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Optimal Duration of Antibiotic Treatment in CAP
JAMA Intern Med; 2016 Sep 4; Uranga, et al
In hospitalized patients with community-acquired pneumonia (CAP), the Infectious Diseases Society of America/American Thoracic Society recommendations for duration of antibiotic treatment can be safely implemented, according to a recent study. The IDSA guidelines recommend a minimum of 5 days of treatment, patients achieving an afebrile state for 48 to 72 hours, and patients meeting no more than 1 CAP-associated instability criteria before therapy discontinuation. The clinical trial included 312 hospitalized patients diagnosed with CAP and randomized at day 5 to an intervention group (n=162) treated with antibiotics for a minimum of 5 days, or to a control group (n=150). Main outcomes included clinical success rate at days 10 and 30 since admission and CAP-related symptoms at days 5 and 10 measured with the 18-item CAP symptom questionnaire score range, 0-90 (higher scores indicated more severe symptoms). Researchers found:
- Clinical success was 48.6% in the control group and 56.3% in the intervention group at day 10 and 88.6% in the control group and 91.9% in the intervention group at day 30.
- Mean CAP symptom questionnaire scores were 24.7 vs 27.2 at day 5 and 18.6 vs 17.9 at day 10.
- Clinical success was 50.4% in the control group and 59.7% in the intervention group at day 10, and 92.7% in the control group and 94.4% in the intervention group at day 30 in per-protocol analysis.
- Mean CAP symptom questionnaire scores were 24.3 vs 26.6 at day 5, and 18.1 vs 17.6 at day 10.
JAMA Intern Med. 2016;176(9):1257-1265. doi:10.1001/jamainternmed.2016.3633.
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The IDSA criteria tested and supported in this study have the potential to decrease adverse effects as well as cost from overuse of antibiotics. Physicians understandably want to be as certain as possible that a patient’s pneumonia is sufficiently treated, so in the absence of good data, often opt for a longer course of treatment. The average antibiotic course in the usual care group was 10 days and the study shows equivalent outcomes with 5 days of treatment. This is a straightforward, well-performed, real-world study which strongly supports and provides evidence for a change in the standard of care for uncomplicated CAP to be based on how patients are doing. For patients who are afebrile for 48 to 72 hours, and stable, 5 days of antibiotic therapy appears to be sufficient. —Neil Skolnik, MD