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SCOUT-CAP – Is Shorter Duration Better for Pediatric Pneumonia?

February 16, 2022

Written by Clay Smith

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An abstruse composite outcome encompassing both clinical response and adverse effects of antibiotics was superior in children who received 5 vs 10 days of antibiotics for pediatric community acquired pneumonia (CAP).

Why does this matter?
Standard duration for pediatric CAP is 10 days. But with increasing antibiotic resistance and the potential side effects of treatment, would a shorter duration do as well?

Just putting SCOUT-CAP on your RADAR
This was a RCT with 380 children with CAP who were treated as outpatients with either 5 or 10 days of antibiotics (mostly amoxicillin). All received either real drug or matching placebo for days 6-10 to maintain blinding. They used a wonky composite primary outcome called RADAR* (response adjusted for duration of antibiotic risk ), which is, “a composite end point that ranks each child’s clinical response, resolution of symptoms, and antibiotic-associated adverse effects in an ordinal desirability of outcome ranking (DOOR).” You know it’s obscure when there is an acrostic within an acronym (sorry…I just got a little DOOR in my RADAR). Anyway, for this composite outcome, there was a 69% probability of a more favorable RADAR in the short-term group.

They also swabbed the oropharynx of 171 of the children, about half in each group, about 3 weeks after diagnosis and found more resistance genes among the prokaryotes in the 10-day group than the 5-day group. The clinical significance of this is not known, but it may indicate a greater chance of resistance with longer duration of antibiotic exposure.

Overall, this study seems consistent with SAFER and CAP-IT, in that a shorter course of antibiotics is probably OK for non-severe pediatric CAP.

Short- vs Standard-Course Outpatient Antibiotic Therapy for Community-Acquired Pneumonia in Children: The SCOUT-CAP Randomized Clinical Trial. JAMA Pediatr. 2022 Jan 18. doi: 10.1001/jamapediatrics.2021.5547. Online ahead of print.

*What’s odd is that there were no differences in any of the individual components for clinical response or adverse effects in the short or long term groups, yet the “RADAR” was better in the short-duration group. After reading a paper explaining RADAR and DOOR, I finally understood that a shorter duration of therapy is ranked higher. In other words, if you get the same clinical response (with the same or better adverse effects) using a shorter course of antibiotic therapy, this is objectively better and yields a better RADAR rank. I just found it a little frustrating to have to read a paper in order to understand the primary outcome of this paper.

What are your thoughts?