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Review supports shorter antibiotic durations for uncomplicated respiratory infections
Chris Dall, MA
Today at 3:47 p.m.
Antimicrobial Stewardship A literature review and analysis indicates that the available evidence supports shorter courses of antibiotics for non–intensive care unit community-acquired pneumonia (non-ICU CAP) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD), Dutch researchers reported yesterday in The Lancet Infectious Diseases.
To evaluate the current evidence base for shortening antibiotic duration in respiratory tract infections (RTIs), which are significant driver of antibiotic prescribing globally, researchers from Amsterdam University Medical Center conducted an umbrella review of systematic reviews addressing antibiotic treatment durations for CAP, AECOPD, hospital-acquired pneumonia (HAP), acute sinusitis, and streptococcal pharyngitis, tonsillitis and pharyngotonsillitis. The primary outcomes of interest were clinical and bacteriologic cure, microbiologic eradication, mortality, relapse rate, and adverse events.
The researchers say they conducted the review because, while numerous trials and systematic reviews and meta-analyses have generally supported shorter antibiotic durations for RTIs, particularly for CAP and AECOPD, the evidence hasn't truly filtered into daily practice.
"This raises the question whether the findings of the conducted studies are non-conclusive or inconsistent (suggesting a knowledge gap), or whether the results of original studies and meta-analyses align (highlighting an implementation gap)," they wrote.
Five-day course equivalent to longer course
Of the 30 reviews identified by the researchers, 14 (of which 8 were meta-analyses) found moderate-quality evidence that 5 days of antibiotics is clinically non-inferior to a longer course for non-ICU CAP, but the evidence was insufficient to support anything shorter than 5 days. For AECODP, 8 reviews (including 5 meta-analyses) found sufficient evidence supporting a treatment duration of 5 days, but evidence for shorter durations was scarce.
"Although the quality of the reviews was generally low and the quality of evidence varied between type of infection, the available evidence for non-ICU CAP and AECOPD supports a short-course treatment duration of 5 days in patients who have clinically improved," the authors wrote. "Efforts of the scientific community should be directed at implementing this evidence in daily practice."
Evidence for shorter durations for non-ventilator-associated HAP and acute sinusitis was scarce, however. And for pharyngotonsillitis (8 reviews, of which 6 did a meta-analysis), the analysis found sufficient evidence to support short-course cephalosporin but not short-course penicillin when dosed three times a day.
Addressing the implementation gap
The study authors say additional reviews or meta-analyses of treatment durations for RTIs are unnecessary.
"Instead, there is a need for high-quality RCTs [randomized controlled trials] to provide evidence on treatment durations of less than 5 days for CAP and AECOPD, to assess the optimal treatment duration for HAP and sinusitis, and to support short-course treatment with a more frequent dosing scheme of penicillin in patients with pharyngotonsillitis," they wrote.
In an accompanying commentary, experts from the Vanderbilt University Medical Center and Agha Khan University Hospital in Pakistan say that while the study makes clear that the existing evidence supports shorter antibiotic treatments for most uncomplicated RTIs, uptake of shorter treatments in clinical practice is likely to remain a challenge. They argue that antibiotic stewardship programs can play an important role in addressing the implementation gap.
"The shift to shorter antibiotic treatment durations is the next frontier of antibiotic stewardship," they wrote.
​
Review supports shorter antibiotic durations for uncomplicated respiratory infections
Chris Dall, MA
Today at 3:47 p.m.
Antimicrobial Stewardship A literature review and analysis indicates that the available evidence supports shorter courses of antibiotics for non–intensive care unit community-acquired pneumonia (non-ICU CAP) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD), Dutch researchers reported yesterday in The Lancet Infectious Diseases.
To evaluate the current evidence base for shortening antibiotic duration in respiratory tract infections (RTIs), which are significant driver of antibiotic prescribing globally, researchers from Amsterdam University Medical Center conducted an umbrella review of systematic reviews addressing antibiotic treatment durations for CAP, AECOPD, hospital-acquired pneumonia (HAP), acute sinusitis, and streptococcal pharyngitis, tonsillitis and pharyngotonsillitis. The primary outcomes of interest were clinical and bacteriologic cure, microbiologic eradication, mortality, relapse rate, and adverse events.
The researchers say they conducted the review because, while numerous trials and systematic reviews and meta-analyses have generally supported shorter antibiotic durations for RTIs, particularly for CAP and AECOPD, the evidence hasn't truly filtered into daily practice.
"This raises the question whether the findings of the conducted studies are non-conclusive or inconsistent (suggesting a knowledge gap), or whether the results of original studies and meta-analyses align (highlighting an implementation gap)," they wrote.
Five-day course equivalent to longer course
Of the 30 reviews identified by the researchers, 14 (of which 8 were meta-analyses) found moderate-quality evidence that 5 days of antibiotics is clinically non-inferior to a longer course for non-ICU CAP, but the evidence was insufficient to support anything shorter than 5 days. For AECODP, 8 reviews (including 5 meta-analyses) found sufficient evidence supporting a treatment duration of 5 days, but evidence for shorter durations was scarce.
"Although the quality of the reviews was generally low and the quality of evidence varied between type of infection, the available evidence for non-ICU CAP and AECOPD supports a short-course treatment duration of 5 days in patients who have clinically improved," the authors wrote. "Efforts of the scientific community should be directed at implementing this evidence in daily practice."
Evidence for shorter durations for non-ventilator-associated HAP and acute sinusitis was scarce, however. And for pharyngotonsillitis (8 reviews, of which 6 did a meta-analysis), the analysis found sufficient evidence to support short-course cephalosporin but not short-course penicillin when dosed three times a day.
Addressing the implementation gap
The study authors say additional reviews or meta-analyses of treatment durations for RTIs are unnecessary.
"Instead, there is a need for high-quality RCTs [randomized controlled trials] to provide evidence on treatment durations of less than 5 days for CAP and AECOPD, to assess the optimal treatment duration for HAP and sinusitis, and to support short-course treatment with a more frequent dosing scheme of penicillin in patients with pharyngotonsillitis," they wrote.
In an accompanying commentary, experts from the Vanderbilt University Medical Center and Agha Khan University Hospital in Pakistan say that while the study makes clear that the existing evidence supports shorter antibiotic treatments for most uncomplicated RTIs, uptake of shorter treatments in clinical practice is likely to remain a challenge. They argue that antibiotic stewardship programs can play an important role in addressing the implementation gap.
"The shift to shorter antibiotic treatment durations is the next frontier of antibiotic stewardship," they wrote.
​