Duration of Antibiotic Therapy “Shorter is Better”

Duration of Antibiotic Therapy  “Shorter is Better”

Hello everyone,
My name is Wesley Kufel and I am a Clinical Assistant Professor at Binghamton University School of Pharmacy and Pharmaceutical Sciences in Binghamton, NY. I am also practicing as a clinical infectious diseases pharmacist at SUNY Upstate University Hospital and Im a also a Clinical Assistant Professor in the Department of Medicine at SUNY Upstate Medical University Hospital in Syracuse, NY. My background and training are in infectious diseases and antimicrobial stewardship. This question comes up every day during clinical practice: What is the appropriate duration of antibiotic therapy for this patient for this particular indication? This is a common question that arises and may not be as simple and easy as one might think. Duration of antibiotic therapy is dependent on many factors and there is a delicate balance for antibiotic durations to ensure antibiotic effectiveness while minimizing adverse effects and collateral damage. Antibiotics are a shared resource that are essential to managing patients with infectious-related problems. However antibiotics are
often over prescribed and prescribed for excessive durations that contribute to
the development of antibiotic resistant bacteria antibiotic resistance is
increasing throughout the world and limited antibiotic agents are in the
pipeline for development As you can see here, at least 30% of antibiotics prescribed in the outpatient setting are unnecessary antibiotic stewardship
programs are essential to assist in the reduction of inappropriate antibiotic
prescribing and minimize excessive antibiotic durations the goal of
antibiotic stewardship programs is to prescribe the right antibiotic at the
right dose for the right indication and very importantly for the right duration
I’m going to focus this presentation on prescribing antibiotics for the right
duration and review key data supporting shorter antibiotic courses for common
infectious disease states in the outpatient setting as you can see here I
wanted to provide an example of a common scenario where antibiotics are
prescribed for excessive durations sinusitis is the most common condition
for which antibiotic therapy is prescribed in the United States. 90-98% of sinusitis cases are viral in etiology
and do NOT require antibiotics. However, antibiotics are often prescribed for excessive durations. Current nationally-recognized guidelines
recommend 5-7 days of antibiotic treatment for most BACTERIAL sinusitis cases. However, a Centers for Disease Control and Prevention (CDC) study found that almost 70% of antibiotic prescriptions for sinusitis are for 10 days, which is longer than the recommended treatment duration. Providers should follow clinical guidelines to protect patients from excessive durations and optimize antibiotic therapy This is just one example of a common infectious diseases problem where antibiotics are overprescribed. So Why do we care about excessive durations of antibiotic therapy? There are potential negative consequences of prescribing antibiotics longer than needed. First, excessive durations of antibiotics can put selective pressure on bacteria to lead to the development of antibiotic-resistant bacteria that are difficult to manage with currently available antibiotic therapies. Second, all antibiotics are associated with adverse effects, with some antibiotics having more significant adverse effects than others such as acute kidney injury, electrolyte imbalances, cardiac abnormalities, and diarrhea including risk of Clostridioides difficile-associated diarrhea that can be severe and require hospitalization. According to the CDC, antibiotics are responsible for almost 1 out of 5 emergency department visits for an adverse event. Antibiotics are not benign medications and it’s important to recognize this when antibiotics are prescribed for unnecessary durations. So You may be wondering, “Why are these antibiotics prescribed for excessive antibiotic durations?” and this is largely due to multiple factors. One of these factors is often provider unfamiliarity. Providers in the outpatient setting see multiple conditions and may not be “up to date” on recent guideline practices and management of infectious disease states. Additionally, some providers may have learned from someone who is considered a senior provider and follow their prescribing patterns that may be based on historic data to recommend prolonged durations. There has also been this consensus to treat infection based on what I like to refer to as “football scores”. It is very common for treatment durations to be rounded to the nearest football score such as 7 days, 10 days, or 14 days, yet this is really not based on any specific data. This practice often results in longer than necessary durations and treating for these particular durations should be avoided in many situations. Another potential reason is there are often default durations in order entry systems when providers are prescribing antibiotics. For example, when a provider enters an orders an antibiotic, the duration is defaulted automatically to 10 days and this is often easy for providers to just “accept” this duration. Rather than having a default duration for individual antibiotics, I recommend to leave this field blank so that providers are required to manually enter a specific duration of therapy for that particular anibiotic This has previously been shown to reduce duration of antibiotic therapy from a simple change in provider order entry systems. It is also important to consider all antibiotics that a patient has received from both the inpatient and outpatient setting. As an example, I often recognize that the intended duration of antibiotic therapy for a particular infectious process to be a total of 7 days for example The patient is admitted to the hospital and receives part of this antibiotic course while inpatient, such as a 3 day course and then is discharged. Instead of prescribing the remaining 4 days of antibiotic therapy on discharge, I often recognize the “clock or duration reset” so that the discharge prescription is for a 7-day course so now the patient received a total of 10 days of antibiotics instead of the intended 7-day course. Lastly and in my opinion most importantly, there may be a “fear” from providers that treating for shorter courses may not work as well as treating for longer courses of antibiotics. So now let’s review common some infectious disease states where shorter courses of
antibiotic therapy are equivalent in efficacy to longer courses of therapy based on published literature. Dr. Brad Spellberg, an infectious diseases physician in California and leader in antibiotic stewardship, has published reviews summarizing data to support shorter courses of antibiotics I wanted to highlight some of the common infections that are encountered in the outpatient setting. As discussed before, the majority of sinusitis cases are viral in nature and DO NOT require antibiotics. However, when deemed a true bacterial infection, 5 days of antibiotics has been shown to be comparable to 10 days this is a considerable reduction in days of therapy as the duration is half of the “longer” course. Again, respiratory viruses are a common cause of acute bronchitis and in many cases, antibiotics are not necessary. However, for true acute bacterial bronchitis, 5 days or less of antibiotics have been shown to be comparable to 7 days or more. Additionally, A 3-5-day course of antibiotics have been shown to be comparable to a 7-10-day course for community-acquired pneumonia, which is a significant difference in the amount of antibiotics prescribed. A 5-7-day course has been shown to be comparable to a 10-14-day course of antibiotics for pyelonephritis, which is approximately an entire week less of antibiotics. Lastly, skin infections are another commonly encountered infection in the outpatient setting and a 5-6-day course of antibiotics has been shown to be comparable to a 10-14-day course. These are just some of the examples of common infections in the outpatient setting where shorter courses of antibiotics have been shown to be equivalent in efficacy to longer therapy. To wrap-up this presentation, I wanted to highlight the key points from this presentation. *Antibiotics are a shared resource that are often prescribed for excessive durations which may contribute to more antibiotic-related adverse effects and lead to the development of antibiotic-resistant bacteria. In this presentation
we reviewed, published data support shorter compared to longer antibiotic courses for common infections. Appropriate antibiotic prescribing through antibiotic stewardship is essential to minimize excessive antibiotic durations Thanks for taking the time to review this presentation. And as a reminder, always double check yourself to ensure you are prescribing an appropriate duration of antibiotic because shorter courses are often better. Thank you, and have a great day.

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