This post is part of a series recognizing Antimicrobial Awareness Week 2024. Today, we are sharing some examples of clinical situations where shorter antibiotic duration of treatment are recommended. This post was written by Jeremy Tigh, PharmD.
The duration of antibiotic therapy for bacterial infections historically reflected long-standing dogma and relied largely on expert opinion and tradition. In the setting of a lack of high-quality data, and early false concerns for the development of resistance with short durations, longer fixed durations of therapy were sought after knowing that overtreatment occurred but ensured that every patient was “maximally cured.”1-2 In 2010 Paul Sax, MD wrote a satirical piece in the New England Journal of Medicine’s blog highlighting the lore in figuring out the length of antibiotic therapy, using non-evidence-based multiples of 5 (fingers on a hand) or 7 (days of the week).3 Since that piece, there has been an ongoing push towards studying proper durations of therapy, a movement dubbed “Shorter is Better” by expert in the field Brad Spellberg, MD.4-7 This refers to shortening the number of days an antibiotic course is given, while not increasing risk for treatment failure. This leads to less risk of harm including decreased antibiotic resistance, fewer adverse effects, and less Clostridioides difficile infection. Newer evidence supports shorter durations for some common infections. It is the goal of this document to encourage translating this evidence into current practice.
Key Points8-10: Since 2019, IDSA has endorsed 5 days of antibiotics for patients with CAP who are clinically improving on therapy. A recent randomized controlled trial found antibiotics could be safely stopped at 3 days in patients who met markers for clinical stability (afebrile 48-72 hours, spO2 >90%, etc.). In patients with an initially elevated procalcitonin, antimicrobials can be stopped when it returns to normal (<0.25 ng/mL) or decreases by ³80%. Extra-pulmonary infections or those with infections caused by Pseudomonas aeruginosa or Staphylococcus aureus may require longer courses of treatment.
Key Points11-14: For uncomplicated cystitis, evidence supports 3 days of TMP-SMX (Bactrim) or 5 days of nitrofurantoin. Alternate options include 3 days of fluoroquinolones or 5 days of a beta-lactam (e.g., amoxicillin-clavulanate, cephalexin, cefuroxime). For complicated cystitis (including catheterized patients and those with urologic abnormalities), evidence supports 7 days of treatment. For pyelonephritis, longer courses of 7 days (fluoroquinolone) to 10-14 (TMP/SMX, beta-lactams) days are appropriate. Bacteria in the urine without any urinary symptoms is considered asymptomatic bacteriuria and should NOT be treated (exceptions: pregnancy, impending urologic surgery).
Key Points15-18: Multiple studies have demonstrated that 7 days of total antibiotic therapy is noninferior to 14 days in clinically stable patients who have adequate source control. Conversion to oral antibiotics is appropriate in patients who demonstrate clinical improvement while on IV therapy. Should use an oral antibiotic with demonstrated susceptibility against causative pathogen and high bioavailability (TMP/SMX, levofloxacin, cephalexin, amoxicillin-clavulanate). Longer durations may be necessary for immunocompromised patients, those with inadequate source control, or for certain pathogens such as Pseudomonas aeruginosa.
Key Points19-21: Treatment for 5-7 days is appropriate for most patients if there has been improvement in symptoms. Longer courses may be required for severe infections or infections without source control (undrained abscess). Diabetes alone is not an indication for a longer course
Key Points22-23: More than 1 in 5 antibiotics prescribed in adults are for sinusitis. In adults, acute bacterial rhinosinusitis should only be diagnosed when symptoms persist without evidence of improvement for at least 10 days beyond the onset of symptoms or after double worsening. In adults, 5-7 days of therapy is appropriate if improvement after 3-5 days of treatment occurs: 7-10 days if delayed response or switch to alternative therapy due to lack of response (Augmentin). In children, longer treatment duration of 10-14 days is recommended.
Key Points24: 10 days for penicillin, amoxicillin, 1st generation oral cephalosporins, clindamycin. 5 days for azithromycin (not preferred due to increasing macrolide resistance)
Key Points25: Amoxicillin, amoxicillin-clavulanate (preferred if antibiotic exposure within 30 days, recurrent infection), or oral cephalosporins: For children <2 years and children (any age) with tympanic membrane perforation or history of recurrent infection: 10 days. For children >2 years with intact tympanic membrane and no history of recurrent AOM 5-7 days.
References:
Document adapted from Public Health Ontario: Shorter is Smarter Resources.
- Llewelyn M J, Fitzpatrick J M, Darwin E, Tonkin-Crine S, Gorton C, Paul J et al. The antibiotic course has had its day BMJ 2017; 358 :j3418 doi:10.1136/bmj.j3418
- Rice LB. The Maxwell Finland Lecture: for the duration-rational antibiotic administration in an era of antimicrobial resistance and Clostridium difficile. Clin Infect Dis. 2008;46(4):491-496. doi:10.1086/526535
- https://blogs.jwatch.org/hiv-id-observations/index.php/how-to-figure-out-the-length-of-antibiotic-therapy/2010/10/22/
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