ACP Recommends Shorter Antibiotic Courses for Common Infections
By Laura Freeman
New guidelines, developed with the help of UAB physicians, that recommend shorter courses of antibiotics for four common infections are being welcomed by clinicians across Alabama and the U.S.
"This gives us clear, concise best-practice advice we can use in treating conditions that require antibiotics, namely COPD exacerbations with bronchitis, community acquired pneumonia, urinary tract infections and cellulitis," Lauren Pacheco, MD, internal medicine specialist and faculty member at Princeton Baptist Medical Center, said. "When I was in training, and more recently in talking with the physicians I'm helping to train, there has been a lot of discussion about shorter duration antibiotic treatment. We want to be good stewards of antibiotics to avoid resistance, as well as to minimize the effects on the patient's microbiome. The new guidelines will help us achieve those goals."
UAB infectious disease specialist Rachel Lee, MD, is first author on the guidelines. "I was working on cases with the paper's senior author, Robert Centor, MD, who is professor emeritus in the UAB Department of Medicine," Lee said. "We were discussing the effectiveness of shorter duration antibiotic treatment and the need for updating guidelines so physicians would have the information to confidently make decisions about when to prescribe a shorter course.
"Dr. Centor is a member of the American College of Physician's Scientific Medical Policy Committee. He brought up the issue before the committee while I started gathering data. It took just over a year of compiling data, writing, reviews in the committee's quarterly meetings and peer review."
The recently released guidelines recommend starting with a five-day course for acute bronchitis with COPD, and community acquired pneumonia. In cellulitis, five to six days of treatment against streptococci are suggested. Recommendations for urinary tract infections vary based on the specific medication prescribed. Treatment can range from a single dose to three to five days, or as much as 14 days for particular medications and circumstances. Specific guidelines are posted on the American College of Physicians website under best practices advice.
There are estimates that at least 30 percent of the antibiotics prescribed are unnecessary and often continued too long.
"We see an average of 791 antibiotic prescriptions per 1,000 people annually in the US. In Alabama that number is 1,158 antibiotic prescriptions per 1,000 people," Lee said. "We need to look at how we're using antibiotics and make sure we're prescribing the right antibiotic for the right infection and the right number of days.
"In the past, there was a tendency to prescribe a longer course of antibiotics to be sure of eliminating any lingering bacteria that might become resistant. However, more recent studies suggest that longer duration can play a role in driving resistance. I also read a paper pointing out how having a seven-day week seems to influence the timing in many of our treatments. Instead of having the calendar govern how we prescribe, it makes more sense to base treatment on how the bacterium behaves and how our patient's bodies respond.
"That requires follow-up. We need to instruct patients carefully on when they need to check back with us, and make it easy for them to contact us--or set up a system to check back with them to see how they are responding to the antibiotic.
"If the infection isn't resolving as expected, we need to look into why. Could there be an underlying fungal infection we need to treat so the antibiotic can be more effective against the cellulitis? Do we need to do more testing to verify that it is bacteria and we've identified the right kind and prescribed accordingly?"
The CDC has identified antibiotic resistance as a serious threat to the health of the United States.
"So far, we've been able to come up with alternatives and the good news is that there are more new antibiotics in the pipelines than there were a few years ago," Pacheco said "However, when we run into resistance, we may have to bring out the big guns. That could mean in-patient IVs and possibly a greater risk of side effects.
"Every city has its own resistant bacteria profile, and so does every hospital. If you're dealing with an infection that isn't responding as it should, you might want to check it against the strains known to be in the area."
The best antibiotic is prevention.
"We learned a lot about infection control during the pandemic and in dealing with MRSA," Pacheco said. "When infections happen, especially when they happen repeatedly or in a care setting, we need to track down the source. We should also be mindful of how we might be able to reduce risk as a patient's condition improves. Does the patient still need a catheter? Is it time to move from a central line to IV?"
Guidelines for other conditions frequently requiring antibiotics are likely to be updated in the future. On the horizon, Dr. Lee is interested in working on a new project comparing the effectiveness of oral and injectable antibiotics against bacterial infections.