Appropriate Use of Short-Course Antibiotics in Common Infections

Best Practice Advice from the American College of Physicians

The American College of Physicians (ACP) and the Centers for Disease Control and Prevention have recognized antibiotic-resistant infections as a global threat. Antimicrobial overuse, particularly with broad-spectrum antibiotics, drives resistance and causes adverse events in up to 20% of patients, ranging from allergic reactions to Clostridioides difficile infections.

In a Best Practice Advice document issued by the American College of Physicians and published online in the Annals of Internal Medicine, recommendations are presented for prescribing appropriate and short-duration antibiotic therapy for patients with common bacterial infections.

Clinicians play a key role in reducing the antimicrobial resistance. Best Practice Advice defines appropriate antibiotic use as prescribing the right antibiotic at the right dose for the right duration for a specific condition.

For several types of infections, studies and meta-analyses have shown that compared with longer courses of antibiotics, shorter courses show similar clinical outcomes with fewer drug-related adverse events.

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The researchers recommend limiting antibiotic treatment duration to 5 days when managing patients with chronic obstructive pulmonary disease (COPD) exacerbations and acute uncomplicated bronchitis who have clinical signs of bacterial infection.

For community-acquired pneumonia (CAP), clinicians should prescribe antibiotics for a minimum of 5 days.

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 women with uncomplicated bacterial cystitis.

Short-course therapy 5 to 14 days with fluoroquinolones or TMP-SMZ based on antibiotic susceptibility is recommended for women and men with uncomplicated pyelonephritis.

A 5-6 days course of antibiotics active against streptococci is recommended for patients with nonpurulent cellulitis.

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 to reduce growing antibiotic resistance.

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Abstract

Description: Antimicrobial overuse is a major health care issue that contributes to antibiotic resistance. Such overuse includes unnecessarily long durations of antibiotic therapy in patients with common bacterial infections, such as acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTIs), and cellulitis. This article describes best practices for prescribing appropriate and short-duration antibiotic therapy for patients presenting with these infections.

Methods: The authors conducted a narrative literature review of published clinical guidelines, systematic reviews, and individual studies that addressed bronchitis with COPD exacerbations, CAP, UTIs, and cellulitis. This article is based on the best available evidence but was not a formal systematic review. Guidance was prioritized to the highest available level of synthesized evidence.

Best practice advice 1: 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).

Best practice advice 2: Clinicians should prescribe antibiotics for community-acquired pneumonia 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.

Best practice advice 3: 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 days) or TMP-SMZ (14 days) based on antibiotic susceptibility.

Best practice advice 4: 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.