapediatrics.2020.6735

Corresponding Author: Jeffrey M. Pernica, MD, MSc, Division of Infectious Diseases, Department of Pediatrics, McMaster University, 1280 Main St W, Hamilton, ON L8S 4K1, Canada (pernica@mcmaster.ca).

Author Contributions: Dr Pernica had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Pernica, Harman, Kam, Carciumaru, Khan, Main, Smieja, Thabane, Loeb.

Acquisition, analysis, or interpretation of data: Pernica, Harman, Kam, Vanniyasingam, Crawford, Dalgleish, Slinger, Fulford, Main, Smieja, Thabane.

Drafting of the manuscript: Pernica, Carciumaru, Dalgleish, Main, Thabane.

Critical revision of the manuscript for important intellectual content: Pernica, Harman, Kam, Vanniyasingam, Crawford, Khan, Slinger, Fulford, Smieja, Loeb.

Statistical analysis: Vanniyasingam, Thabane.

Obtained funding: Pernica, Thabane.

Administrative, technical, or material support: Harman, Kam, Carciumaru, Crawford, Dalgleish, Khan, Slinger, Fulford, Main, Smieja, Loeb.

Supervision: Harman, Kam, Carciumaru, Thabane.

Conflict of Interest Disclosures: Dr Pernica reported receiving grant funding from bioMerieux SA for a study of enteropathogen diagnostics for children with severe gastroenteritis in Botswana outside the submitted work. Dr Loeb reported receiving personal fees from Avibr and Sunovion Pharmaceuticals Inc outside the submitted work and a contract with the World Health Organization to work on the antibiotic section of the Essential List of Medicines. No other disclosures were reported.

Funding/Support: This study was supported by Hamilton Health Sciences (New Investigator Fund and an Early Career Award), the PSI Foundation, and Pediatric Emergency Research Canada.

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We acknowledge the efforts of our data monitoring committee, including Tania Principi, MD (Chair), Adrienne Davis, MD, (The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada) and Hubert Wong, PhD (University of British Columbia, Vancouver, British Columbia, Canada). They received no compensation for their contributions to this article.

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