Perspective from Kathryn A. Boling, MD
Disclosures: Fincher reports no relevant financial disclosures. Lee reports personal fees from ACP during the conduct of the study and personal fees from Prime Education and Medscape outside the submitted work. Please see the guideline for all other authors' relevant financial disclosures.
April 05, 2021
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ACP recommends shorter antibiotic courses for common bacterial infections

Perspective from Kathryn A. Boling, MD
Disclosures: Fincher reports no relevant financial disclosures. Lee reports personal fees from ACP during the conduct of the study and personal fees from Prime Education and Medscape outside the submitted work. Please see the guideline for all other authors' relevant financial disclosures.
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ACP, citing previous data that indicate at least 30% of outpatient antibiotic prescriptions in the U.S. were “unnecessary” and “often continued for too long,” issued best practices for appropriate antibiotic use in several bacterial infections.

The guidance, recently published in Annals of Internal Medicine, discusses the “right antibiotic at the right dose for the right duration” for uncomplicated bronchitis with COPD exacerbations, community-acquired pneumonia, UTIs and cellulitis.

According to ACP, at least 30% of outpatient antibiotic prescriptions are unnecessary and continue longer than needed.
Reference: Lee RA, et al. Ann Intern Med. 2021;doi:10.7326/M20-7355.

“This guidance on appropriate use of antibiotics is important for practicing physicians when treating these common conditions in our patients,” ACP President Jacqueline W. Fincher, MD, MACP, said in a press release. “As antibiotic resistance remains a huge issue in the U.S., educating our clinicians to adopt shorter course antibiotic therapy is paramount.”

Rachael A. Lee, MD, MSPH, a member of the Scientific Medical Policy Committee of the ACP and an associate professor of infectious diseases and internal medicine at the University of Alabama at Birmingham, and colleagues reviewed 38 articles consisting of published clinical guidelines, systematic reviews and individual studies to develop the best practice guidelines. Based on this review, they recommend to:

  • cap the length of antibiotic treatment to 5 days for patients with COPD exacerbations and acute uncomplicated bronchitis who have signs of a bacterial infection, including increased sputum purulence plus increased dyspnea or sputum volume;
  • treat community-acquired pneumonia with antibiotics for at least 5 days, and extend therapy based on “validated measures of clinical stability” such as capability to eat and resumption of normal vital signs and mental activity;
  • prescribe either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole for 3 days or a single dose of fosfomycin to women with uncomplicated bacterial cystitis;
  • prescribe 5 to 7 days of fluoroquinolones or 14 days of trimethoprim-sulfamethoxazole based on antibiotic susceptibility to men and women with uncomplicated pyelonephritis; and
  • prescribe a 5- to 6-day regimen of antibiotics active against streptococci in patients with nonpurulent cellulitis, particularly for those patients who can self-monitor and are in close contact with their primary care physician.

The researchers noted that clinicians often default to a 10-day antibiotic course, “regardless of the condition.” But there are several benefits to shortening the duration of treatment, they added.

“When clinically safe and supported by evidence, shortening the duration of antibiotic therapy decreases overall antibiotic exposure, reducing the selection pressure for resistant organisms as well as a patient's risk for adverse effects from antibiotics,” Lee and colleagues wrote.