Wise Use of Antibiotics: Antibiotic Durations – Shorter IS Better!

Why does duration matter?

Antimicrobial resistance is a growing global health concern. In the United States alone, antimicrobial resistance leads to more than 2.8 million infections per year with more than 35,000 deaths.¹ Studies have shown that longer antibiotic durations are associated with the emergence of antibiotic resistance.² As 85%-95% of antibiotic use occurs in outpatient settings, it is important for ambulatory clinicians to be thoughtful about antibiotic prescribing, including choice of agent, dose, and duration.³

Previously, there was a lack of robust scientific data to determine ideal duration to treat many common outpatient infections, and clinicians relied on long (10-14 days) durations based on historical approaches. Growing evidence supports the safety of shortening standard treatment durations for these infections to five to seven days, sometimes even shorter. If a shorter course is found to be as efficacious as a longer course, it is thought to be inherently better, given the improved adherence, decreased side effects, and decreased costs to families.

Urinary tract infections (UTIs)

Two large multi-center trials, SCOUT and STOP, compared five days of antibiotics to the standard 10 days of antibiotics for febrile UTIs in children 2months of age and older.^4,5 These trials found treatment success in 96-97% of patients receiving the shorter antibiotic course, supporting use of shorter durations for children outside of the neonatal period who are improving.

Skin and soft tissue infections (SSTIs)

The Infectious Diseases Society of America’s SSTI guidelines recommend five to seven days of antibiotics for most SSTIs.⁶ These recommendations are based on an extensive literature review including a randomized control trial comparing five days to 10 days of antibiotics for cellulitis. The study found no difference in clinical outcome with a 98% cure rate for both study populations.⁷

Community-acquired pneumonia (CAP)

There are two pediatric trials supporting shorter durations for CAP. The first is the SAFER trial, which compared five days to 10 days of high-dose amoxicillin and found no statistical differences between the groups.⁸ The second, the SCOUT-CAP trial, also compared five days to 10 days of antibiotics and additionally looked at the development of bacterial resistance genes during treatment. There were no differences in clinical cure between the groups; however, the shorter course of antibiotics was associated with a significantly lower frequency of antibiotic resistance genes detected on throat swabs at the end of therapy.⁹

Acute bacterial rhinosinusitis

Most data on the treatment of acute sinusitis are in the adult population but can be extrapolated to the pediatric population. A meta-analysis of randomized controlled trials comparing short course (defined as up to seven days) to long course antibiotics for sinusitis found no differences in clinical success between the two groups, but did find that adverse events were fewer in the short course treatment group.¹⁰

Acute otitis media (AOM)

Many children with AOM can benefit from shorter courses of antibiotics. Many studies have identified that children with AOM receive 10 days of antibiotics despite recommendations for shorter courses of five to seven days for a large subgroup of children.¹¹ Guidelines continue to recommend 10 days of antibiotics for children with severe disease or those younger than 2 years, but a 2020 quality improvement project to increase the number of patients receiving five days of antibiotics for AOM showed no differences in treatment failure or recurrence rates with shorter durations, even in children with severe disease.¹²

Streptococcal pharyngitis

Although literature is emerging to suggest that shorter antibiotic treatment durations of five days are safe for these infections, national guidelines continue to support 10 days.¹³ Reducing the dose to once-daily amoxicillin has been well studied and supported, which helps decrease the amount of antimicrobial pressure.¹⁴

What can clinicians do?

It is hard to keep up with emerging literature, and we often fall back on our training and old practice habits of longer antimicrobial durations.¹⁵ The Children’s Mercy Evidence Based Practice group reviews literature and updates their clinical pathways regularly. Listed below are some pathways that provide recommended antibiotic choices and durations for common infections.

Urinary Tract Infection (UTI) | Children's Mercy

Skin and Soft Tissue Infections | Children's Mercy

Community Acquired Pneumonia | Children's Mercy

Sinusitis: Acute Bacterial | Children's Mercy

Acute Otitis Media | Children's Mercy

Pharyngitis | Children's Mercy

References:

1. Antimicrobial resistance facts and stats. Centers for Disease Control and Prevention. February 4, 2025. https://www.cdc.gov/antimicrobial-resistance/data-research/facts-stats/index.html
2. Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. 2003;290(19):2588-2598.
3. Antibiotic use in the United States. Centers for Disease Control and Prevention. September 15, 2025. https://www.cdc.gov/antibiotic-use/hcp/data-research/antibiotic-prescribing.html
4. Zaoutis T, Shaikh N, Fisher BT, et al. Short-course therapy for urinary tract infections in children: the SCOUT randomized clinical trial. JAMA Pediatr. 2023;177(8):782-789.
5. Montini G, Tessitore A, Console K, et al. Short oral antibiotic therapy for pediatric febrile urinary tract infections: a randomized trial. 2024;153(1):e2023062598.
6. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):147-159.
7. Pernica JM, Harman S, Kam AJ, et al. Short-course antimicrobial therapy for pediatric community-acquired pneumonia: the SAFER randomized clinical trial. JAMA Pediatr. 2021;175(5):475-482.
8. Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC. Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med. 2004;164(15):1669-1674.
9. Williams DJ, Creech CB, Walter EB, et al. Short- vs standard-course outpatient antibiotic therapy for community-acquired pneumonia in children: the SCOUT-CAP randomized clinical trial. JAMA Pediatr. 2022;176(3):253-261.
10. Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials. Br J Clin Pharmacol. 2009;67:161-171.
11. Katz SE, Jenkins TC, Stein AB, et al. Durations of antibiotic treatment for acute otitis media and variability in prescribed durations across two large academic health systems. J Pediatric Infec Dis Soc. 2024;13(9):455-465.
12. Frost HM, Lou Y, Keith A, Byars A, Jenkins TC. Increasing guideline-concordant durations of antibiotic therapy for acute otitis media. J Pediatr. 2021;240:221-227.
13. El Feghaly RE, Jaggi P, Katz SE, Poole NM. “Give me five”: the case for 5 days of antibiotics as the default duration for acute respiratory tract infections. J Pediatric Infec Dis Soc. 2024;13(6):328-333.
14. Pharyngitis clinical pathway. Children’s Mercy.

https://www.childrensmercy.org/health-care-providers/evidence-based-practice/cpgs-cpms-and-eras-pathways/pharyngitis-clinical-practice-guideline/

15. Fernandez-Lazaro CI, Brown KA, Langford BJ, Daneman N, Garber G, Schwartz KL. Late-career physicians prescribe longer courses of antibiotics. Clin Infect Dis. 2019;69(6):1467-1475.