Antibiotic Treatment of Common Infections

More Evidence to Support Shorter Durations

Benjamin J. Smith; George Heriot; Kirsty Buising


Curr Opin Infect Dis. 2020;33(6):433-440. 

In This Article

Respiratory Tract Infection

Over the last 20 years, there has been a significant shift in recommendations for treatment of community-acquired pneumonia (CAP) with increasing evidence that therapy can be truncated with no difference in outcomes.[16,17] Randomized controlled trials have demonstrated noninferiority of a range of shortened antibiotic regimens including five versus 10 days of ceftriaxone, seven versus 10 days of cefuroxime and five versus 10 days of levofloxacin.[18–20] A metaanalysis of patients with community-acquired pneumonia treated with less than seven days compared with longer durations found no differences in rates of clinical failure or mortality.[21] A multicentre RCT from the Netherlands found that patients with mild–moderate community-acquired pneumonia with early signs of improvement may be treated with even shorter courses.[22] This approach of using a minimum of five days antibiotic therapy with cessation guided by the resolution of vital sign abnormalities has been recently validated in a Spanish RCT which found a significant reduction in treatment duration (median five versus 10 days) without an increase the rate of adverse outcomes.[23]

Evidence now supports similar shifts toward short-course therapy for hospital-acquired and ventilator-associated pneumonia with a metaanalysis including over 1000 patients demonstrating that short courses (7–8 days) are as effective as longer courses (10–15 days).[24] Some experts have advised that short-course therapy be used cautiously in patients with infection due to nonfermenting gram-negative bacilli (such as P. aeruginosa) because of a possible increased risk of infection relapse.[25]

Although the overall benefits of antibiotic therapy in the treatment of tonsillopharyngitis may be modest,[26] treatment is advised for individuals with severe disease or risk factors for nonsuppurative complications.[17] A recent RCT has provided some evidence that in severe tonsillopharyngitis caused by group A streptococcus a five-day course of penicillin V can be as effective as the traditional 10-day course.[27]

Acute otitis media is uncommon in adults and therefore treatment recommendations are largely extrapolated from studies in children. In a majority of cases, antibiotic therapy does not significantly alter outcomes or improve symptomatic relief and can be safely withheld.[28] If there are indications for antibiotic therapy, such as systemic features or immunocompromise, then five days is recommended.[29] A similar management approach can be used for acute, uncomplicated sinusitis.