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Science Daily are reporting: Are Antibiotics Being Used For Too Long?
Taking antibiotics for three days is just as effective for community acquired pneumonia as continuing treatment for the recommended 7-10 days, finds a study in this week's British Medical Journal. Shorter treatment can also help contain growing resistance rates.
The study raises questions about the optimal duration of antibiotic therapy for common infections.
Community acquired pneumonia is one of the most important indications for antibiotic prescriptions in hospitals. But a lack of evidence to support short course therapy means it has become accepted practice to continue treatment for days after symptoms have improved.
Researchers in the Netherlands compared the effectiveness of discontinuing treatment with amoxicillin after three days or eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia.
119 patients who substantially improved after the conventional three days' treatment with intravenous amoxicillin were randomly assigned to oral amoxicillin (63 patients) or placebo (56 patients) three times daily for five days. Patients were assessed at days 7, 10 (two days after treatment ended), 14, and 28.
In the three day and eight day treatment groups, the clinical success rate at day 10 was 93% for both, and at day 28 was 90% compared with 88%. Both groups had similar resolution of symptoms, x-ray results, and length of hospital stay.
These findings show that discontinuing amoxicillin treatment after three days is not inferior to discontinuing it after eight days in adults with mild to moderate-severe community acquired pneumonia who have substantially improved after an initial three days' treatment, say the authors.
A shorter duration of treatment can also help to reduce overall antibiotic consumption and resistance rates for respiratory infections, they conclude.
This study suggests that current guidelines recommending 7-10 days should be revised, says Dr John Paul from the Royal Sussex County Hospital, in an accompanying commentary.
Not only does the study yield strong evidence in favour of short course therapy for a subset of patients with community acquired pneumonia, but also shows how centres can cooperate to tackle longstanding areas of uncertainty in clinical microbiology and infectious diseases, he writes. Many other common clinical situations would repay the efforts of comparable approaches.
Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study BMJ 2006;332:1355 (10 June),
Objective To compare the effectiveness of discontinuing treatment with amoxicillin after three days or eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia who substantially improved after an initial three days' treatment.
Setting Nine secondary and tertiary care hospitals in the Netherlands.
Participants Adults with mild to moderate-severe community acquired pneumonia (pneumonia severity index score 110).
Interventions Patients who had substantially improved after three days' treatment with intravenous amoxicillin were randomly assigned to oral amoxicillin (n = 63) or placebo (n = 56) three times daily for five days.
Main outcome measures The primary outcome measure was the clinical success rate at day 10. Secondary outcome measures were the clinical success rate at day 28, symptom resolution, radiological success rates at days 10 and 28, and adverse events.
Results Baseline characteristics were comparable, with the exception of symptom severity, which was worse in the three day treatment group. In the three day and eight day treatment groups the clinical success rate at day 10 was 93% for both (difference 0.1%, 95% confidence interval - 9% to 10%) and at day 28 was 90% compared with 88% (difference 2.0%, - 9% to 15%). Both groups had similar resolution of symptoms. Radiological success rates were 86% compared with 83% at day 10 (difference 3%, - 10% to 16%) and 86% compared with 79% at day 28 (difference 6%, - 7% to 20%). Six patients (11%) in the placebo group and 13 patients (21%) in the active treatment group reported adverse events (P = 0.1).
Conclusions Discontinuing amoxicillin treatment after three days is not inferior to discontinuing it after eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia who substantially improved after an initial three days' treatment.
I am not surprised regarding the results of this study, but would urge all to interpret this information cautiously and not extrapolate to podiatric usage. First, over 90% of foot infections are caused by Staph, and most of these are penicillinase producing strains, which means that this study, using Amox, was not targeting relevant bugs. Secondly, Skin and related soft tissue infections of the lower extremity occur in a (relatively) less vascularized part of the body, which means that either differing doses or longer duration of therapy is necessary when treating infection. Finally, given the increasing prevalence of resistant staph, causing an upswing in the need for newer fantastically expensive drugs, we should aim to be effective, full stop. The difference between 7 and 10 days may be academic, but to go to even fewer days risks failure and of course, this puts one at risk from a medical-legal perspective as well. Cheers.