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September 2016

The New Antibiotic Mantra—“Shorter Is Better”

Author Affiliations
  • 1Los Angeles County+University of Southern California Medical Center, Los Angeles
  • 2Department of Medicine, Keck School of Medicine at University of Southern California, Los Angeles
JAMA Intern Med. 2016;176(9):1254-1255. doi:10.1001/jamainternmed.2016.3646

In ad 321, Roman Emperor Constantine the Great codified that there would be 7 days in a week. Even in the modern era of evidence-based-medicine, this 1695-year-old decree remains a primary reference for duration of antibiotic therapy: it leads physicians to treat infections in intervals of 7 days. Thus, it is gratifying when clinical trials challenge the standard antibiotic duration of 7 to 14 days.

In the past, community-acquired pneumonia was treated with a 7- to 14-day course of antibiotics. However, clinical trials in the early 2000s demonstrated that 3 or 5 days of protocol-specified antibiotics are as efficacious as longer courses of therapy for patients with mild to moderately severe community-acquired pneumonia.1,2 To this body of literature is now added a new randomized trial, in this issue of JAMA Internal Medicine, by Uranga et al,3 comparing short-course vs longer courses of therapy for hospitalized patients with community-acquired pneumonia. The trial used a pragmatic design in that treating physicians were allowed to select their preferred antibiotic for the first 5 days of therapy. Patients were randomized such that on day 5 those in the control group continued the therapy selected by their treating physicians and those in the experimental group had their antibiotics stopped if they were afebrile for 48 hours and had no more than 1 sign of clinical instability (eg, hypotension, tachycardia, tachypnea, or hypoxia). These criteria for stopping the antibiotic applied to 70.1% of patients in the experimental arm. Although patients admitted to the intensive care unit were excluded from the trial, a substantial number (approximately 40%) of patients in both arms had Pneumonia Severity Index scores of IV to V, indicative of severe illness. In contrast, prior studies of short-course antibiotic therapy have focused primarily on patients with mild to moderate illness.

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