ACP Releases Practice Advice for Short-Course Antibiotics in Common Infections

A Scientific Medical Policy Committee convened by the American College of Physicians (ACP) has published best-practice advice for the appropriate use of short-course antibiotics in the management of common infections, including acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTIs), and cellulitis. The 4 evidence-based best-practice advice statements were outlined in the Annals of Internal Medicine.¹

Antibiotics in COPD Exacerbations and Acute Uncomplicated Bronchitis

The ACP recommends limiting the duration of antibiotic treatment to 5 days when used to manage patients with COPD exacerbations. According to the ACP panel, this advice also applies to patients with acute uncomplicated bronchitis who show signs of bacterial infection. Previous recommendations made by the ACP have been against initiating antibiotics in patients with bronchitis unless the clinician suspects pneumonia. Although antibiotics are generally recommended for patients with COPD, they should be used only if there is a high pretest probability that bacterial infection is the cause.

The duration of antibiotic use in these patients as recommended by the ACP is based on a meta-analysis of 21 randomized controlled trials that found a short course of antibiotics in chronic bronchitis and COPD acute exacerbations was no different than long-term antibiotic treatment in terms of clinical improvement.

In the best-practice statement, the ACP notes that clinicians should choose an antibiotic based on effective treatment for the most commonly reported bacterial pathogens, including Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Such antibiotics may include aminopenicillin with clavulanic acid, a macrolide, or a tetracycline.

Antibiotics in Community-Acquired Pneumonia

Similar to its recommendation for antibiotic use in bronchitis and COPD, the ACP recommends that clinicians prescribe antibiotics for CAP but sets the duration of therapy at a minimum of 5 days. The use of validated measures of clinical stability should guide therapy extension after the initial 5 days. These validated measures of clinical stability could include the resolution of vital sign abnormalities, normal mentation, and improved ability to eat.

The CAP recommendation was based on current evidence from meta-analyses and randomized controlled trials that support shorter-duration antibiotics in CAP. In addition, the ACP best-practice statement largely reflects recommendations made in the 2019 Infectious Diseases Society of America (IDSA)/American Thoracic Society guideline for the treatment of CAP.

Uncomplicated Bacterial Cystitis and Pyelonephritis

For UTIs, the ACP suggests that empirical antibiotics should be used to target Escherichia coli, which accounts for more than 75% of all cases of bacterial cystitis. The ACP panel recommends prescribing short-course antibiotics for women with uncomplicated bacterial cystitis. Specifically, the panel recommends prescribing nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 days, or single-dose fosfomycin.

Guidance from the Infectious Diseases Society of America/European Society of Clinical Microbiology and Infectious Diseases (IDSA/ESCMID) provides further recommendations for treatment duration depending on the antibiotic type. For instance, the IDSA/ESCMID guidelines recommend 5 days of nitrofurantoin, 3 days of TMP-SMX, or a single dose of fosfomycin.

As such, these recommendations were integrated into the ACP best-practice statements. While fluoroquinolones may be highly effective when given for 3 days, the ACP panel recommends against prescribing this treatment empirically, given its toxicity profile. Instead, the ACP suggests fluoroquinolones should be given only to patients with a history of resistant organisms.

In addition, the ACP recommends that clinicians prescribe short-course antibiotic therapy for men and women with uncomplicated pyelonephritis. The best-practice statement recommends using fluoroquinolones for 5 to 7 days or TMP-SMZ for 14 days in patients with uncomplicated pyelonephritis based on antibiotic susceptibility.

For pyelonephritis, the ACP states that “TMP-SMX should not be used alone as an empirical therapy without culture and susceptibility testing in pyelonephritis,” due primarily to concerns regarding the risk of resistance and treatment failure.

Nonpurulent Cellulitis

The ACP best-practice advice recommends the use of a 5- to 6-day course of antibiotics against streptococci in patients with nonpurulent cellulitis. The panel specifically states that this antibiotic regimen should be prescribed for patients who have the ability to self-monitor and can have a close follow-up appointment with a primary care physician.

This best-practice advice statement was based on randomized controlled trials as well as guideline recommendations from the IDSA. In 2014, the IDSA guideline recommended antibiotics for uncomplicated cellulitis but stated that clinicians should consider extending the therapy if an infection does not improve after the initial 5-day treatment period. The more recent DANCE (Duration of Antibiotic Therapy for Cellulitis; ClinicalTrials.gov Identifier: NCT02032654) trial found no difference between a 6- vs 12-day course of a penicillin (flucloxacillin) in terms of cure rates.

Limitations

The ACP best-practice advice can be applied to most patients, but the panel wrote that the advice may not be applicable to patients who are immunocompromised, pregnant, or have complicated infections due to other causes, complicated anatomy, or recent resistant bacterial infection history. “If there is not appropriate improvement,” the authors stated in a summary of the advice, “the clinician should reassess for other causes of the patient’s symptoms.”²

References

1. Lee RA, Centor RM, Humphrey LL, Jokela JA, Andrews R, Qaseem A. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Published online April 6, 2021. Ann Intern Med. doi:10.7326/M20-7355
2. Lee RA, Centor RM, Humphrey LL, Jokela JA, Andrews R, Qaseem A. Summary for patients: appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Published online April 6, 2021. Ann Intern Med. 2021;10.7326/P21-0003. doi:10.7326/P21-0003