Optimal Duration of Antibiotic Treatment for Group A Streptococcal Pharyngitis in Children: A Systematic Review and Dose-Response Meta-Analysis
- 1Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton,
Abstract
ImportanceGroup A streptococcal (GAS) pharyngitis drives substantial morbidity and antibiotic prescribing in children. Ten days of antibiotics remains standard, although shorter courses could reduce treatment burdens, cumulative antibiotic exposure, and selective pressure for resistance. Whether shorter courses achieve comparable outcomes remains uncertain.
ObjectiveTo assess the effects of oral antibiotic treatment duration on clinical outcomes in children and adolescents with GAS pharyngitis.
Data SourceMEDLINE, Embase, CENTRAL, Web of Science, and CINAHL from inception to July 2025, without language restrictions.
Study SelectionRandomized trials of participants [≤]18 years with suspected or confirmed GAS pharyngitis comparing different durations of oral antibiotics, or oral antibiotics against placebo or no treatment.
Data Extraction and SynthesisPairs of reviewers selected studies and extracted data. Random-effects dose-response meta-analysis summarized the effect of duration on outcomes. The GRADE approach guided judgments about the certainty of evidence.
Main Outcomes and MeasuresClinical cure, relapse, adverse events, mortality, serious adverse events, acute rheumatic fever, purulent complications, and poststreptococcal glomerulonephritis.
ResultsForty-five trials enrolling 22,636 participants met eligibility criteria. Moderate certainty evidence suggests little to no clinically important difference between 5 vs 10 days in clinical cure (14 fewer cures per 1000 [95% CI 27 fewer to 2 fewer]), relapse (5 fewer per 1000 [11 fewer to 3 more]), or adverse events (10 more per 1000 [6 fewer to 30 more]). Sensitivity analyses excluding macrolides produced similar results. Low certainty evidence also suggests little to no clinically important difference in clinical cure, relapse, or adverse events between 3 vs 10 days of treatment, but nearly all evidence came from trials of azithromycin, and these findings do not establish the effects of 3-day regimens of penicillins or other antibiotics. Serious adverse events were rare: no deaths and 4 cases of acute rheumatic fever among 776 and 8,818 participants, respectively, making clinically important differences across treatment durations unlikely.
Conclusions and RelevanceFor children at low risk of acute rheumatic fever, 5 days of oral antibiotics likely provides similar benefits and harms as 10 days while reducing treatment burden and antibiotic exposure. The effects of 3-day regimens remains uncertain.
FundingCanadian Institutes of Health Research (CIHR). Grant No. 540708
Key PointsO_ST_ABSQuestionC_ST_ABSDo shorter courses of oral antibiotics provide clinical outcomes comparable with 10 days of treatment in children and adolescents with group A streptococcal pharyngitis?
FindingsIn this systematic review and dose-response meta-analysis of 45 randomized trials enrolling 22 636 participants, 5 days compared with 10 days of antibiotic treatment produced no clinically important differences in clinical cure, relapse, or adverse events. Evidence for 3-day regimens was less certain and came almost entirely from azithromycin trials.
MeaningFive-day antibiotic courses likely provide an effective alternative to 10-day courses for children in populations resembling those enrolled in trials, but evidence remains insufficient for 3-day regimens of penicillins or other antibiotics. These findings may not extrapolate to populations with a higher risk of complications.
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BibTeX
@misc{lima2026optimal,
title = {{Optimal Duration of Antibiotic Treatment for Group A Streptococcal Pharyngitis in Children: A Systematic Review and Dose-Response Meta-Analysis}},
author = {J. P. Lima and M. Dorri and M. Ling and B. Lee and S. Kirsh and S. Dhanoya and A. Walch and T. Jassal and M. Raji Lahiji and A. Chou and H. Li and A. Cui and O. Chang and M. Bigler and J. M. Pernica and M. Eltorki and D. Yamamura and B. J. Langford and M. Loeb and A. Tse-Chang and N. Le Saux and D. Zeraatkar},
howpublished = {medRxiv},
year = {2026},
month = jun,
doi = {10.64898/2026.06.25.26356472},
url = {https://www.medrxiv.org/content/10.64898/2026.06.25.26356472v2},
note = {CC BY},
}
RIS
TY - UNPB
TI - Optimal Duration of Antibiotic Treatment for Group A Streptococcal Pharyngitis in Children: A Systematic Review and Dose-Response Meta-Analysis
AU - J. P. Lima
AU - M. Dorri
AU - M. Ling
AU - B. Lee
AU - S. Kirsh
AU - S. Dhanoya
AU - A. Walch
AU - T. Jassal
AU - M. Raji Lahiji
AU - A. Chou
AU - H. Li
AU - A. Cui
AU - O. Chang
AU - M. Bigler
AU - J. M. Pernica
AU - M. Eltorki
AU - D. Yamamura
AU - B. J. Langford
AU - M. Loeb
AU - A. Tse-Chang
AU - N. Le Saux
AU - D. Zeraatkar
PY - 2026
DA - 2026/06/25
PB - medRxiv
DO - 10.64898/2026.06.25.26356472
UR - https://www.medrxiv.org/content/10.64898/2026.06.25.26356472v2
AB - ImportanceGroup A streptococcal (GAS) pharyngitis drives substantial morbidity and antibiotic prescribing in children. Ten days of antibiotics remains standard, although shorter courses could reduce treatment burdens, cumulative antibiotic exposure, and selective pressure for resistance. Whether shorter courses achieve comparable outcomes remains uncertain. ObjectiveTo assess the effects of oral antibiotic treatment duration on clinical outcomes in children and adolescents with GAS pharyngitis. Data SourceMEDLINE, Embase, CENTRAL, Web of Science, and CINAHL from inception to July 2025, without language restrictions. Study SelectionRandomized trials of participants [≤]18 years with suspected or confirmed GAS pharyngitis comparing different durations of oral antibiotics, or oral antibiotics against placebo or no treatment. Data Extraction and SynthesisPairs of reviewers selected studies and extracted data. Random-effects dose-response meta-analysis summarized the effect of duration on outcomes. The GRADE approach guided judgments about the certainty of evidence. Main Outcomes and MeasuresClinical cure, relapse, adverse events, mortality, serious adverse events, acute rheumatic fever, purulent complications, and poststreptococcal glomerulonephritis. ResultsForty-five trials enrolling 22,636 participants met eligibility criteria. Moderate certainty evidence suggests little to no clinically important difference between 5 vs 10 days in clinical cure (14 fewer cures per 1000 [95% CI 27 fewer to 2 fewer]), relapse (5 fewer per 1000 [11 fewer to 3 more]), or adverse events (10 more per 1000 [6 fewer to 30 more]). Sensitivity analyses excluding macrolides produced similar results. Low certainty evidence also suggests little to no clinically important difference in clinical cure, relapse, or adverse events between 3 vs 10 days of treatment, but nearly all evidence came from trials of azithromycin, and these findings do not establish the effects of 3-day regimens of penicillins or other antibiotics. Serious adverse events were rare: no deaths and 4 cases of acute rheumatic fever among 776 and 8,818 participants, respectively, making clinically important differences across treatment durations unlikely. Conclusions and RelevanceFor children at low risk of acute rheumatic fever, 5 days of oral antibiotics likely provides similar benefits and harms as 10 days while reducing treatment burden and antibiotic exposure. The effects of 3-day regimens remains uncertain. FundingCanadian Institutes of Health Research (CIHR). Grant No. 540708 Key PointsO_ST_ABSQuestionC_ST_ABSDo shorter courses of oral antibiotics provide clinical outcomes comparable with 10 days of treatment in children and adolescents with group A streptococcal pharyngitis? FindingsIn this systematic review and dose-response meta-analysis of 45 randomized trials enrolling 22 636 participants, 5 days compared with 10 days of antibiotic treatment produced no clinically important differences in clinical cure, relapse, or adverse events. Evidence for 3-day regimens was less certain and came almost entirely from azithromycin trials. MeaningFive-day antibiotic courses likely provide an effective alternative to 10-day courses for children in populations resembling those enrolled in trials, but evidence remains insufficient for 3-day regimens of penicillins or other antibiotics. These findings may not extrapolate to populations with a higher risk of complications.
ER -