Five days of antibiotics adequate for community-acquired pneumonia

By Will Boggs MD

NEW YORK (Reuters Health) - For most patients with community-acquired pneumonia (CAP), five days of antibiotics provide adequate treatment, researchers from Spain report.

"The duration of antibiotic treatment in CAP should be based on clinical stability criteria leading to a significant reduction in treatment duration without increasing the rate of adverse outcomes," Dr. Ane Uranga from Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain told Reuters Health by email.

The Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) suggest a minimum of five days of treatment for patients achieving an afebrile state for 48 to 72 hours and patients meeting no more than 1 CAP-associated instability criteria before therapy discontinuation.

Despite these clinically based recommendations, arbitrarily long treatments remain common.

Dr. Uranga's team assessed whether the duration of antibiotic treatment based on the IDSA/ATS criteria was as effective as conventional treatment in a randomized clinical trial in four teaching hospitals in the Basque Country in Spain.

Patients in the intervention group received a minimum of five days of antibiotics, and the antibiotic treatment was stopped at this point if the body temperature was 37.8°C or less for 48 hours and they had no more than one CAP-associated sign of clinical instability. In the control group, the duration of antibiotics was left up to the treating physician.

Clinical success rates were similar at day 10: 56.3% (90/162) in the intervention group and 48.6% (71/150) in the control group (P=0.18).

By day 30, clinical success rates had improved in both groups, but they remained non-significantly different, the authors reported online July 25 in JAMA Internal Medicine.

In multilevel analyses, differences between the intervention and control groups in clinical success at days 10 or 30 were not significant.

Among secondary outcomes, time receiving antibiotic treatment was significantly longer in the control group (median, 10 days) than in the intervention group (median, 5 days), and far more patients in the intervention group received antibiotics for only five days (70.1% vs 2.9%).

The groups did not differ significantly in time until clinical improvement, days to return to normal activity, radiographic resolution, adverse effects, mortality, in-hospital complications, or length of hospital stay.

Thirty-day readmission rates were significantly higher in the control group (6.6% vs 1.4%).

"There are patients who will require longer duration therapy, especially those with an uncommon etiology (P. aeruginosa or S. aureus, among others) or who required a chest tube or if their condition was complicated by extrapulmonary infection, such as meningitis or endocarditis," Dr. Uranga said.

"Future research should focus on withdrawing antibiotic treatment based on clinical stability criteria, not only in severe CAP but also among different types of pneumonia," she concluded.

Dr. Brad Spellberg from Keck School of Medicine at University of Southern California in Los Angeles, who wrote an editorial related to this report, told Reuters Health, "The results were gratifying in that they validate that short-course antibiotics are effective even for more severe cases of community-acquired pneumonia, typified by pneumonia severity index (PSI) 4 and 5 category infection. This is the first time that has been shown, as prior studies of short-course therapy had no PSI 5 infections, and limited PSI 4s."

"We are treating for too long even for infections that are caused by bacteria, and this is contributing to the selection of antibiotic resistance," he said. "The old saying that to prevent resistance you have to complete the course of therapy even after symptoms have resolved is wrong and was never based on any data or evidence."

In his editorial, he advises, "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. Health care professionals should be encouraged to allow patients to stop antibiotic treatment as early as possible on resolution of symptoms of infection."

"Shorter is better," Dr. Spellberg concluded.

Dr. Giulio DiDiodato from Royal Victoria Regional Health Center, Barrie, Ontario, Canada, who has also researched short-duration antibiotic therapy, told Reuters Health, "Since the advent of the antibiotic era, we have known from published results that patients with CAP have recovered even after a single dose of antibiotic, and many patients with CAP recover on their own without the need for any antibiotics."

"The vast majority of patients who are immunologically competent likely require minimal antibiotic exposure to recover from CAP, and I am sure that it won't be long until we start to see randomized controlled trials on even shorter courses of antibiotic therapy for CAP," Dr. DiDiodato said.

"I actually believe the most important observation in this paper is that even patients who recover continue to experience symptoms from their CAP despite more than adequate treatment, and these symptoms are not ameliorated by longer durations of therapy," he said. "This is usually the trigger for physicians to prescribe either prolonged courses of treatment or additional courses of treatment; that their patients continue to complain that they are not fully recovered. Physicians should use this paper, along with many other previous publications, to explain and reassure to their patients that the symptoms from pneumonia persist for a long time even after effective therapy, and longer courses of antibiotic treatment will do nothing to abbreviate this convalescent phase of their illness."

SOURCE: http://bit.ly/2aseVle

JAMA Intern Med 2016.

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