ACP recommends shorter antibiotic courses for common bacterial infections
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ACP, citing previous data that indicate at least 30% of outpatient antibiotic prescriptions in the U.S. were “unnecessary” and “often continued for too long,” issued best practices for appropriate antibiotic use in several bacterial infections.
The guidance, recently published in Annals of Internal Medicine, discusses the “right antibiotic at the right dose for the right duration” for uncomplicated bronchitis with COPD exacerbations, community-acquired pneumonia, UTIs and cellulitis.
“This guidance on appropriate use of antibiotics is important for practicing physicians when treating these common conditions in our patients,” ACP President Jacqueline W. Fincher, MD, MACP, said in a press release. “As antibiotic resistance remains a huge issue in the U.S., educating our clinicians to adopt shorter course antibiotic therapy is paramount.”
Rachael A. Lee, MD, MSPH, a member of the Scientific Medical Policy Committee of the ACP and an associate professor of infectious diseases and internal medicine at the University of Alabama at Birmingham, and colleagues reviewed 38 articles consisting of published clinical guidelines, systematic reviews and individual studies to develop the best practice guidelines. Based on this review, they recommend to:
- cap the length of antibiotic treatment to 5 days for patients with COPD exacerbations and acute uncomplicated bronchitis who have signs of a bacterial infection, including increased sputum purulence plus increased dyspnea or sputum volume;
- treat community-acquired pneumonia with antibiotics for at least 5 days, and extend therapy based on “validated measures of clinical stability” such as capability to eat and resumption of normal vital signs and mental activity;
- prescribe either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole for 3 days or a single dose of fosfomycin to women with uncomplicated bacterial cystitis;
- prescribe 5 to 7 days of fluoroquinolones or 14 days of trimethoprim-sulfamethoxazole based on antibiotic susceptibility to men and women with uncomplicated pyelonephritis; and
- prescribe a 5- to 6-day regimen of antibiotics active against streptococci in patients with nonpurulent cellulitis, particularly for those patients who can self-monitor and are in close contact with their primary care physician.
The researchers noted that clinicians often default to a 10-day antibiotic course, “regardless of the condition.” But there are several benefits to shortening the duration of treatment, they added.
“When clinically safe and supported by evidence, shortening the duration of antibiotic therapy decreases overall antibiotic exposure, reducing the selection pressure for resistant organisms as well as a patient's risk for adverse effects from antibiotics,” Lee and colleagues wrote.
Perspective
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I do not necessarily disagree with the guideline for antibiotic use. However, there have been times when I have followed infection control guidelines, such as 3 days of antibiotics for an uncomplicated UTI or 5 days of antibiotics for bronchitis, but my patients were not completely treated by the shortened medication regime.
Therefore, I am a little reluctant to universally cut off antibiotic use at a certain time point. I would much rather make my own decisions based on what I know about the patient, their comorbidities, how willing they are to come back for follow-up, the likelihood that they will take the medication as prescribed, the severity and location of the infection and finally, how they were treated and the outcome of previous infections.
So, while the ACP guideline published on antibiotics, or any guideline on any topic for that matter, is a good place to start with, the guideline should just guide, not rule.
Perspective
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Helen W. Boucher, MD, FACP, FIDSA
With this guideline, the ACP has taken previously published Infectious Diseases Society of America guidelines and a Global Initiative for Chronic Obstructive Lung Disease, or GOLD, guideline and highlighted the fact that in all of these cases, a shorter course of antibiotics is effective. Therefore, the main takeaway message here is that less is more. This is a good message and provides support for the importance of good antimicrobial stewardship.
Chief, division of geographic medicine and infectious diseases, Tufts Medical Center
Director, Levy Center for Integrated Management of Antimicrobial Resistance, Tufts Medical Center
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