ACP Issues Practice Advice for Short-Course Antibiotics for 4 Common Infections

The American College of Physicians (ACP) recently issued best practice advice for the appropriate use of short-course antibiotics in the treatment of 4 common infections.

The report, published in the Annals of Internal Medicine, was based on available evidence on acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTI) and cellulitis.

“Inappropriate use is becoming an important contributor to antibiotic resistance,” Amir Qaseem, MD, PhD, MHA, vice president of clinical policy and the Center for Evidence Reviews at ACP, told Contagion. “I think it’s an important issue that we all look at because out of 250 million courses of antibiotics in the U.S. right now, 30% are considered unnecessary and often are used for too long.”

He pointed out that the United States sees about 2.6 million antibiotic-resistant infections and nearly 36,000 death each year, costing around $30 billion.

“You can see how big of an impact the overuse of antibiotics has,” Qaseem said.

The report includes the following 4 guidelines for inpatient or outpatient settings:

Antibiotic treatment should be limited to 5 days for patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of bacterial infection.

Antibiotics should be prescribed for a minimum of 5 days for CAP with extension guided by measures of clinical stability.

Uncomplicated bacterial cystitis in women should be treated with short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 days, or a single dose of fosfomycin. Uncomplicated pyelonephritis should be treated with either fluoroquinolones for 5 to 7 days or TMP-SMZ for 14 days based on antibiotic susceptibility.

Nonpurulent cellulitis should be treated with a 5- to 6-day course of antibiotics active against streptococci.

The report includes detailed rationale behind each practice advice and notes that if a patient isn’t responding to treatment, physicians should reassess the illness rather than defaulting to longer antibiotic therapy.

Evidence and guidelines have been moving toward short-course antibiotics for several types of infections for which similar clinical outcomes and fewer drug-related adverse events have been reported. However, adherence to these recommendations has lagged, with many physicians defaulting to 10-day courses of antibiotics.

An update to the US Centers for Disease Control and Prevention antibiotic use guidelines in 2019 included data suggesting that many antibiotics were prescribed for durations longer than recommended.

A previous report in Contagion said some reasons for longer durations have included concerns that treatment failure is more likely with shorter courses and fears of resistance emerging after therapy, and physicians have commonly advised patients to take all of the antibiotics prescribed to them, even if they start to feel better. However, a growing body of evidence suggests that, in many cases, these fears are unfounded.

Antimicrobial stewardship programs have focused on reducing unnecessary prescriptions. This report looked at the role of duration.

“Overuse of antibiotics also includes unnecessarily long durations of antibiotic therapy in patients with bacterial infections,” Qaseem said. “So when you’re talking about too much antibiotic use, it’s not just the prescription, but if you’re prescribing it, if it’s being used beyond what is needed.”

Qaseem said the next steps are to continue spreading awareness about “the importance of prescribing the right antibiotic at the right dose for the right duration for the right condition” along with engaging a public panel to participate in the discussion.