Shorter Course Of Antibiotics Likely Better For Some Bacterial Infections, ACP Says

A shorter course of antibiotics may be appropriate for some common bacterial infections, according to the American College of Physicians (ACP), which just released a new Best Practice Advice on antibiotic prescribing.

The Advice covers acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia, urinary-tract infection, and cellulitis.

"These conditions are among the most common . . . that internists and other physicians and clinicians see routinely in the outpatient and inpatient clinical areas, and are some of the most frequent reasons why antibiotics are prescribed," ACP President Dr. Jacqueline Fincher told Reuters Health by email. "We are seeing such a significant increase in antibiotic resistance and adverse effects - e.g., C. difficile infections from overuse or prolonged use - and there are no new antibiotics coming out."

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"It is estimated based on CDC surveillance that about 30% of antibiotic prescriptions are unnecessary," she said, "and up to 20% of patients receiving an antibiotic have some type of adverse effect or event from the antibiotic."

With that said, she added, there are still situations in which a longer course is appropriate. "Every physician is making these decisions on the frontline in real time looking at the individual patient and their particular medical problems - e.g., the patient is not getting better after the shorter course, they are immunocompromised, they have other comorbid conditions that may require extension of therapy, such as diabetes or a more deep-seated infection."

Also, she noted, a patient may have what looks like a simple bladder infection, but the urine culture comes back three days later resistant to the antibiotic the patient was empirically started on.

"The infection may now involve the upper tract - i.e., kidney - and is now a more complicated pyelonephritis requiring a different antibiotic and a more prolonged course," Dr. Fincher said.

The Best Practice Advice was developed after a literature search for clinical guidelines, systematic reviews and individual studies that addressed the targeted conditions. Guidance was prioritized to the highest available level of synthesized evidence.

The Advice, published in Annals of Internal Medicine, says clinicians should:

1. Limit antibiotic treatment to five days for patients with COPD exacerbations and acute uncomplicated bronchitis who have signs of a bacterial infection - i.e., increased sputum purulence plus increased dyspnea, and/or increased sputum volume.

2. Prescribe antibiotics for community-acquired pneumonia for at least five days. Extension beyond that should be guided by measures of clinical stability, including resolution of vital-sign abnormalities, ability to eat, and normal mentation.

3. Prescribe short-course antibiotics for women with uncomplicated bacterial cystitis - i.e., either nitrofurantoin for five days, trimethoprim-sulfamethoxazole (TMP-SMZ) for three days, or fosfomycin as a single dose; men and women with uncomplicated pyelonephritis should receive either with fluoroquinolones (five to seven days) or TMP-SMZ (14 days), based on antibiotic susceptibility.

4. Prescribe a five-to-six-day course of antibiotics active against streptococci for patients with nonpurulent cellulitis.

Dr. Fincher noted, "Multiple conditions are being looked at by the CDC along with a presidential commission looking at antibiotic resistance at the national level. We're trying to get the 'low-hanging fruit' first."

Dr. Chanu Rhee of Harvard Medical School and Brigham and Women's Hospital, in Boston, coauthor of a recent study on inappropriate antibiotic prescribing for community-onset sepsis (https://bit.ly/3bugf1Q), commented by email, "I generally agree with these recommendations, but one condition for which I think these guidelines could have pushed the envelope a little bit more is for pyelonephritis."

"The ACP committee took their guidance from the IDSA/ESCMID guidelines that were published back in 2011, which recommend a fluoroquinolone for seven days or TMP-SMX for 14 days," he told Reuters Health. "However, several subsequent studies have shown that shorter courses of fluoroquinolones and TMP-SMX are just as effective. The IDSA/ESCMID guidelines are currently being updated and I expect that their new recommended treatment durations will be shorter."

"Longer is generally not better when it comes to the duration of antibiotic treatment," he said. "In fact, relatively short courses of antibiotics will be just as successful in treating most infections while reducing the risk of antibiotic resistance and side effects."

—Marilynn Larkin

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