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Original Investigation
Less Is More
September 2016

Duration of Antibiotic Treatment in Community-Acquired PneumoniaA Multicenter Randomized Clinical Trial

Author Affiliations
  • 1Department of Pneumology, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
  • 2Research Unit, Basurto University Hospital, Bilbao, Bizkaia, Spain
  • 3Research Unit, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
  • 4Department of Pneumology, Basurto University Hospital, Bilbao, Bizkaia, Spain
  • 5Department of Pneumology, Alava University Hospital, Vitoria, Alava, Spain
  • 6Department of Pneumology, San Eloy Hospital, Barakaldo, Bizkaia, Spain
JAMA Intern Med. 2016;176(9):1257-1265. doi:10.1001/jamainternmed.2016.3633
Abstract

Importance  The optimal duration of antibiotic treatment for community-acquired pneumonia (CAP) has not been well established.

Objective  To validate Infectious Diseases Society of America/American Thoracic Society guidelines for duration of antibiotic treatment in hospitalized patients with CAP.

Design, Setting, and Participants  This study was a multicenter, noninferiority randomized clinical trial performed at 4 teaching hospitals in Spain from January 1, 2012, through August 31, 2013. A total of 312 hospitalized patients diagnosed as having CAP were studied. Data analysis was performed from January 1, 2014, through February 28, 2015.

Interventions  Patients were randomized at day 5 to an intervention or control group. Those in the intervention group were treated with antibiotics for a minimum of 5 days, and the antibiotic treatment was stopped at this point if their body temperature was 37.8°C or less for 48 hours and they had no more than 1 CAP-associated sign of clinical instability. Duration of antibiotic treatment in the control group was determined by physicians.

Main Outcomes and Measures  Clinical success rate at days 10 and 30 since admission and CAP-related symptoms at days 5 and 10 measured with the 18-item CAP symptom questionnaire score range, 0-90; higher scores indicate more severe symptoms.

Results  Of the 312 patients included, 150 and 162 were randomized to the control and intervention groups, respectively. The mean (SD) age of the patients was 66.2 (17.9) years and 64.7 (18.7) years in the control and intervention groups, respectively. There were 95 men (63.3%) and 55 women (36.7%) in the control group and 101 men (62.3%) and 61 women (37.7%) in the intervention group. In the intent-to-treat analysis, clinical success was 48.6% (71 of 150) in the control group and 56.3% (90 of 162) in the intervention group at day 10 (P = .18) and 88.6% (132 of 150) in the control group and 91.9% (147 of 162) in the intervention group at day 30 (P = .33). The mean (SD) CAP symptom questionnaire scores were 24.7 (11.4) vs 27.2 (12.5) at day 5 (P = .10) and 18.6 (9.0) vs 17.9 (7.6) at day 10 (P = .69). In the per-protocol analysis, clinical success was 50.4% (67 of 137) in the control group and 59.7% (86 of 146) in the intervention group at day 10 (P = .12) and 92.7% (126 of 137) in the control group and 94.4% (136 of 146) in the intervention group at day 30 (P = .54). The mean (SD) CAP symptom questionnaire scores were 24.3 (11.4) vs 26.6 (12.1) at day 5 (P = .16) and 18.1 (8.5) vs 17.6 (7.4) at day 10 (P = .81).

Conclusions and Relevance  The Infectious Diseases Society of America/American Thoracic Society recommendations for duration of antibiotic treatment based on clinical stability criteria can be safely implemented in hospitalized patients with CAP.

Trial Registration  clinicaltrialsregister.eu Identifier: 2011-001067-51

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