Editorial
Duration of Antibiotic Treatment in Community-Acquired Pneumonia
Duración del tratamiento antibiótico en la neumonía adquirida en la comunidad
Ane Uranga Echeverría
Servicio de Neumología, Hospital de Galdakao-Usansolo, Galdácano, Vizcaya, Spain
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"Duración del tratamiento antibiótico en la neumonía adquirida en la comunidad" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The optimal duration of antibiotic treatment in community-acquired pneumonia (CAP) has not been completely established, and there are discrepancies even between various clinical guidelines published to date. The <span class="elsevierStyleItalic">British Thoracic Society</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> recommends 7 days of antibiotic treatment in patients with uncomplicated mild to moderate CAP. In 2011, the <span class="elsevierStyleItalic">ERS</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> published guidelines recommending that treatment should not exceed 8 days in responding patients defined by clinical stability criteria. However, as far back as 2007, the <span class="elsevierStyleItalic">IDSA</span>/<span class="elsevierStyleItalic">ATS</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> recommended a minimum treatment of 5 days, providing that the patient remained a febrile for 48–72<span class="elsevierStyleHsp" style=""></span>h, with no more than 1 sign of clinical instability.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Efforts to cut back on widespread antibiotic use have been associated with multiple benefits, such as a decrease in microbial resistance, fewer adverse effects, and improved treatment adherence. The use of low-dose and long-duration (>5 days) beta-lactamics is associated with an increase in pharyngeal carriage of penicillin-resistant <span class="elsevierStyleItalic">Streptococcus pneumoniae.</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> Despite this, reducing the duration of antibiotic treatment in CAP can be complicated in routine clinical practice.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this respect, Moussaoui et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> conducted a clinical trial in 186 patients with CAP and a pneumonia severity score (PSI) of less than 110 points, who were given amoxicillin. In patients who presented an initial improvement after 72<span class="elsevierStyleHsp" style=""></span>h, 3 days of amoxicillin was equivalent to continuing the treatment for 8 days. Clinical cure was achieved after 10 days in 93% of cases in both groups.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In view of the concentration-dependent bactericide activity and prolonged post-antibiotic effect of quinolones, it is logical to presume that by increasing the dose, and therefore the peak concentration and area under the curve, the duration of antibiotic treatment can be reduced without affecting efficacy. Dunbar et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> compared a 5-day course of levofloxacin 750<span class="elsevierStyleHsp" style=""></span>mg versus a 10-day course of 500<span class="elsevierStyleHsp" style=""></span>mg of the same antibiotic in patients with CAP PSI I–IV. He found that both were at least equally effective, and that fever was resolved earlier in the first group.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Macrolides are known to have a long half-life and excellent lung penetration, which undoubtedly facilitates their use in short regimens. Some authors have even compared single-dose 2-g microsphere formulation regimens versus 7-day levofloxacin doses of 500<span class="elsevierStyleHsp" style=""></span>mg, with similar clinical cure rates.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A recent meta-analysis compared short (<7 days) vs longer (>7 days) treatments in patients with mild-moderate CAP, confirming the non-inferiority of the former in terms of clinical cure, mortality, bacteriological cure and adverse effects.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> However, all studies to date, with the exception of CURB65 3–5 conducted by Choudhury et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> have evaluated patients with mild and moderate CAP. CURB65 3–5 was a prospective, observational study in which the authors developed a propensity score to divide patients with initial clinical improvement into 2 groups: those receiving antibiotics for 7 days vs more than 7 days. The 30-day mortality, need for mechanical ventilation, and complications were similar in both groups, with no significant differences observed. Furthermore, on performing a multivariate analysis, they observed that factors such as age, earlier time to clinical stability and a lower CURB65 score at admission, were significantly associated with shorter duration of antibiotic treatment. In contrast, multilobar involvement was associated with longer duration.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The resolution of fever and clinical improvement in general are undoubtedly important markers for choosing the duration of antibiotic treatment. However, clinical criteria are subject to intra-professional variability. For this reason, biomarkers of systemic inflammation have been evaluated as a guideline for the duration of antibiotic treatment. Various studies have shown procalcitonin (PCT), a prohormone of calcitonin, to be very useful for developing algorithms that can determine the duration of treatment.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The ProHOSP<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> study, despite including subjects with lower respiratory tract infections that could increase the viral etiology, found a reduction of up to 3 days in the PCT algorithm group, with no increase in complications. A recent meta-analysis published by Schuetz et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> evaluating the impact of PCT on reducing the duration of antibiotic treatment in patients with lower respiratory tract infection, found no differences in mortality or therapeutic failure. Similarly, an analysis of the subgroup of patients with CAP showed that antibiotic treatment in the group following PCT-based guidelines was reduced by 3.34 days, with no increase in mortality or therapeutic failure.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, the duration of antibiotic treatment in most patients with CAP and initial improvement can be safely reduced. However, there are still some aspects to be clarified. First, the pharmacodynamic differences between antibiotics makes it difficult to standardize duration criteria. Secondly, most studies have focused on mild to moderate CAP, and therefore more clinical trials are required to evaluate the results in elderly patients and those with severe CAP. In the words of a well-known British author, “Time is a drug. Too much of it kills you”. We often prescribe 10-day courses of antibiotics without considering the implications this may have for our patients. This practice is now being side-lined by the more reasonable strategy of individualizing the duration of antibiotic treatment in patients with CAP.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Uranga Echeverría A. Duración del tratamiento antibiótico en la neumonía adquirida en la comunidad. Arch Bronconeumol. 2015;51:613–614.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "BTS guidelines for the management of community acquired pneumonia in adults: update 2009" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W.S. Lim" 1 => "S.V. Baudouin" 2 => "R.C. George" 3 => "A.T. Hill" 4 => "C. Jamieson" 5 => "I. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 51 | 13 | 64 |
| 2024 September | 85 | 28 | 113 |
| 2024 August | 84 | 37 | 121 |
| 2024 July | 101 | 21 | 122 |
| 2024 June | 100 | 34 | 134 |
| 2024 May | 116 | 43 | 159 |
| 2024 April | 69 | 38 | 107 |
| 2024 March | 63 | 21 | 84 |
| 2024 February | 49 | 32 | 81 |
| 2023 March | 39 | 6 | 45 |
| 2023 February | 190 | 20 | 210 |
| 2023 January | 203 | 31 | 234 |
| 2022 December | 170 | 59 | 229 |
| 2022 November | 173 | 42 | 215 |
| 2022 October | 176 | 41 | 217 |
| 2022 September | 168 | 36 | 204 |
| 2022 August | 531 | 37 | 568 |
| 2022 July | 154 | 46 | 200 |
| 2022 June | 146 | 36 | 182 |
| 2022 May | 88 | 49 | 137 |
| 2022 April | 125 | 56 | 181 |
| 2022 March | 174 | 47 | 221 |
| 2022 February | 202 | 41 | 243 |
| 2022 January | 141 | 48 | 189 |
| 2021 December | 127 | 40 | 167 |
| 2021 November | 106 | 59 | 165 |
| 2021 October | 114 | 57 | 171 |
| 2021 September | 106 | 57 | 163 |
| 2021 August | 159 | 54 | 213 |
| 2021 July | 125 | 53 | 178 |
| 2021 June | 70 | 72 | 142 |
| 2021 May | 101 | 45 | 146 |
| 2021 April | 349 | 153 | 502 |
| 2021 March | 267 | 49 | 316 |
| 2021 February | 136 | 39 | 175 |
| 2021 January | 121 | 35 | 156 |
| 2020 December | 145 | 45 | 190 |
| 2020 November | 112 | 29 | 141 |
| 2020 October | 98 | 35 | 133 |
| 2020 September | 109 | 30 | 139 |
| 2020 August | 86 | 24 | 110 |
| 2020 July | 92 | 32 | 124 |
| 2020 June | 83 | 16 | 99 |
| 2020 May | 92 | 27 | 119 |
| 2020 April | 111 | 23 | 134 |
| 2020 March | 80 | 20 | 100 |
| 2020 February | 67 | 17 | 84 |
| 2020 January | 75 | 17 | 92 |
| 2019 December | 73 | 18 | 91 |
| 2019 November | 59 | 19 | 78 |
| 2019 October | 73 | 38 | 111 |
| 2019 September | 64 | 22 | 86 |
| 2019 August | 63 | 26 | 89 |
| 2019 July | 45 | 18 | 63 |
| 2019 June | 42 | 19 | 61 |
| 2019 May | 71 | 30 | 101 |
| 2019 April | 122 | 33 | 155 |
| 2019 March | 77 | 26 | 103 |
| 2019 February | 74 | 25 | 99 |
| 2019 January | 66 | 37 | 103 |
| 2018 December | 64 | 45 | 109 |
| 2018 November | 91 | 40 | 131 |
| 2018 October | 123 | 37 | 160 |
| 2018 September | 70 | 20 | 90 |
| 2018 May | 23 | 2 | 25 |
| 2018 April | 69 | 13 | 82 |
| 2018 March | 50 | 6 | 56 |
| 2018 February | 77 | 14 | 91 |
| 2018 January | 171 | 7 | 178 |
| 2017 December | 101 | 12 | 113 |
| 2017 November | 30 | 21 | 51 |
| 2017 October | 20 | 16 | 36 |
| 2017 September | 30 | 16 | 46 |
| 2017 August | 32 | 23 | 55 |
| 2017 July | 24 | 23 | 47 |
| 2017 June | 38 | 42 | 80 |
| 2017 May | 33 | 24 | 57 |
| 2017 April | 30 | 34 | 64 |
| 2017 March | 28 | 16 | 44 |
| 2017 February | 15 | 23 | 38 |
| 2017 January | 16 | 19 | 35 |
| 2016 December | 35 | 29 | 64 |
| 2016 November | 44 | 30 | 74 |
| 2016 October | 65 | 38 | 103 |
| 2016 September | 50 | 24 | 74 |
| 2016 August | 37 | 8 | 45 |
| 2016 July | 39 | 19 | 58 |
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