Short- vs long-course antibiotic therapy for pneumonia: a comparison of systematic reviews and guidelines for the SIMI Choosing Wisely Campaign

Duration of Antimicrobial Treatment in Adult Patients with Pneumonia: A Narrative Review

Pneumonia remains a major global health concern, causing significant morbidity and mortality among adults. This narrative review assesses the optimal duration of antimicrobial treatment in adults with community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). Current evidence about the impact of treatment duration on clinical outcomes demonstrates that shorter antibiotic courses are non-inferior, regarding safety and efficacy, compared to longer courses, particularly in patients with mild to moderate CAP, which is in line with the recommendations of international guidelines. Data are limited regarding the optimal antimicrobial duration in HAP patients, and it should be individually tailored to each patient, taking into account the causative pathogen and the clinical response. Shorter courses are found to be as effective as longer courses in the management of VAP, except for pneumonia caused by non-fermenting Gram-negative bacteria; however, duration should be balanced between the possibility of higher recurrence rates and the documented benefits with shorter courses. Additionally, the validation of reliable biomarkers or clinical predictors that identify patients who would benefit from shorter therapy is crucial. Insights from this review may lead to future research on personalized antimicrobial therapies in pneumonia, in order to improve patient outcomes.

The optimal antibiotic treatment duration for community-acquired pneumonia in adults diagnosed in general practice in Denmark (CAP-D): an open-label, pragmatic, randomised controlled trial

BACKGROUND

Use of antibiotics is the main driver of antimicrobial resistance which is considered one of the biggest threats to human health. In Denmark, most antibiotics are prescribed in general practice. Acute lower respiratory tract infections, including community-acquired pneumonia (CAP), are among the most frequent indications for antibiotic prescribing. Phenoxymethylpenicillin is established as first-line treatment in general practice in Denmark. However, the treatment duration with phenoxymethylpenicillin is mostly based on traditions. Both 5 and 7 days of treatment is recommended in Danish guidelines, and when asking the general practitioners about what treatment duration, they prescribe the variation is even bigger. Several hospital-based studies have proven short course (≤ 6 days) antibiotic treatment non-inferior to long course (≥ 7 days) treatment of CAP. No evidence exists on the optimal treatment duration for CAP in non-hospitalised patients. This randomised controlled trial aim to investigate the optimal treatment duration with phenoxymethylpenicillin for CAP in adults diagnosed in general practice in Denmark.

METHODS

This is an open-label, pragmatic, randomised controlled, five-arm DURATIONS trial. Participants will be recruited from at least 24 general practices in Denmark. Eligible participants are adults, with no pre-existing lung disease, presenting with symptoms of CAP, and in whom the general practitioner finds it relevant to treat with antibiotics. The study will compare treatment with phenoxymethylpenicillin 1.2 MIE q.i.d. in 3, 4, 5, 6, and 7 days.

DISCUSSION

This study will provide evidence for the optimal antibiotic treatment duration of CAP in general practice and inform future guidelines on CAP in all countries using phenoxymethylpenicillin for the treatment of acute respiratory tract infections in adults. The results of this study might also be used to guide treatment recommendations in other countries using phenoxymethylpenicillin. Moreover, a (potential) reduction in antibiotic use might lower the development of antimicrobial resistance, increase patient treatment adherence, reduce risks of adverse events, and lower the economical exp TRIAL REGISTRATION: ClinicalTrials.gov: NCT06295120. Registered 28 February 2024.  The Scientific Ethics Committee for the North Denmark Region: N-20230039.

Optimal duration of antibiotic treatment for community-acquired pneumonia in adults: a systematic review and duration-effect meta-analysis

OBJECTIVES

To find the optimal treatment duration with antibiotics for community-acquired pneumonia (CAP) in adults.

DESIGN

Systematic review and duration-effect meta-analysis.

DATA SOURCES

MEDLINE, Embase and CENTRAL through 25 August 2021.

ELIGIBILITY CRITERIA

All randomised controlled trials comparing the same antibiotics used at the same daily dosage but for different durations for CAP in adults. Both outpatients and inpatients were included but not those admitted to intensive care units. We imposed no date, language or publication status restriction.

DATA EXTRACTION AND SYNTHESIS

Data extraction by two independent reviewers. We conducted a random-effects, one-stage duration-effect meta-analysis with restricted cubic splines. We tested the non-inferiority with the prespecified non-inferiority margin of 10% examined against 10 days . The primary outcome was clinical improvement on day 15 (range 7-45 days).

SECONDARY OUTCOMES

all-cause mortality, serious adverse events and clinical improvement on day 30 (15-60 days).

RESULTS

We included nine trials (2399 patients with a mean (SD) age of 61.2 (22.1); 39% women). The duration-effect curve was monotonic with longer duration leading to a lower probability of improvement, and shorter treatment duration (3-9 days) was likely to be non-inferior to 10-day treatment. Harmful outcome curves indicated no association. The weighted average percentage of the primary outcome in the 10-day treatment arms was 68%. Using that average, the absolute clinical improvement rates of the following durations were: 3-day treatment 75% (95% CI: 68% to 81%), 5-day treatment 72% (95% CI: 66% to 78%) and 7-day treatment 69% (95% CI: 61% to 76%).

CONCLUSIONS

Shorter treatment duration (3-5 days) probably offers the optimal balance between efficacy and treatment burden for treating CAP in adults if they achieved clinical stability. However, the small number of included studies and the overall moderate-to-high risk of bias may compromise the certainty of the results. Further research on the shorter duration range is required.

PROSPERO REGISTRATION NUMBER

CRD 42021273357.

Shorter versus longer durations of antibiotic treatment for patients with community-acquired pneumonia: a protocol for a systematic review and meta-analysis

INTRODUCTION

Community-acquired pneumonia (CAP), frequently encountered in both outpatient and inpatient settings, is the leading cause of infectious disease-related mortality. While equipoise regarding the optimal duration of antimicrobial therapy to treat CAP remains, recent studies suggest shorter durations of therapy may achieve optimal outcomes. We have therefore planned a systematic review and meta-analysis evaluating the impact of shorter versus longer durations of antibiotic therapy for patients with CAP.

METHODS AND ANALYSIS

We searched Ovid MEDLINE, Embase, CINAHL and Cochrane Central Register of Controlled Trials from inception to September 2021 for randomised controlled trials evaluating shorter versus longer duration of antibiotics. Eligible studies will compare durations with a minimum difference of two days of antibiotic therapy, irrespective of antibiotic agent, class, route, frequency or dosage, and will report on any patient-important outcome of benefit or harm. Paired reviewers working independently will conduct title and abstract screening, full-text screening, data extraction and risk of bias (RoB) evaluation using a modified Cochrane RoB 2.0 tool. We will perform random-effects modelling for meta-analyses, with study weights generated using the inverse variance method, and will assess certainty in effect estimates using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The Instrument for assessing the Credibility of Effect Modification Analyses (ICEMAN) tool will inform assessments of credibility of subgroup effects based on severity of illness, drug class, duration of therapy, setting of CAP acquisition and RoB.

ETHICS AND DISSEMINATION

The results will be of importance to general practitioners and internists managing CAP, and may directly inform international clinical guidance. Where concerns regarding antimicrobial resistance continue to grow internationally, this evidence summary may motivate new recommendations regarding shorter durations of therapy. We intend to disseminate our findings via national and international conferences, and publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021283990.

Learning Analytics Applied to Clinical Diagnostic Reasoning Using a Natural Language Processing-Based Virtual Patient Simulator: Case Study

BACKGROUND

Virtual patient simulators (VPSs) log all users' actions, thereby enabling the creation of a multidimensional representation of students' medical knowledge. This representation can be used to create metrics providing teachers with valuable learning information.

OBJECTIVE

The aim of this study is to describe the metrics we developed to analyze the clinical diagnostic reasoning of medical students, provide examples of their application, and preliminarily validate these metrics on a class of undergraduate medical students. The metrics are computed from the data obtained through a novel VPS embedding natural language processing techniques.

METHODS

A total of 2 clinical case simulations (tests) were created to test our metrics. During each simulation, the students' step-by-step actions were logged into the program database for offline analysis. The students' performance was divided into seven dimensions: the identification of relevant information in the given clinical scenario, history taking, physical examination, medical test ordering, diagnostic hypothesis setting, binary analysis fulfillment, and final diagnosis setting. Sensitivity (percentage of relevant information found) and precision (percentage of correct actions performed) metrics were computed for each issue and combined into a harmonic mean (F₁), thereby obtaining a single score evaluating the students' performance. The 7 metrics were further grouped to reflect the students' capability to collect and to analyze information to obtain an overall performance score. A methodological score was computed based on the discordance between the diagnostic pathway followed by students and the reference one previously defined by the teacher. In total, 25 students attending the fifth year of the School of Medicine at Humanitas University underwent test 1, which simulated a patient with dyspnea. Test 2 dealt with abdominal pain and was attended by 36 students on a different day. For validation, we assessed the Spearman rank correlation between the performance on these scores and the score obtained by each student in the hematology curricular examination.

RESULTS

The mean overall scores were consistent between test 1 (mean 0.59, SD 0.05) and test 2 (mean 0.54, SD 0.12). For each student, the overall performance was achieved through a different contribution in collecting and analyzing information. Methodological scores highlighted discordances between the reference diagnostic pattern previously set by the teacher and the one pursued by the student. No significant correlation was found between the VPS scores and hematology examination scores.

CONCLUSIONS

Different components of the students' diagnostic process may be disentangled and quantified by appropriate metrics applied to students' actions recorded while addressing a virtual case. Such an approach may help teachers provide students with individualized feedback aimed at filling competence drawbacks and methodological inconsistencies. There was no correlation between the hematology curricular examination score and any of the proposed scores as these scores address different aspects of students' medical knowledge.

Short vs long-course antibiotic therapy in pyelonephritis: a comparison of systematic reviews and guidelines for the SIMI choosing wisely campaign

BACKGROUND

The Italian Society of Internal Medicine (SIMI) Choosing Wisely Campaign has recently proposed, among its five items, to reduce the prescription of long-term intravenous antibiotics if not indicated. The aim of our study was to assess the available evidences on optimal duration of antibiotic treatment in pyelonephritis through a systematic review of secondary studies.

MATERIALS AND METHODS

We searched for all guidelines on pyelonephritis and systematic reviews assessing the optimal duration of antibiotic therapy in this type of infection. We compared the recommendations of the three most cited and recent guidelines on the topic of interest. We extracted data of non-duplicated RCT from the selected systematic reviews and performed meta-analyses for clinical and microbiological failure. A trial sequential analysis (TSA) was also achieved to identify the need for further evidence.

RESULTS

We identified 4 systematic reviews, including data from 10 non-duplicated RCTs (1536 patients). The meta-analysis showed a higher rate of clinical cure for short-course antibiotic treatment (RR for clinical failure 0.70, 95% CI [0.53-0.94]). No significant difference in the rate of microbiological failure (RR 1.06, 95% CI [0.75-1.49]) was observed. In terms of clinical cure, the TSA suggests that current evidence is sufficient to consider short course at least as effective as long-course treatment. Selected guidelines recommend considering shorter courses, but do not cite most of the published RCTs.

CONCLUSIONS

Short-course antibiotic treatment is at least as effective as longer courses for both microbiological and clinical success in the treatment of acute uncomplicated pyelonephritis.