Best Practice for Use of Short-Course Antibiotics in Common Infections

Best Practice for Use of Short-Course Antibiotics in Common Infections
Lauren Ostlund, PharmD, Broadway Family Medicine

Background: Healthcare providers are asked to navigate the fine balance between efficacy and safety when determining medication regimens for patients. When it comes to the use of antibiotics, this ambivalence is accentuated due to the potential risks that come with both under- and over-treatment. As antibiotic resistance continues to be a concern in patient care, the importance of appropriate antibiotic use in common infections remains at the forefront of prescribers’ minds; treatment courses need to be long enough to clear the infection, but short enough to mitigate antibiotic resistance and unnecessary patient exposure to adverse effects. There is also a thought that shorter courses may lead to increased adherence to antibiotic regimens due to the potential for decreased monetary cost and regimen complexity, which may then help support reduction in antibiotic resistance.

Evidence & Discussion: A mitigation factor for decreasing antibiotic resistance includes shorter durations of antibiotic courses when cure outcomes lack a statistically significant difference when compared to longer durations of antibiotic treatment. A recently published article from the American College of Physicians (ACP) discusses best practice advice for short-course antibiotic treatments of the following common bacterial infections: acute bronchitis in chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTIs), and cellulitis. Antibiotic selection should still include assessment of most commonly reported bacterial pathogens and resistance patterns to increase effectiveness of chosen treatment.

Avoiding antibiotic treatment in patients with bronchitis has been encouraged to prevent unnecessary exposure to antibiotics and their subsequent adverse effects when the cause is likely non-bacterial. However, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for treatment of COPD exacerbations recommends five to seven days of antibiotic treatment if the patient has evidence to support presence of bacterial infection (i.e. increased sputum purulence and increased dyspnea and/or increased sputum volume). Analysis of additional studies now supports treatment in COPD exacerbations with evidence of bacterial infection to be limited to five days.

Support for limiting the duration of antibiotics to five days in the treatment of CAP, as long as the patient is clinically stable (i.e. resolved vital sign abnormalities and normal mentation and ability to eat) is also supported by ACP. Supporting evidence was evaluated from the Infectious Diseases Society of America (IDSA) and the American Thoracic Society guideline for CAP.

Shorter courses of antibiotics in women with uncomplicated bacterial cystitis are further classified based on choice of treatment: five days of treatment with nitrofurantoin, three days of treatment with trimethoprim-sulfamethoxazole, or a one-dose treatment with fosfomycin. In men or women with uncomplicated pyelonephritis, five to seven days of treatment with a fluoroquinolone or 14 days of treatment with trimethoprim-sulfamethoxazole should be used depending on antibiotic susceptibility testing results. This evidence is supported by the guidelines through IDSA and the European Society for Microbiology and Infectious Diseases. These recommendations do not cover complicated UTIs or UTIs in the presence of pregnancy.

In the case of nonpurulent cellulitis, five to six days of antibiotic treatment is typically adequate, especially if close follow up is achievable and if the patient is able to monitor the infection site at home. This recommendation was supported by ACP after review of IDSA, the National Institute for Health and Care Excellence, and a new randomized control trial.

Clinical Impact: Healthcare providers should recognize the potential detrimental impact of antibiotic resistance and of preventable side effects from longer duration antibiotic treatment. Evidence supporting shorter courses of antibiotic therapies in common infections has the potential to combat this growing concern. Furthermore, continuous research in the lowest effective doses and shortest effective courses of therapy may continue to help decrease overuse of antibiotic regimens for common bacterial infections.

 

References:

  1. Lee RA, Centor RM, Humphrey LL, Jokela JA, Andrews R, Qaseem A. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Ann Intern Med. 2021;174:822-827. doi: 10.7326/M20-7355. 6 April 2021.
  2. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2021 report). Global initiative for chronic obstructive lung disease.
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