ACP Guidance on Antibiotic Use: 4 Conditions Ideal for Short-course Treatment
Longer antibiotic treatment courses can often be safely and effectively shortened, according to the ACP guidance; 4 common conditions serve as examples.
The American College of Physicians on April 5, 2021 published a guidance titled, "Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of Physicians."
The Scientific Medical Policy Committee of the ACP reviewed 38 articles consisting of published clinical guidelines, systematic reviews, and individual studies addressing bronchitis with COPD exacerbations, community acquired pneumonia, urinary tract infections, and cellulitis.
The resulting recommendations, the authors point out, are not based on a formal systematic review but rather on the "best available evidence" Guidance was prioritized to the highest available level of synthesized evidence.
The following slides offer the 4 specific Best Practice Advice statements from ACP and short notes from the guidance on each.
Rationale for ACP Antibiotic Guidance. Of 250 million antibiotic courses prescribed in 2014, at least 30% were considered unnecessary and often the courses were too long. ACP and the Centers for Disease Control and Prevention recognize antibiotic-resistant infections as a “national threat.”
ACP Definition of Appropriate Antibiotic Use. Prescribing the right antibiotic, at the right dose, for the right duration, for a specific condition.
Purpose of ACP Antibiotic Guidance. The purpose of this best practice advice is to describe appropriate use of shorter durations of antibiotic therapy for common bacterial infections seen in both inpatient and outpatient health care settings
Best Practice Advice #1: COPD Exacerbation and Acute Uncomplicated Bronchitis. Clinicians should limit antibiotic treatment duration to 5 days when managing patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection (presence of increased sputum purulence in addition to increased dyspnea, and/or increased
sputum volume).
1. COPD Exacerbation and Acute Uncomplicated Bronchitis. Acute uncomplicated bronchitis: typically self-limited, viral; ACP recommends against antibiotics unless pneumonia is present. COPD: antibiotics recommended given high pretest probability of bacterial cause. The Global Strategy for Prevention, Diagnosis and Management of COPD (GOLD) guidelines recommend antibiotics in presence of clinical signs of bacterial infection; base choice on most common pathogens.
COPD Exacerbation, Treatment. Most commonly-reported bacterial pathogens: Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Treatment may include an aminopenicillin with clavulanic acid, a macrolide, or a tetracycline.
ACP Best Practice Advice #2: Community Acquired Pneumonia. Clinicians should prescribe antibiotics for community-acquired pneumonia (CAP) for a minimum of 5 days. Extension of therapy after 5 days of antibiotics should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation.
2. Community Acquired Pneumonia. Pneumonia in nonimmunocompromised patients presenting with fever, productive cough with purulent sputum, dyspnea, pleuritic chest pain. Empirical therapy should cover common pathogens, eg, S pneumoniae, H influenzae, Mycoplasma pneumoniae, Staphylococcus aureus, and atypical pathogens, eg, Legionella species,
2. Community Acquired Pneumonia: Evidence supports shorter-duration antibiotic therapy. The 2019 Infectious Disease Society of American (IDSA)/American Thoracic Society (ATS) guideline for the treatment of CAP recommends minimum 5 d antibiotics.
ACP Best Practice Advice #3. UTI: Uncomplicated Cystitis and Pyelonephritis. In women with uncomplicated bacterial cystitis, clinicians should prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim–sulfamethoxazole (TMP–SMZ) for 3 days, or fosfomycin as a single dose. In men and women with uncomplicated pyelonephritis, clinicians should prescribe short-course therapy either with fluoroquinolones (5 to 7 d) or TMP–SMZ (14 d) based on antibiotic susceptibility.
3. UTI Uncomplicated Cystitis. Infectious cystitis common reason for antibiotic use in healthy women. Escherichia coli accounts for >75% of all bacterial cystitis; use empirical antibiotics to target. Note: Fluoroquinolones are very effective in 3-d regimens but carry high risk of adverse effects; do not prescribe empirically; reserve for patients with hx of resistant organisms.
3. UTI: Pyelonephritis. Current length of treatment recommendation is based on IDSA/European Society of Clinical Microbiology and Infectious Diseases (ESCMID) 2011 guidelines. More recent data on shorter-course therapy found no significant difference in clinical failure with fluoroquinolones.
ACP Best Practice Advice #4: Cellulitis. In patients with nonpurulent cellulitis, clinicians should use a 5- to 6-day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care.
4. Cellulitis: Treatment recommendations: cephalosporin, penicillin, or clindamycin, except: when cellulitis is associated with penetrating trauma; in patients with evidence of MRSA elsewhere, MRSA nasal colonization, injection drug use, systemic inflammatory response syndrome. Include another antimicrobial effective against both MRSA and streptococci.
