Short-Course Antimicrobial Therapy for Community-Acquired Pneumonia

Short-course versus long-course therapy of the same antibiotic for community-acquired pneumonia in adolescent and adult outpatients

BACKGROUND

Community-acquired pneumonia (CAP) is a lung infection that can be acquired during day-to-day activities in the community (not while receiving care in a hospital). Community-acquired pneumonia poses a significant public health burden in terms of mortality, morbidity, and costs. Shorter antibiotic courses for CAP may limit treatment costs and adverse effects, but the optimal duration of antibiotic treatment is uncertain.

OBJECTIVES

To evaluate the efficacy and safety of short-course versus longer-course treatment with the same antibiotic at the same daily dosage for CAP in non-hospitalised adolescents and adults (outpatients). We planned to investigate non-inferiority of short-course versus longer-term course treatment for efficacy outcomes, and superiority of short-course treatment for safety outcomes.

SEARCH METHODS

We searched CENTRAL, which contains the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE, Embase, five other databases, and three trials registers on 28 September 2017 together with conference proceedings, reference checking, and contact with experts and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing short- and long-courses of the same antibiotic for CAP in adolescent and adult outpatients.

DATA COLLECTION AND ANALYSIS

We planned to use standard Cochrane methods.

MAIN RESULTS

Our searches identified 5260 records. We did not identify any RCTs that compared short- and longer-courses of the same antibiotic for the treatment of adolescents and adult outpatients with CAP.We excluded two RCTs that compared short courses (five compared to seven days) of the same antibiotic at the same daily dose because they evaluated antibiotics (gemifloxacin and telithromycin) not commonly used in practice for the treatment of CAP. In particular, gemifloxacin is no longer approved for the treatment of mild-to-moderate CAP due to its questionable risk-benefit balance, and reported adverse effects. Moreover, the safety profile of telithromycin is also cause for concern.We found one ongoing study that we will assess for inclusion in future updates of the review.

AUTHORS' CONCLUSIONS

We found no eligible RCTs that studied a short-course of antibiotic compared to a longer-course (with the same antibiotic at the same daily dosage) for CAP in adolescent and adult outpatients. The effects of antibiotic therapy duration for CAP in adolescent and adult outpatients remains unclear.

Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis

PURPOSE

There is little consensus on the most appropriate duration of antibiotic treatment for community-acquired pneumonia. The goal of this study is to systematically review randomized controlled trials comparing short-course and extended-course antibiotic regimens for community-acquired pneumonia.

METHODS

We searched MEDLINE, Embase, and CENTRAL, and reviewed reference lists from 1980 through June 2006. Studies were included if they were randomized controlled trials that compared short-course (7 days or less) versus extended-course (>7 days) antibiotic monotherapy for community-acquired pneumonia in adults. The primary outcome measure was failure to achieve clinical improvement.

RESULTS

We found 15 randomized controlled trials matching our inclusion and exclusion criteria comprising 2796 total subjects. Short-course regimens primarily studied the use of azithromycin (n=10), but trials examining beta-lactams (n=2), fluoroquinolones (n=2), and ketolides (n=1) were found as well. Of the extended-course regimens, 3 studies utilized the same antibiotic, whereas 9 involved an antibiotic of the same class. Overall, there was no difference in the risk of clinical failure between the short-course and extended-course regimens (0.89, 95% confidence interval [CI], 0.78-1.02). In addition, there were no differences in the risk of mortality (0.81, 95% CI, 0.46-1.43) or bacteriologic eradication (1.11, 95% CI, 0.76-1.62). In subgroup analyses, there was a trend toward favorable clinical efficacy for the short-course regimens in all antibiotic classes (range of relative risk, 0.88-0.94).

CONCLUSIONS

The available studies suggest that adults with mild to moderate community-acquired pneumonia can be safely and effectively treated with an antibiotic regimen of 7 days or less. Reduction in patient exposure to antibiotics may limit the increasing rates of antimicrobial drug resistance, decrease cost, and improve patient adherence and tolerability.

How long should we treat community-acquired pneumonia?

PURPOSE OF REVIEW

The studies reviewed in this article suggest that a shorter duration of antibiotic therapy is comparable to standard therapy in the treatment of community-acquired pneumonia and promotes reduction of adverse events, microbial resistance, cost, and improved patient compliance.

RECENT FINDINGS

Community-acquired pneumonia has traditionally been treated with a 7-14-day course of antimicrobial therapy. Since there have been few well controlled trials regarding the optimal duration of therapy, however, there has been no consensus on length of therapy among different organizational guidelines. Several recent studies have demonstrated that shorter course antibiotic regimens are effective in the treatment of community-acquired pneumonia.

SUMMARY

Short-course antibiotic therapy is equivalent to standard length of therapy for clinical cure and bacterial eradication. Minimization of drug exposure, however, reduces selection pressure for resistant strains, strengthens patient compliance, and potentially reduces adverse events such as Clostridium difficile infections.