Take Diagnostic Uncertainty Into Account

Letters to the Editor Shorter Versus Longer Antibiotic Treatment in Children With Community-Acquired Pneumonia A Systematic Review With Meta-Analyses by Alexander Benkendorff, Sibylle Puntscher, Magdalena Flatscher-Thöni, Nikolai Mühlberger, Anne Göhner, Susanne Beck, Anneke Clara Bergt, Laura Krabbe, Thomas L. Heise, Lea Gorenflo, Siegbert Rieg, Markus Hufnagel, Claudia Breuer, Angela M. Kunzler, Uwe Siebert, Jörg J. Meerpohl, and Christine Schmucker in issue 9/2026

In their systematic review (1), Benkendorff et al. conclude that a 3-day course of amoxicillin in younger children with clinically diagnosed, outpatient-treated, non-severe pediatric community-acquired pneumonia (pCAP) may be as effective as a 5- or 10-day course. However, most children in the included studies, for whom a shorter treatment duration appeared to be sufficient, probably had a viral infection—but this was not adequately investigated. This constitutes a crucial criterion for indication: If a viral etiology is suspected in children and adolescents with pCAP treated in the outpatient setting, antibiotics should either not be prescribed or be discontinued promptly, in accordance with the recommendations of the current AWMF guideline coordinated by the German Society of Pediatric Pulmonology (GPP) and the German Society for Pediatric Infectious Diseases (DGPI) (2), as well as those of AnTiB, the Professional Association of Pediatricians and Adolescent Medicine (BVKJ), and the DGPI (3). In contrast, if a bacterial infection is highly probable, antimicrobial therapy should be administered for at least 5 days based on the current evidence. It is well known that the challenge lies in the fact that the bacterial or viral etiology of pCAP cannot be reliably distinguished on the basis of either clinical findings or biomarkers. Pronounced clinical symptoms and significantly elevated biomarkers make a bacterial infection likely; in this situation, antimicrobials should be used as first-line therapy and for a sufficiently long duration. On the other hand, young children with bronchial obstruction or a detected virus frequently have a viral infection; in these patients, antibiotics should not be prescribed or should be discontinued early, not least for reasons of antimicrobial stewardship.

The question of the minimum treatment duration is also relevant for other pediatric respiratory tract infections, such as acute otitis media. Here, the same group of authors was unable to draw any conclusions regarding a shorter treatment duration due to the lack of evidence (4).

DOI: 10.3238/arztebl.m2026.0105

Prof. Dr. med. Tobias Tenenbaum
Klinik für Kinder- und Jugendmedizin, Sana Klinikum Lichtenberg, Berlin, [e-mail]

PD Dr. med. Michael Barker
Senatsverwaltung für Wissenschaft, Gesundheit und Pflege, Berlin, Germany

Conflict of interest statement

TT is a member of the Advisory Board of Sanofi, Pfizer, bioMérieux, and
AstraZeneca. He is Past President of the DGPI and Vice President of the WSPID

MB declares that no conflict of interest exists.

References

1. Benkendorff A, Puntscher S, Flatscher-Thöni M, et al.: Shorter versus longer antibiotic treatment in children with community-acquired pneumonia: A systematic review with meta-analyses. Dtsch Arztebl Int 2026; 123: 240–7

2. Gesellschaft für Pädiatrische Pneumologie e.V. (GPP), Deutsche Gesellschaft für Pädiatrische Infektiologie (DGPI): S2k-Leitlinie: Management der ambulant erworbenen Pneumonie bei Kindern und Jugendlichen. 2025.

3. AnTiB B, DGPI: Antibiotische Therapie in der ambulanten Pädiatrie 2026. https://dgpi.de/absap-guidelines-2026/ (last accessed on 10 June 2026).

4. Benkendorff A, Puntscher S, Flatscher-Thoni M, et al.: Shorter versus longer antibiotic therapy for children with acute otitis media: A systematic review. Eur J Pediatr 2026; 185: 155