Short- versus Long-Course Antibacterial Therapy for Community-Acquired Pneumonia

Alfa Institute of Biomedical Sciences (AIBS), Athens, GreeceDepartment of Critical Care, Attikon University Hospital, University of Athens, Athens, Greece.
Drugs (Impact Factor: 4.34). 09/2008; 68(13):1841-54. DOI: 10.2165/00003495-200868130-00004
Source: PubMed


The evidence for traditionally recommended 7- to 14-day duration of antibacterial therapy for community-acquired pneumonia (CAP) is not well established.
We endeavoured to assess the effectiveness and safety of shorter than traditionally recommended antibacterial therapy for CAP.
We performed a meta-analysis of randomized controlled trials (RCTs) comparing short- (< or = 7 days) versus long- (> or = 2 days difference) course therapy for CAP with the same antibacterial regimens, in the same daily dosages.
Five RCTs involving adults (including outpatients and inpatients who did not require intensive care) and two RCTs involving children (aged 2-59 months, residing in developing countries) were included. All RCTs were double-blind and assessed patients with CAP of mild to moderate severity. No differences were found between short- (adults 3-7 days; children 3 days) and long- (adults 7-10 days; children 5 days) course regimens (adults - amoxicillin, cefuroxime, ceftriaxone, telithromycin and gemifloxacin; children - amoxicillin) regarding clinical success at end-of-therapy (six RCTs; 5107 patients [1095 adults, 4012 children]; fixed-effect model [FEM]; odds ratio [OR] = 0.89; 95% CI 0.74, 1.07), clinical success at late follow-up, microbiological success, relapses, mortality (seven RCTs; 5438 patients; FEM; OR = 0.57; 95% CI 0.23, 1.43), adverse events (five RCTs; 3214 patients; FEM; OR = 0. 90; 95% CI 0.72, 1.13) or withdrawals as a result of adverse events. No differences were found in subset analyses of adults or children, and of patients treated with no more than 5-day short-course regimens versus at least 7-day long-course regimens.
No difference was found in the effectiveness and safety of short- versus long-course antimicrobial treatment of adult and paediatric patients with CAP of mild to moderate severity.

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Available from: Alexandros P Grammatikos, Feb 13, 2014
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    • "The aforementioned trials [14–16, 20, 22] were all included in a recent meta-analysis of Dimopoulos et al. [24]. The authors compared short- (≤7 days) versus long- (≥2 days difference) course monotherapy regimens for CAP, confirming that short-course antimicrobial therapy was equivalent to standard length of therapy for clinical cure and bacterial eradication rates, relapses, adverse events, and mortality. "
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    ABSTRACT: Community acquired pneumonia (CAP) represents the most common cause of infection-related morbidity and mortality worldwide. Appropriate treatment of CAP is challenging and sometimes limited by the availability to obtain rapid and timely identification of the etiologic agent in order to initiate or deescalate the correct antimicrobial therapy. As a consequence, prescribers frequently select empiric antimicrobial therapy using clinical judgment, local patterns of antimicrobial resistance, and, sometimes, individual patient expectations. These issues may contribute to prolonged courses of inappropriate therapy. In this review, we discuss the evidence and recommendations from international guidelines for the management of CAP and the clinical trials that specifically addressed duration of antimicrobial therapy for CAP in adults. In randomized controlled trials comparing the clinical efficacy of a short-course antimicrobial regimen versus an extended-course regimen, no differences in terms of clinical success, bacterial eradication, adverse events, and mortality were observed. The use of biomarkers, such as procalcitonin, to guide the initiation and duration of antimicrobial therapy may reduce total antibiotic exposure and treatment duration, healthcare costs, and the risk of developing antimicrobial resistance. In clinical practice, antimicrobial stewardship interventions may improve the management of CAP and may help in reducing treatment duration. Sometimes "less is more" in CAP.
    Full-text · Article · Jan 2014 · The Scientific World Journal
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    • "Several narrative reviews [54,55] and meta-analyses [22,23] of RCTs have provided evidence of the efficacy and safety of treating mild to moderate CAP with short-duration antibiotic therapy (5 to 7 days). The 13 studies of pneumonia identified for this review included 5 studies of CAP that provided the prevalence of bacteremia; in total, 80 patients with bacteremia were randomly assigned in equal numbers to short (3 to 7 days) and long (7 to 10 days) durations of therapy. "
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    ABSTRACT: The optimal duration of antibiotic therapy for bloodstream infections is unknown. Shorter durations of therapy have been demonstrated to be as effective as longer durations for many common infections; similar findings in bacteremia could enable hospitals to reduce antibiotic utilization, adverse events, resistance and costs. A search of the MEDLINE, EMBASE and COCHRANE databases was conducted for the years 1947-2010. Controlled trials were identified that randomized patients to shorter versus longer durations of treatment for bacteremia, or the infectious foci most commonly causing bacteremia in critically ill patients (catheter-related bloodstream infections (CRBSI), intra-abdominal infections, pneumonia, pyelonephritis and skin and soft-tissue infections (SSTI)). Twenty-four eligible trials were identified, including one trial focusing exclusively on bacteremia, zero in catheter related bloodstream infection, three in intra-abdominal infection, six in pyelonephritis, thirteen in pneumonia and one in skin and soft tissue infection. Thirteen studies reported on 227 patients with bacteremia allocated to 'shorter' or 'longer' durations of treatment. Outcome data were available for 155 bacteremic patients: neonatal bacteremia (n = 66); intra-abdominal infection (40); pyelonephritis (9); and pneumonia (40). Among bacteremic patients receiving shorter (5-7 days) versus longer (7-21 days) antibiotic therapy, no significant difference was detected with respect to rates of clinical cure (45/52 versus 47/49, risk ratio 0.88, 95% confidence interval [CI] 0.77-1.01), microbiologic cure (28/28 versus 30/32, risk ratio 1.05, 95% CI 0.91-1.21), and survival (15/17 versus 26/29, risk ratio 0.97, 95% CI 0.76-1.23). No significant differences in clinical cure, microbiologic cure and survival were detected among bacteremic patients receiving shorter versus longer duration antibiotic therapy. An adequately powered randomized trial of bacteremic patients is needed to confirm these findings.
    Full-text · Article · Nov 2011 · Critical care (London, England)
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    • "The duration of antibiotic therapy for sepsis is mostly based on expert opinion [2], but its reduction is arguably the most promising approach to decrease emergence and selection of antibiotic resistance. During the past 10 years, great progress has been made to decrease the antibiotic treatment duration for various types of infections, including community-acquired pneumonia and ventilator-associated pneumonia, by implementing fixed 8-day stopping rules [3,4]. A more tailored approach could be the use of algorithms based on the longitudinal course of biomarkers to facilitate individual decision-making and choose the right moment for discontinuation of antibiotic therapy. "
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    ABSTRACT: Every day, critical care physicians around the world face the same challenge of the optimal timing of antimicrobial administration: when to start and when to stop antibiotics. Duration of antibiotic therapy for sepsis is mostly based on expert opinion, but its reduction is arguably the most promising approach to decrease emergence and selection of antibiotic resistance. The study by Hochreiter and colleagues presents another piece of evidence suggesting that procalcitonin may indeed be a valuable diagnostic parameter to guide antibiotic treatment duration, despite the ongoing controversy about the diagnostic accuracy of pro-calcitonin.
    Full-text · Article · Aug 2009 · Critical care (London, England)
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