Guidelines Advise Shorter Antibiotic Course for Pneumonia

Tara Haelle

July 15, 2016

In an attempt to balance responsible stewardship of antibiotics with safe, effective treatment of specific hospital-associated infections, new guidelines recommend an antibiotic course lasting 7 days or less for treatment of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), two categories that replace the previous inclusive category of healthcare-associated pneumonia.

The new guidelines, issued by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society, also recommend that each hospital develop an antibiogram: a local analysis of the bacterial strains causing pneumonia with a focus on infections in the intensive care unit, along with the antibiotics that successfully treat those bacterial infections.

"Once clinicians are updated regularly on what bugs are causing VAP and HAP in their hospitals as well as their sensitivities to specific antibiotics, they can choose the most effective treatment," lead author Andre C. Kalil, MD, MPH, from the University of Nebraska Medical Center in Omaha, said in an IDSA news release. These antibiograms help "individualize care, ensuring patients will be treated with the correct antibiotic as soon as possible," Dr Kalil said in his statement.

The new recommendations were published online July 14 in Clinical Infectious Diseases, and replace the previous set published in 2005.

Multidisciplinary Effort

Dr Kalil led a multidisciplinary panel that developed the guidelines in an attempt to limit the development of antibiotic resistance without compromising patient safety, relying on evidence from recent systematic reviews and meta-analyses. "The findings do not lead to any specific recommendations, rather they provided guidance for the panelists for several of the treatment recommendations," the authors write.

Together, HAP and VAP account for 20% to 25% of hospital-acquired infections, and an estimated 10% to 15% of these cases result in death. When viewed separately, Dr Kalil and colleagues note that approximately one in 10 patients on mechanical ventilators develop VAP, and 13% of the infections are fatal.

Yet research has not shown that longer courses of antibiotics have any greater benefit than shorter courses. Longer courses are, however, associated with more adverse effects such as diarrhea, a greater risk for Clostridium difficile, increased medical costs, and increased risk for antibiotic resistance.

The authors therefore recommend a 7-day course of antibiotic treatment for VAP and HAP, but they acknowledge that "[t]here exist situations in which a shorter or longer duration of antibiotics may be indicated, depending upon the rate of improvement of clinical, radiologic, and laboratory parameters." They also recommend de-escalating antimicrobial therapy, using narrow-spectrum antibiotics instead of broad-spectrum ones, and starting with monotherapy instead of combination therapy.

The organizations also "suggest using [procalcitonin] levels plus clinical criteria to guide the discontinuation of antibiotic therapy, rather than clinical criteria alone," in patients with HAP or VAP, although the authors note that the recommendation is based on relatively low quality evidence.

Other recommendations focus on using noninvasive methods to diagnose VAP, relying exclusively on clinical criteria to determine whether to begin antibiotic treatment, and empiric treatment options for specific clinical circumstances. Most of these recommendations, however, also rely on low-quality evidence.

In developing antibiograms, the authors recommend that each institution also determine how often they should be updated. "Considerations should include their rate of change, resources, and the amount of data available for analysis," the authors write.

The guidelines do include specific recommendations for initial empiric antibiotic therapy based on whether the infection is VAP or HAP, risk for methicillin-resistant Staphylococcus aureus, risk for mortality, and presence of gram-positive or gram-negative antibiotics, among other clinical considerations.

"In patients with suspected VAP, we recommend including coverage for S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens," the authors write. "For patients being treated empirically for HAP, we recommend prescribing an antibiotic with activity against S. aureus."

The guidelines were developed with financial support for conference calls, meeting space, and administrative support from the IDSA and the American Thoracic Society. No industry funding was used in developing these guidelines. Seven coauthors report receiving research grants or advisory or consultancy fees from one or more of the following: Allergan, Melinta, Merck, MotifBio, Nabriva, Tetraphase, Sensor Kenesis Group, Pfizer, Cempra, Biofire Diagnostics, Aradigm, Gilead; Bayer, Astellas, Roche, Angellini, Novartis, Nektar Therapeutics, and Infectopharm.

Clin Infect Dis. Published online July 14, 2016. Full text

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