3 vs. 5 Days of Amoxicillin for Childhood Pneumonia: An RCT

Pneumonia is the most common infection in children and leading to most common cause of mortality and morbidity in in children globally. Bacterial cause is mostly streptococcus pneumonia in children of 3 months to 5 years of age. Traditionally 7-10 antibiotic is used for uncomplicated community acquired pneumonia. World health organization (WHO) recommends 5 days of antibiotic for non-severe pneumonia with oral amoxicillin while National institute for health and care excellence (NICE) guidelines 2025 recommends 3-days course of amoxicillin in uncomplicated community acquired pneumonia.1,2 Most studies show Short course antibiotic is as effective as long course of antibiotic with fewer side effect. The SAFARI trial demonstrated non-inferiority of 5-day versus 10-day amoxicillin therapy in children with Community acquired pneumonia, with comparable clinical cure rates and reduced antibiotic exposure.3 Similarly, a systematic review and meta-analysis by Pernica et al. found that short-course antibiotic therapy (≤5 days) was associated with similar clinical success rates compared to longer courses in pediatric respiratory infections.4 Mortality due to childhood pneumonia is strongly linked to poverty-related factors such as undernutrition, lack of safe drinking water and sanitation, indoor and outdoor air pollution as well as inadequate access to health care.

Pneumonia kills more children than any other infectious disease, claiming the lives of over 700,000 children under 5 every year, or around 2,000 every day. This includes around 190,000 newborns. Almost all of these deaths are preventable. Globally, there are over 1,400 cases of pneumonia per 100,000 children, or 1 case per 71 children every year, with the greatest incidence occurring in South Asia (2,500 cases per 100,000 children) and West and Central Africa (1,620 cases per 100,000 children).5 No disease kills more children aged less than five years than pneumonia, not least in Pakistan where one-fifth of the population is in this age group. The annual incidence of ARI (acute respiratory infection) in Pakistani children aged less than five years is 4% in the community a group constituting roughly 22% of the country's population of 160 million. Taking this 4% figure, we can calculate that there are 15 million episodes of ARI every year among under-fives.6 The Khyber Pakhtunkhwa province faces particular challenges due to limited healthcare access, malnutrition, and suboptimal vaccination coverage which leads to major burden of pneumonia in less than 5 years' children.7 There is need of local data about effectiveness of short course antibiotic in uncomplicated community acquired pneumonia. 3-day oral amoxicillin has better compliance and less side effect of medicine. Short course of oral amoxicillin is cost effective as pneumonia is more common in low socioeconomic population and 3-day course antibiotic is more economical and has better compliance. Long course of antibiotic leads to antibiotic resistance and adverse effects like diarrhea and other gastrointestinal symptoms.

Inclusion criteria

• Age; ≥ 3 months to 5 years
• Fever; recorded temperature of ≥100.4 f or guardian reported fever within 2 days
• Cough; observed or reported within 3 days
• Tachypnea;
• 3 months to 1 years ≥ 50 breaths per minute
• 1 years to 5 years ≥ 40 breaths per minute
• C- reactive protein ≥ 40
• White blood cells ≥ 12200
• Chest X-ray;
• Presence of a dense opacity occupying a portion or whole of lobe with or without air Broncho grams.

Exclusion criteria

• Patient who is Lethargic and unable to tolerate orally.
• Capillary refill greater than 2 second
• Chronic lung disease
• Congenital heart disease or sickle cell anemia patient
• Immunocompromised patient
• malnourished
• Known or suspected tuberculosis patient
• Patient has used prior antibiotic within 2 days
• Allergic to penicillin or amoxicillin
• C-reactive protein greater than 72
• White blood cells greater than 25000
• Chest x rays show linear or patchy or peri bronchial opacity
• Presence of pleural effusions
• Empyema, lung abscess, necrotizing pneumonia or pneumatocele
• Other alternative diagnosis like wheezing syndrome (Bilateral wheezing on auscultation)