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Shortened course of antibiotics similarly effective in treating community-acquired pneumonia

Antibiotic therapy based on clinical stability was safe and equally effective for hospitalized patients with community-acquired pneumonia, compared with the standard antibiotic duration, according to findings published in JAMA Internal Medicine.

These data validate the use of recommendations issued by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS), according to Ane Uranga, MD, from the department of pneumology at the Galdakao-Usansolo Hospital in Spain, and colleagues.

The researchers conducted a multicenter, noninferiority randomized clinical trial to provide evidence based in a real-world setting, as long antibiotic regimens are still common.

"Shortened antibiotic treatments have numerous advantages," Uranga and colleagues wrote. "First, they have been associated with lower rates of antimicrobial resistance among respiratory pathogens. In fact, low doses of -lactam antibiotics for more than 5 days have been associated with an increase in Streptococcus pneumoniae penicillin-resistant nasopharyngeal carriers. Second, reducing the duration of antibiotic treatments could lead to cost savings. Third, unnecessarily long treatments could result in higher rates of adverse effects. Fourth, adherence may improve if treatment duration is shortened."

The study included 312 patients randomly assigned to treatment at four hospitals in Spain between January 2012 and August 2013. Patients assigned to the control group received antibiotic treatment typical of clinical practice and patients in the intervention group (n=162) received antibiotic treatment for 5 days and stopped treatment when their body temperature was 37.8° C or lower for 48 hours and had only one or no sign of clinical instability associated with community-acquired pneumonia (CAP). These symptoms included: "systolic blood pressure less than 90 mm Hg, heart rate greater than 100/min, respiratory rate greater than 24/min, arterial oxygen saturation less than 90%, or PaO₂ less than 60 mm Hg in room air."

Results of a per-protocol analysis showed that clinical success was achieved in 50.4% of participants in the control group and 59.7% of participants in the intervention group at day 10 (P = .12) and 92.7% of participants in the control group and 94.4% of participants in the intervention group at day 30 (P = .54).

Researchers reported safely limiting antibiotic treatment to 5 days in 70.1% of patients in the intervention group.

Uranga and colleagues wrote that their findings showed a shorter antibiotic course was "not inferior" to standard antibiotic treatment schedules.

"Our study indicates that the IDSA/ATS recommendations for shorter duration of antibiotic treatment based on clinical stability criteria can be safely implemented in hospitalized patients with CAP, leading to a significant reduction in treatment duration," they concluded.

In an accompanying editorial, Brad Spellberg, MD, from the Los Angeles County+University of Southern California Medical Center, wrote that the results were both convincing and compelling, stressing that prevention of antibiotic resistance was not related to continuing therapies after symptoms have resolved.

"There is no evidence that taking antibiotics beyond the point at which a patient's symptoms are resolved reduces antibiotic resistance," Spellberg wrote. "To the contrary, specifically for pneumonia, studies have shown that longer courses of therapy result in more emergence of antibiotic resistance, which is consistent with everything we know about natural selection, the driver of antibiotic resistance."

Spellberg explained that physicians should base duration of antibiotic therapy on each patient's response.

"Patients should be told that if their symptoms resolve before completing the antibiotic they should communicate with their physician to determine if they can stop therapy early," he wrote. "Health care professionals should be encouraged to allow patients to stop antibiotic treatment as early as possible on resolution of symptoms of infection. Ultimately, we should replace the old dogma of continuing therapy past resolution of symptoms with a new, evidence-based dogma of ‘shorter is better.’" – by Chelsea Frajerman Pardes

Disclosures: Spellberg reported receiving consulting fees from Cempra, The Medicines Company, MedImmune/AstraZeneca, PTC Therapeutics, Entasis, Tetraphase, Merck, and Genentech; and Data and Safety Monitoring Board fees from Dipexium; and reported owning equity in Motif, BioAIM, and Synthetic Biologics. None of the other authors reported any relevant financial disclosures.