Is 5 days of antibiotic therapy really sufficient for adults hospitalized with community-acquired pneumonia? PRACTICE CHANGER: Prescribe 5 days of antibiotic treatment for inpatients with community-acquired pneumonia because it produces the same clinical success rates as longer treatment regimens, but is associated with fewer negative patient outcomes

Castelli, Gregory

Jarrett, Jennie B.

University of Missouri: MOspace

629JFPONLINE.COM VOL 66, NO 10  |  OCTOBER 2017  |  THE JOURNAL OF FAMILY PRACTICEPriority Updates from the Research Literature from the Family Physicians Inquiries Network PURLs®Gregory Castelli,  PharmD; Jennie B. Jarrett, PharmD, BCPS, MMeEdUniversity of Pittsburgh Medical Center St.  Margaret, Pa (Dr. Castelli);  University of Illinois at Chicago (Dr. Jarrett) D E P U T Y  E D I T O RCorey Lyon, DOUniversity of Colorado Family Medicine Residency, Denver When to “CAP” off treatment  for pneumoniaIs 5 days of antibiotic therapy really sufficient for adults hospitalized with community-acquired pneumonia? PRACTICE CHANGERPrescribe 5 days of antibiotic treatment for inpatients with community-acquired pneu-monia because it produces the same clinical success rates as longer treatment regimens, but is associated with fewer negative patient outcomes.1 STRENGTH OF RECOMMENDATION B: Based on a single, good-quality random-ized control trial.Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016;176:1257-1265.1 ILLUSTRATIVE CASEA 65-year-old woman is admitted to your in-patient service from your family health center. She is diagnosed with community-acquired pneumonia (CAP) based on a 5-day history of cough and fever and a positive chest x-ray. She now requires oxygen at rest. She has a past medical history of hypertension and diabetes, both of which have been controlled on oral medications. Antibiotic therapy is initiated for the treatment of the pneumonia, but what treatment duration is ideal? The World Health Organization esti-mates that pneumonia is the third most common cause of mortal-ity worldwide, causing 3.2 million deaths per year.2 Appropriate prescribing of antibiotics is critical for the successful treatment of CAP. The Infectious Diseases Society of Amer-ica (IDSA) and the American Thoracic So-ciety (ATS) created consensus guidelines, published in 2007, for the treatment of CAP.3 These guidelines recommend a minimum 5-day course of antibiotics if the patient is clinically stable, which is defined as: afebrile for 48 hours, heart rate ≤100 beats/minute, respiratory rate ≤24 respirations/minute, systolic blood pressure ≥90 mm Hg, oxygen saturation ≥90%, normal mental status, and able to tolerate oral intake. Longer antibiotic treatment durations are recommended on an individualized basis, if, for example, the iso-lated pathogen is not susceptible to the initial antibiotic or if the infection was caused by an extrapulmonary source. However, these recommendations are not routinely followed. Practitioners often make it their custom to prescribe longer courses of antibiotics.4 And yet we know that there are several reasons to consider shorter courses of antibiotics, including lower health care costs, fewer adverse effects, and lower rates of bacterial resistance.5-7 ❚ Two meta-analyses were performed to compare the safety and efficacy of short- (≤7 days) vs long-course (>7 days) antibiotic therapy in CAP.8,9 Both meta-analyses found no difference in efficacy or safety between shorter and longer courses of antibiotic treat-ment regimens for CAP. Secondary outcomes noted a trend toward decreased antibiotic- associated adverse events with shorter courses of therapy.8,9 While these meta-analyses supported shorter courses of antibiotics for CAP, there are limitations to the broad implementa-tion of their findings. Studies included in these analyses utilized a variety of antibi-630 THE JOURNAL OF FAMILY PRACTICE  |   OCTOBER 2017  |   VOL 66, NO 10PURLs®otic treatment regimens and longer courses (7 days vs 5 days) that are not recommended by the IDSA/ATS guidelines. Additionally, studies included both inpatient and out-patient treatment groups, so findings may not apply to an exclusively inpatient CAP population.8,9 This study sought to validate the IDSA/ATS guidelines recommending a 5-day course of antibiotics for hospitalized patients with CAP.1STUDY SUMMARYNo differences in clinical outcomes  between 5 days of Tx—and longerThis multicenter, double-blind, noninferior-ity randomized trial compared short-term antibiotic treatment duration (5 days) to physician-discretion antibiotic treatment du-ration among 312 patients ≥18 years of age admitted for CAP to one of 4 teaching hospi-tals in Spain.1 Pneumonia was diagnosed on chest radiograph with at least one symptom: cough, fever, dyspnea, or chest pain. Patients were excluded if, among other things, they had an immunocompromising condition, lived in a nursing home, had a recent hospi-tal stay, used antibiotics within the previous 30 days, or had an uncommon pathogen, such as Pseudomonas aeruginosa or Staphy-lococcus aureus.1Patients were randomized after receiv-ing a minimum of 5 days of antibiotics to an intervention group (where, if clinically stable, no further antibiotics were given) or a con-trol group (where physicians determined an-tibiotic duration).1 Primary outcomes were clinical success rate at Days 10 and 30 from admission, defined as resolution of signs and symptoms of CAP without further antibiotics, and improvement of CAP-related symptoms as determined by an 18-item CAP symptom questionnaire. This questionnaire was scored 0 to 90, where higher scores indicated greater severity. Secondary outcomes included: du-ration of antibiotic use, time to clinical im-provement, mortality, hospital readmission, hospital length of stay, and CAP recurrence.1A total of 312 patients were random-ized with 162 patients in the interven-tion group and 150 patients in the control group. The mean age of patients in the in-tervention and control groups was 66.2 and 64.7 years, respectively. Other baseline de-mographics were similar between the groups. Nearly 80% of patients received quinolone treatment; <10% received a beta-lactam plus a macrolide.1Clinical success rates were similar for the control and intervention groups, respec-tively, at Day 10 (49% vs 56%; P=.18) and Day 30 (89% vs 92%; P=.33). There was shorter median treatment duration with antibiotics in the intervention group compared with the control group (5 days vs 10 days; P<.001) and fewer 30-day hospital readmissions (1.4% vs 6.6%; P=.02). There were no differences for other secondary outcomes.1WHAT’S NEWClinical support for 2007 guidelinesThis is the first study to clinically support the IDSA/ATS guidelines, which state that a 5-day course of antibiotic therapy for hospi-talized adults with CAP is effective and with-out increased risk of adverse events.CAVEATSGeneralizability to other meds and settings is unclearThis study focused on antibiotic duration for the treatment of CAP in hospitalized pa-tients and mainly used quinolone antibiot-ics. It remains unclear if duration of therapy is as effective in the outpatient setting or when using alternative antibiotic regimens. If patients continued to have symptoms (such as fever or low oxygen saturation on room air) after 5 days of antibiotic treatment, antibiotic treatment was continued in the study. Thus, patients in real life who continue to have symptoms may need individualized therapy and may require more than 5 days of antibiotics. CHALLENGES TO IMPLEMENTATIONAntibiotics end before clinical  improvement occursThis study noted an average of 12 days in both groups for patients to achieve clinical This is the first study to support the efficacy of the 5-day course of antibiotics for hospitalized CAP patients recommended by IDSA/ATS guidelines.improvement, with upwards of 15 to 18 days for patients to return to normal activity. Pa-tients and providers may be dissatisfied if the treatment course ends days before clinical improvement of symptoms. This may cause prescribers to lengthen the duration of anti-biotic therapy inappropriately.               JFPACKNOWLEDGEMENTThe PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsi-bility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.Copyright © 2017. The Family Physicians Inquiries Network. References  1.   Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treat-ment in community-acquired pneumonia: a multicenter ran-domized clinical trial. JAMA Intern Med. 2016;176:1257-1265.  2.   World Health Organization. The top 10 causes of death. Available at: http://www.who.int/mediacentre/factsheets/fs310/en/index.html. Accessed September 5, 2017. 3.   Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guide-lines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S27-S72.  4.   Aliberti S, Blasi F, Zanaboni AM, et al. Duration of antibiotic ther-apy in hospitalised patients with community-acquired pneumo-nia. Eur Respir J. 2010;36:128-134. 5.   Guillemot D, Carbon C, Balkau B, et al. Low dosage and long treatment duration of ß-lactam: risk factors for carriage of penicillin-resistant Streptococcus pneumoniae. JAMA. 1998;279: 365-370. 6.   Opmeer BC, el Moussaoui R, Bossuyt PM, et al. Costs associated with shorter duration of antibiotic therapy in hospitalized pa-tients with mild-to-moderate severe community-acquired pneu-monia. J Antimicrob Chemother. 2007;60:1131-1136. 7.   File TM Jr. Clinical efficacy of newer agents in short-duration therapy for community-acquired pneumonia. Clin Infect Dis. 2004;39(suppl 3):S159-S164. 8.   Li JZ, Winston LG, Moore DH, et al. Efficacy of short-course an-tibiotic regimens for community-acquired pneumonia: a meta-analysis. Am J Med. 2007;120:783-790. 9.   Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, et al. Short- versus long-course antibacterial therapy for commu-nity-acquired pneumonia: a meta-analysis. Drugs. 2008;68: 1841-1854.      INSTANT POLL How confident are you when it comes  to prescribing medications for obesity?Visit us @  jfponline.comONLINE EXCLUSIVES •   APPLIED EVIDENCE Effectively engaging patients in everyday  health-care decisions•   CASE REPORT Fever, rash, and leukopenia in a 32-year-old man • Dx?PHOTO ROUNDS FRIDAY  Test your diagnostic skills at www.jfponline.com/articles/photo-rounds-friday.htmlPLUS  Today’s headlines in family medicine    Statins for primary prevention  of CVD: To start or not to start? Doug Campos-Outcalt, MD, MPAGET UPDATES FROM US ONwww.facebook.com/JFamPract   http://twitter.com/JFamPract   http://bit.ly/JFP_GooglePlusFACEBOOK          TWITTER          GOOGLE+   How to protect your  patient—and yourself— when prescribing opioids Edwin A. Salsitz, MD3IN3 take-home points in 3 minutes (or less)3VIDEO631JFPONLINE.COM VOL 66, NO 10  |  OCTOBER 2017  |  THE JOURNAL OF FAMILY PRACTICEVISIT US ONLINE  @JFPONLINE.COM

When to "CAP" off treatment for pneumonia

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When to "CAP" off treatment for pneumonia

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