Originally published by our sister publication Pharmacy Practice News
For many common infectious diseases in both adult and pediatric populations, a significant body of evidence now shows that short-course antimicrobials are just as effective as long courses.
However, changing decades of practice can be challenging, acknowledged presenters at the ACCP 2024 Annual Meeting, in Phoenix. So, how can prescribing practices be moved toward shorter courses?
“Historically, most of our durations of antimicrobial therapy were in reality somewhat ‘made up,’ in the sense of whatever is convenient,” said Christopher Bland, PharmD, the Albert W. Jowdy Professor in Pharmacy Care at the University of Georgia College of Pharmacy, in Athens. “A week is seven days, so let’s choose that. If one week is good, two weeks must be better. For years, these were fairly arbitrary numbers, with 10 days considered a middle ground.”
In the case of gram-negative bloodstream infections, “we always used to treat for a full two weeks,” Dr. Bland added. “But with significant antimicrobial resistance, we began to question these durations, since every day of antibiotics a patient receives increases their risk of a side effect, including a new infection like C. difficile [Clostridioides difficile] colitis.”
As for which infections warrant a shorter duration of therapy, “for infections such as community-acquired pneumonia [CAP], urinary tract infections [UTIs] or intraabdominal infections, we can get therapy duration down to between three and five days in many cases.” For example, the 2017 Surgical Infections Society guidelines recommend four days of antibiotic therapy after source control for complicated intraabdominal infections (Surg Infect [Larchmt] 2017;18[1]:1-76). (Source control encompasses all measures, including debridement and drainage, used to control a focus of invasive infection and to restore the optimal function of the affected area.)
“Even for some gram-negative bloodstream infections such as E. coli [Escherichia coli], we’ve gotten that down to essentially one week, as long as there is good source control,” Dr. Bland added (Clin Infect Dis 2019;69[7]:1091-1098).
The same is true of many pediatric infections, noted Holly Maples, PharmD, a professor and the Jeff and Kathy Lewis Sanders Distinguished Chair in Pediatric Pharmacy at the University of Arkansas for Medical Sciences College of Pharmacy, in Little Rock. “The literature confirms that we do not need to utilize as many days of treatment in common pediatric infections, like strep throat, ear infections, UTIs, CAP, and skin and soft tissue infections. As long as we are getting the right drug started at the right dose, we have evidence in [multiple] indications supporting five days of treatment. That’s pretty exciting.”
For example, Dr. Maples noted, the SCOUT-CAP trial, comparing five with 10 days of antibiotics in children with CAP, found that the five-day approach achieved similar clinical response and antibiotic-associated adverse effects while reducing antibiotic exposure and resistance (JAMA Pediatr 2022;176[3]:253-261). Although the SCOUT trial in pediatric UTIs found a slightly higher rate of treatment failure in short-course therapy (4.2% vs. 0.6%), the investigators concluded that the overall low failure rate suggests it is a reasonable treatment option (JAMA Pediatr 2023;177[8]:782-789).
Longer Isn’t Always Worse
There are still some circumstances in which longer courses of antibiotics are necessary, the presenters agreed. “With complicated MRSA [methicillin-resistant Staphylococcus aureus] infections, of course, those often are going to be treated for a longer time, four to six weeks in many cases,” Dr. Bland said. “And you always have to be cautious with prosthetic joint infections because source control is very difficult.”
In children, harder-to-reach infections such as meningitis, or bone infections such as osteomyelitis, are examples of situations that still require a longer course of antimicrobial therapy. “That said, we do have evidence in osteomyelitis that we don’t have to use IV antibiotics for as long as we have in the past, and instead can convert kids over from IV to oral medications, which places them at less risk for additional infections from having an IV line in place,” Dr. Maples noted (N Engl J Med 2019;380[5]:425-436).
Although the evidence for short-course antimicrobial therapy in so many disease states, for both adult and pediatric populations, has been accumulating, many prescribers are still defaulting to the longer courses, Dr. Bland said. “We need to make it practical for clinicians to make this switch,” he said. “One important factor is pharmacist involvement at time of hospital discharge. Many patients are prescribed significantly longer courses of antibiotics at discharge versus those patients who receive all antibiotic therapy while hospitalized. Having a pharmacist involved at this critical junction of transition in care can lessen the likelihood of this happening [JAMA Netw Open 2022;5:e2211331].”
Changing the wording in the medical record also can influence prescribing. “For example, sometimes when we report a culture out, rather than stipulating what the organism is, it can be beneficial to say what it is not,” he said. “One study found that a report saying that no MRSA, Staphylococcus aureus or Pseudomonas aeruginosa had been identified in the respiratory culture led to more discontinuation of drugs that covered those organisms—almost twice the amount of discontinuation over the study period. Most laboratories can work with informatics to accomplish this wording within the electronic health record [EHR] [Antimicrob Steward Healthc Epidemiol 2022;2:e15].”
Communication Is Key
Dr. Maples stressed the importance of getting this message to emergency departments, urgent care centers and community-based pediatricians. “In our [EHR], we are creating discharge prescriptions with specific durations by indication, so that the provider doesn’t have to fill that in anymore. If a child has acute otitis media and the provider goes to the preference list, a five-day duration of amoxicillin pops up, nudging them to what is recommended. They can still override and change it if they believe that is needed, but having the prefilled duration helps overcome that training and years of practice that says, ‘I’ve always done 10 days or 14 days.’”
Such efforts are more effective within integrated healthcare systems, she acknowledged. “It’s harder when you are trying to get this message out to community pediatricians all across your state, especially in very rural areas. One thing we are doing with our Epic platform here at Arkansas Children’s is opening up the EHR so that providers throughout the state can see our pathways and recommendations to help get that message across.”
Dr. Bland reported that he serves on the speakers bureau and/or as a consultant to Shionogi Inc. Dr. Maples reported no relevant financial disclosures.