# Shorter versus longer antibiotic therapy for children with acute otitis media: A systematic review

## TL;DR

Shorter antibiotic treatments for children with ear infections may not be as effective as longer ones and could raise healthcare costs.

## Contribution

This review found no evidence that shorter antibiotic courses are as effective as longer ones for treating children's ear infections.

## Key findings

- Shorter antibiotic therapies showed worse outcomes in some studies for pediatric acute otitis media.
- No non-inferiority was found for shorter treatment durations in twelve RCTs.
- Shorter treatments may increase healthcare costs if not equally effective.

## Abstract

Overuse of antibiotics increases the risk of side effects and microbial resistance and leads to rising healthcare costs. Acute otitis media (AOM) is the leading cause of antibiotic prescription amongst children. However, recommendations differ regarding the duration of therapy. This systematic review compared short-course versus long-course antibiotic therapy on treatment outcomes of children with AOM and examined further implications of different treatment durations. To evaluate clinical efficacy, we performed systematic searches in MEDLINE, Embase, and CENTRAL (until 5 February 2024), searched trial registries and screened reference lists of systematic reviews including health technology assessment (HTA) reports. Randomized controlled trials (RCTs) comparing short-course and long-course antibiotic therapies in children with AOM were included. Non-inferiority was assumed for differences of less than 10%. Twelve RCTs investigating different antibiotic agents with a total of 3 409 children were included – mostly conducted before the year 2000 and mostly with a high risk of bias. No comparisons of short-course and long-course antibiotic therapies met the criteria for non-inferiority for treatment success; five studies even showed statistically significantly worse results with a shorter duration of therapy. Due to high statistical uncertainty, no statistically significant difference but also no non-inferiority could be demonstrated for relapse, mortality, or side effects. Poorer efficacy of shorter treatment durations may lead to higher costs for the healthcare system.

Conclusion: It cannot generally be assumed that a shorter antibiotic therapy leads to equivalent treatment results in children with AOM. However, new high-quality RCTs investigating treatment duration of commonly used antibiotics are highly needed. Shorter therapies offer economic benefits only when they are clinically as effective as longer ones.

Registration: PROSPERO (CRD42024519113).

What is Known:• Shorter antibiotic courses are recommended to reduce adverse effects, antimicrobial resistance, and costs.• For acute otitis media (AOM), a leading cause for antibiotic prescription in children, the optimal treatment duration remains controversial.What is New:• This systematic review, including data from twelve RCTs, found no evidence of non-inferiority for shorter antibiotic therapies in pediatric AOM. Some studies for some antibiotic agents even showed poorer outcomes of shorter treatment durations. If not equally effective, shorter treatment may also increase costs for the healthcare system.• Additional high-quality RCTs investigating commonly prescribed antibiotic substances like amoxicillin are needed.

What is Known:

• Shorter antibiotic courses are recommended to reduce adverse effects, antimicrobial resistance, and costs.

• For acute otitis media (AOM), a leading cause for antibiotic prescription in children, the optimal treatment duration remains controversial.

What is New:

• This systematic review, including data from twelve RCTs, found no evidence of non-inferiority for shorter antibiotic therapies in pediatric AOM. Some studies for some antibiotic agents even showed poorer outcomes of shorter treatment durations. If not equally effective, shorter treatment may also increase costs for the healthcare system.

• Additional high-quality RCTs investigating commonly prescribed antibiotic substances like amoxicillin are needed.

The online version contains supplementary material available at 10.1007/s00431-026-06788-8.