Duration of antibiotic therapy for common infections
Publication: Official Journal of the Association of Medical Microbiology and Infectious Disease Canada
Volume 6, Number 3
Historically, durations of antimicrobial therapy for common infections have been largely driven by habits or cultural norms rather than robust scientific data (1,2). In general, durations have increased compared with the early days of antimicrobials when patients with pneumococcal pneumonia, for example, were treated for 1 to 4 days (3). The long-standing belief that antimicrobials had few significant adverse effects likely contributed to the paucity of trials to critically evaluate minimum effective treatment durations (4–7). However, in the last decade, increasing infections due to Clostridioides difficile, emergence of multidrug-resistant pathogens, and concern for overall safety of antibiotics have led researchers to look critically at this issue (8–16).
Several reports highlight the problem of longer-than-recommended treatment durations, including a recent study from England that used a primary care database to show that antibiotic treatment durations that exceeded guideline recommendations accounted for 1.3 million days of excess therapy between 2013 and 2015 (9,17). A recent observational study of patients with pneumonia concluded that two-thirds of patients had excess durations, with 93.2% of the excess attributed to antibiotics prescribed at discharge. Each excess day was associated with a 5% increase in the odds of a patient having an antibiotic-associated adverse event (18). Many experts have made rational arguments and coined useful slogans such as “shorter is still better” to emphasize the importance of reducing durations not only to preserve the efficacy of our antibiotics but also to reduce the risk of unnecessarily prolonging durations that have no added benefit (19–21).
The purpose of this practice point is to disseminate contemporary treatment durations for common infectious syndromes for which there are either infectious disease guidelines or substantial evidence to support shorter durations of therapy. Search strategies for appropriate guidelines from North America or Europe, where similar health systems exist, as well as applicable cohort or randomized controlled studies, were carried out between January 2 and June 30, 2020. Subsequently, the draft document was reviewed by the Antimicrobial Stewardship and Resistance Committee (ASRC) of the Association of Medical Microbiology and Infectious Disease (AMMI) Canada and other members at large and approved by the Council of AMMI Canada.
The recommendations do not apply to individuals younger than 2 months of age, individuals who have underlying immune deficiencies, or those who have received immune-modulating agents, chemotherapy, or corticosteroids, where there is lack of data on shorter durations of therapy. Durations of therapy for fungal infection is also beyond the scope of this document. Decisions regarding duration of treatment of individual patients should still take into consideration patient characteristics, the certainty of the clinical diagnosis, clinical response to treatment, and medication side effects. Modifications of duration can also be re-evaluated on a case-by-case basis with ongoing follow-up of patients. Table 1 summarizes current AMMI Canada recommendations for durations of treatment for common infectious syndromes. The sections that follow describe these recommendations in detail.
| Infection | Population | Recommended duration | Comments |
|---|---|---|---|
| Urinary tract | |||
| Uncomplicated cystitis | Women/adolescents | • Nitrofurantoin – 5 d • TMP-SMX – 3 d • Fosfomycin – 1 d | Young non-pregnant female adolescents or adults with normal urinary tracts and normal renal function |
| Complicated cystitis | Men | 7 d | • Afebrile • Urine analysis abnormal and consistent with UTI |
| Febrile UTI | Children | 7–10 d | Assumes upper tract involvement if febrile |
| Pyelonephritis and urosepsis | Adults | • Consider an initial dose of IV dose aminoglycoside or ceftriaxone at outset • Quinolones or β-lactams 7 d | Minimum 7 d, consider longer for other antibiotics, patients who are slow to respond to therapy or underlying urinary tract pathology. Excludes patients with stents/ drains as this will require an individualized approach. |
| Respiratory tract | |||
| Streptococcal pharyngitis | Children and adults | 10 d (penicillin V or amoxicillin) | Studies limited to pediatrics. Some studies suggest 5 d of 4 x daily penicillin for bacterial eradication only |
| Acute otitis media | Children and adults | • 6 mo to 2 y – 10 d • >2 y – 5 d | • Should meet diagnostic criteria including fever • >39°C, moderately ill with bulging tympanic membrane |
| Acute sinusitis (uncomplicated) | Children and adults | 5–7 d | • Excludes complicated sinusitis (eg, epidural, subdural or orbital collection) • Revaluation if not clinically improving |
| CAP | Children and adults | 5–7 d | • Patients with underlying lung disease, immunosuppression or empyema • Must be improved and have normal vital signs for 2 d when using 5 d of therapy • Similar recommendation for uncomplicated CAP associated with S. pneumoniae bacteremia |
| HAP/VAP | Children and adults | ≤7 d | Severely immune suppressed patients with collections or abscesses, S. aureus and Pseudomonas infection |
| Acute bacterial COPD exacerbation | Children and adults | 5–7 d | Only for patients meeting criteria for antibiotic treatment |
| Intra-abdominal | |||
| Uncomplicated appendicitis | Children and adults | Pre-operative antibiotics only | Gangrenous appendicitis or perforated appendicitis without evidence of abscess should be treated for an additional 24–48 h after appendectomy |
| Traumatic bowel perforation | Children and adults | No more than 24 h post-operatively | Operated on within 12 h of trauma |
| Gastroduodenal perforation | Children and adults | No more than 24 h post-operatively | Operated on within 24 h of perforation |
| Intra-abdominal infection/abscess | Children and adults | <7 d after source control | Source control required with drainage of infection. No additional days required if adequate drainage is in place |
| Cellulitis | |||
| Uncomplicated non-purulent or purulent cellulitis | Children and adults | 5–7 d unless hospitalized with extensive or severe disease | Usually due to S. pyogenes (group A Streptococcus) if non purulent or Staphylococcus aureus if purulent cellulitis. incision and drainage with culture recommended for skin abscesses. |
| Osteoarticular | |||
| Acute osteoarticular infections | Children | 3–4 wk | Should be transitioned to oral therapy once clinically able to use limb and CRP decreasing. Complicated infection, MRSA or other pathogens may require longer therapy. |
| Acute vertebral osteomyelitis | Adults | 6 wk | • Not associated with implantable device • Assumes S. aureus but could be longer for Salmonella or Brucella infections |
| Acute native joint osteoarticular infections | Adults | • 2 wk for small joints after drainage • 4 wk for large joints after drainage | Duration recommendation for patients post-surgical drainage, with causal organism and susceptibility profile |
| Bacteremia | |||
| Gram-negative Enterobacterales such as E. coli, usually from a urinary source | Children and adults | 7 d | • Assumes source controlled, (eg, removal of central line, abscess drainage) and not associated with a clinical syndrome requiring longer therapy. • Assumes meningitis ruled out in infants. |
| S. aureus bacteremia (uncomplicated) | Children and adults | • 14 d IV if uncomplicated or following IV line removal • If musculoskeletal infection, IV to oral can be used in children. | Must ensure absence of endocarditis with echocardiogram and or other foci of infection (such as osteomyelitis); infectious diseases consult recommended. |
| S. aureus bacteremia (complicated) | Children and adults | 4–6 wk IV | Endocarditis, metastatic foci of infection, prolonged bacteremia >72 h while on appropriate therapy. Infectious Diseases consult recommended. |
UTI = Urinary tract infection; CAP = Community-acquired pneumonia; S. pneumoniae = Streptococcus pneumoniae; HAP/VAP = Hospital- and ventilator-acquired pneumonia; S. aureus = Staphylococcus aureus; COPD = Chronic obstructive pulmonary disease; IV = Intravenous; S. pyogenes = Streptococcus pyogenes; CRP = C-reactive protein; MRSA = Methicillin-resistant Staphylococcus aureus; E. coli = Escherichia coli
Upper Respiratory Tract Infections
Community-acquired bacterial sinusitis
Community-acquired bacterial sinusitis is usually secondary to a primary viral infection of the upper respiratory tract (viral rhinitis) that results in sinus ostia obstruction and subsequent bacterial proliferation. Patients with bacterial sinusitis either have >10 days of persistent symptoms, severe symptoms, or have initial improvement followed by relapse of symptoms. Symptoms that last longer than 12 weeks suggest chronic sinusitis and are outside the scope of this practice point. In adults, a meta-analysis of 12 randomized controlled trials (RCTs) for acute bacterial sinusitis showed that 3 to 7 days of antibiotic treatment was as effective as 6 to 10 days, and a sensitivity analysis of 5 versus 10 days came to a similar conclusion (22).
Adults
The American Academy of Otolaryngology’s 2015 guidelines for adult patients recommends 5 to 10 days (based on RCTs [grade A evidence, but low to moderate certainty]), with clinical re-evaluation at 7 days to ensure improvement (23). The Infectious Diseases Society of America (IDSA) recommends 5 to 7 days of antibiotics (based on weak, low quality evidence) with a re-evaluation at 3 to 5 days to ensure improvement and no extension of infection (24).
Children
Recommended durations of therapy for children and youth with acute bacterial sinusitis have varied because of scant evidence and difficulty in assessment of chronicity. A proposed practical alternative to prevent longer durations may be to treat for 7 days after the patient is symptom free (25). Pneumococcus and Haemophilus influenzae isolates may be resistant to trimethoprim-sulfamethoxazole and azithromycin, so these antibiotics are not included in the duration recommendations.
AMMI Canada recommendations
The duration of treatment for acute, uncomplicated, community-acquired sinusitis should be 5 to 7 days with a planned re-evaluation at 7 days to ensure clinical resolution. Children should also receive about 7 days of therapy with a β-lactam antibiotic, with follow-up if not improving.
Acute otitis media
A critical issue in therapy for acute otitis media in children is to ensure that criteria for diagnosis are met (typically including a bulging tympanic membrane). Children who have a mild or moderately bulging tympanic membrane, who are mildly ill, alert, responding to antipyretics, have a low-grade fever (<39°C), and mild otalgia, can be safely managed with a ‘watchful waiting’ period of 24 to 48 hours if timely reassessment is possible. Children with a high fever (≥39°C) and who are moderately to severely systemically ill, or children who have severe otalgia or have been significantly ill for 48 hours should be treated with antimicrobials (26). Trials in children over 2 years of age have favoured a duration of 5 to 7 days; however, a trial in children under the age of 2 years noted that 5 days was less effective than 10 days of therapy (27,28).
The Canadian Paediatric Society (CPS) recommends that children with acute otitis media meeting specific diagnostic criteria be treated with amoxicillin for 10 days if under 2 years of age and 5 days if older (26). However, any child with a tympanic membrane perforation or recurrent acute otitis media should receive a 10-day course of amoxicillin.
AMMI Canada recommendations
Duration of therapy for bacterial acute otitis media is 10 days in children under 2 years of age and 5 days in children over 2 years of age.
Streptococcal pharyngitis
Streptococcal pharyngitis, if left untreated, may lead to acute rheumatic fever or local suppurative complications. A meta-analysis demonstrated that there appears to be better bacteriological eradication with a 10-day course of penicillin than with 5 to 7 days, but no differences in rates of relapse or recurrence were noted (29). Another study showed equivalent clinical cure but slightly less bacterial eradication (80% versus 90%) with 5 versus 10 days of penicillin (30).
AMMI Canada recommendations
Ten days is the recommended duration of penicillin V or amoxicillin treatment for Streptococcal pharyngitis.
Lower Respiratory Tract Infections
Community-acquired pneumonia
Adults
Acute community-acquired pneumonia is most commonly caused by viruses (such as influenza), but common pathogens associated with bacterial pneumonia are Streptococcus pneumoniae, H. influenza, and Mycoplasma pneumonia, with some populations, such as nursing home residents, more likely to be infected with gram-negative pathogens that may be multidrug resistant.
A systematic review and meta-analysis of RCTs predominantly of ambulatory or mixed inpatient/outpatient populations with low severity illness concluded that ≤6 days provided equally effective treatment compared with longer durations and may confer a safety benefit owing to fewer adverse effects (33). Failure to respond may indicate local complications such as empyema or other pathogens not commonly seen such as Mycobacterium tuberculosis or endemic fungi such as Blastomyces dermatitidis/gilchristii. One recent observational study reported significantly more antibiotic adverse events in patients who received therapy longer than recommended, predominantly discharge antibiotics, supporting shorter durations as a safer option (20). S. pneumoniae bacteremia associated with uncomplicated pneumonia (not meningitis or other serious infections, such as septic arthritis, which requires longer courses of therapy) is effectively treated with 5 days of intravenous therapy, assuming clinical improvement before the discontinuation of therapy (34).
The 2019 joint American Thoracic Society (ATS)/ IDSA guideline recommends at least 5 days of treatment for both severe and non-severe pneumonia with the caveat that the total duration depends on the achievement of clinical stability for 48 to 72 hours prior to discontinuing antimicrobial therapy (34). Clinical stability was defined as normalization of vital signs, ability to eat, and normal mentation. While historically recommended treatment was longer (14 d) for Staphylococcus aureus, Pseudomonas aeruginosa, and other non-fermenting bacteria, more recent guidance recommends 7 days of therapy for these infections, unless there is reason to extend therapy (eg, S. aureus bacteremia). In complicated pneumonias (eg, empyema, lung abscess), the duration is likely longer, but surgical intervention plays a key role in managing infection and decreasing the duration of antibiotic therapy.
Children
Community-acquired pneumonia that is considered to be bacterial in origin in children is commonly due to S. pneumoniae. Children who are older than 5 years of age and have prolonged cough are more likely to have M. pneumoniae. One study in preschool children with pneumonia found that treatment with amoxicillin for 5 days in the outpatient setting was non-inferior to a 10-day course (35).
The CPS practice point currently recommends a 7- to 10-day course of antimicrobials for uncomplicated pneumonia with the caveat that shorter courses may be just as effective for children with non-severe uncomplicated pneumonia (36,37). The U.K. guidelines from the National Institute for Health and Care Excellence also recommend 5 days for childhood pneumonia (38). Pneumonia complicated by empyema could require drainage and a longer duration of therapy of 14 to 21 days.
AMMI Canada recommendations
The duration of therapy for acute uncomplicated community-acquired pneumonia in adults should be a minimum of 5 days, provided there is clinical stability for 48 to 72 hours. Duration can be extended to 7 days if there is slower resolution or pathogens such as S. aureus or Pseudomonas are identified.
Since viral infections are more common in children, clinicians should use clinical and radiological criteria to distinguish bacterial pneumonia from bronchiolitis in younger children and infants. Duration of therapy should be 5–7 days for uncomplicated pneumonia in children who have clinically improved and have normal vital signs.
Lower respiratory tract infections acquired in hospital
Hospital-acquired pneumonia is associated with significant morbidity and a high case fatality rate. The entity previously labeled as health care–associated pneumonia, which included patients with significant health care contact (eg, dialysis) and those living in long-term care, has been retired and collapsed back into community-acquired pneumonia, as the microbiological etiologies are similar (39). In contrast, hospital-acquired pneumonia and ventilator-associated pneumonia are more likely to be associated with antibiotic-resistant organisms, depending on local hospital epidemiology, patient characteristics, and duration of hospital stay. Empiric therapy is usually broad. Historically, therapy for ventilator-associated pneumonia (and hospital-acquired pneumonia) was prolonged, up to 21 days, until investigators evaluated the relative efficacy of shorter (8 d) versus longer (15 d) therapy and showed no difference in mortality, intensive care unit (ICU) stay, mechanical ventilation–free days or organ failure–free days (40). Patients who received fewer days of antibiotics had less re-infection with resistant organisms. Subsequent studies are summarized in a meta-analysis confirming that 7 to 8 days of therapy is as effective as longer courses, except possibly for patients infected with non-fermenting gram-negative bacilli (eg, P. aeruginosa), where there may be more recurrences with a shorter course; however, clinical outcomes were not affected (41).
European (2017) and IDSA guidelines (2016) both recommend durations of 7 days for ventilator-associated pneumonia (moderate quality evidence) and hospital-acquired pneumonia (very low quality evidence) (39,42,43). However, allowance is made to alter durations both for shorter and longer courses based on clinical response and microbiologic etiology.
AMMI Canada recommendations
The duration of therapy for hospital-acquired pneumonias without abscesses (ventilator-associated or not) should be limited to 7 days, provided there is clinical stability for 48 to 72 hours.
Chronic Obstructive Pulmonary Disease Exacerbation
Acute exacerbations of chronic obstructive pulmonary disease (COPD) caused by infection are most frequently caused by viruses, with bacteria playing a secondary role. Acute exacerbations of COPD should be managed with bronchodilators, anti-inflammatory therapy, and correction of any reversible underlying cause such as environmental or other medical conditions (eg, heart failure, pulmonary embolism). Antibiotics should only be considered when patients fail to respond to these measures or when clinical findings such as fever suggest bacteria as a likely cause or when the patient is severely ill (44).
A recent review showed no differences in clinical outcomes with a duration of <6 days versus ≥7 days, but the shorter duration group had significantly fewer adverse effects (45). Durations of up to 5 days have been compared with longer therapies in a meta-analysis of 21 RCTs. The meta-analysis found that short courses of 5 days were equivalent to longer ones for clinical and bacteriologic cure. Results were the same regardless of antibiotic class (46).
The 2019 Global Initiative for Chronic Obstructive Lung Disease guide recommends 5 to 7 days of antimicrobial therapy in patients with severe disease, or signs of bacterial infection (44). Likewise, NICE guidelines recommend a 5-day course (if antibiotics are indicated) of any antimicrobial class (47). The European Respiratory Society and the ATS guidelines recommend antimicrobial therapy, but do not comment on duration (48).
AMMI Canada recommendations
The duration of treatment for acute exacerbations of COPD that are believed to be caused by bacterial infection should be 5 to 7 days.
Pre-Operative Antimicrobial Prophylaxis
For surgeries that do not involve implantable devices, prophylactic antimicrobials should be administered only when recommended, as many types of surgery do not require prophylaxis (49,50). When recommended, antimicrobials should be given 30 to 60 minutes before surgical incision. There is no evidence of benefit when antimicrobials are continued post-operatively. A study of almost 80,000 patients showed that the risk of C. difficile and acute kidney injury increased in a duration-dependent fashion in adults who received antimicrobials for prophylaxis for >24 hours, strongly suggesting that prolonging duration adds adverse events without decreasing surgical site infections (51,52).
The World Health Organization is definitive that, for surgeries that do not include implants, there is no benefit to prolonging antimicrobials in the post-operative period, and antibiotics should be discontinued at the time of skin closure (53).
Women undergoing cesarean delivery should also receive a timely pre-operative dose of cefazolin to reduce the likelihood of surgical wound infection and endometritis; there is no benefit with prolonging cefazolin after the surgery (54,55). Women with preterm rupture of membranes (<32 weeks gestation), should receive 48 hours of intravenous ampicillin followed by 5 days of oral amoxicillin and either 1 dose of intravenous azithromycin or 2 days of intravenous erythromycin followed by 5 days of oral erythromycin (55).
AMMI Canada recommendations
Surgical prophylaxis, including for cesarean delivery, should be stopped after skin closure. Pregnant women with preterm rupture of membranes should receive 7 days of ampicillin and a macrolide, as previously described, to decrease the risk of infection to the fetus.
Duration of surgical prophylaxis for surgeries involving implants or valves can be extended 24 to 48 hours after surgery, but this recommendation is not based on evidence of benefit, but rather absence of evidence. This recommendation should apply regardless of the presence of drains or chest tubes (53,56).
Intra-Abdominal Infections
An essential component of the management of intra-abdominal infections involves drainage of infected fluid collections or abscesses (source control) as this removes the source of infection, reduces bacterial load, and leads to decreased days of antimicrobials and better overall outcomes.
Patients who undergo appendectomy for acute appendicitis and have a non-perforated appendix need only pre-operative antibiotics (57). For infected intra-abdominal/peritoneal collections, data support using shorter courses of therapy, emphasizing that source control and drainage of abscesses are critical in management. One study compared 4 versus 8 days of therapy after source control and concluded that recurrent surgical site or intra-abdominal infections were similar (58). A second large RCT conducted in ICUs determined that patients treated with shorter courses of 8 days had no differences in length of stay, mortality, or re-operation rates when compared with those treated for 15 days (59). For cholangitis, a systematic review summarizing available literature to 2018 found 4 studies that met inclusion criteria. The authors concluded that, provided there was source control, a shorter course of antibiotics of less than 1 week did not result in higher mortality, longer duration of fever, or higher rates of recurrence (60).
Guidelines from the Surgical Infection Society (2017) and the IDSA (2010) advocate <7 days of therapy for patients with source control (57,61). Tokyo Guidelines for management of acute cholangitis recommend drainage or source control as the mainstay of therapy followed by 4 to 7 days of appropriate, targeted antimicrobial therapy (62,63).
AMMI Canada recommendations
Physicians should strongly advocate for source control (drainage of collections) in the setting of intra-abdominal infections. Duration of therapy for intra-abdominal infections with source control should be less than 7 days.
Urinary Tract Infections
Cystitis or lower tract infection
Acute dysuria, urgency, and frequency, without flank pain or fever, accompanied by pyuria and a positive, single uropathogen in urine define cystitis. Since bacteria are limited to the bladder, short courses of antibiotics are sufficient. Cystitis in non-catheterized men is infrequent and likely indicates prostatitis, obstruction, or upper tract infection. Bacteriuria in pregnancy or post–renal transplant is beyond the scope of this document. Except during pregnancy and prior to urologic surgery, asymptomatic bacteriuria should not be treated (64). AMMI Canada has published a useful toolkit including educational materials for managing asymptomatic bacteriuria called “Symptom Free Pee: LET IT BE” (65).
Short courses of therapy (3–5 d, depending on antibiotic class) for uncomplicated cystitis in otherwise healthy young women is well-supported by robust data and is recommended in IDSA guidelines (66). Single-dose fosfomycin (or 3 d if recurrent/complicated cystitis) also holds promise as a treatment for cystitis owing to the drug’s high concentration. Men should receive 7 days of therapy, as cystitis may be more complicated in this population.
Pyelonephritis
Adults
Uncomplicated pyelonephritis is defined as a UTI with systemic symptoms (usually fever, malaise, chills, or flank or pelvic pain) that occurs in a non-pregnant, premenopausal woman without underlying comorbid conditions or anatomic urologic abnormalities. For adult men, pyelonephritis should be considered complicated, since the presence of a UTI may indicate urinary tract obstruction or a prostatic focus. Recent studies of patients with normal male or female anatomy support a 7-day course of antimicrobials with some caveats (73–76). A meta-analysis found 8 evaluable trials that compared ≤7 with >7 days of treatment for pyelonephritis. The conclusion of the meta-analysis (irrespective of whether fluoroquinolones had been used) was that there were no differences in clinical or microbiological failure between the short and long treatment arms. Longer treatment courses were recommended for pyelonephritis complicated by abscess or stones, as patients with urogenital abnormalities experienced more microbiological failure (but equivalent clinical failure) at the end of follow-up than those with normal anatomy. In this meta-analysis, the percentage of bacteremic patients ranged from 3% to 29% (73). A recent study (65% females) compared a median of 4.5 days of aminoglycoside therapy with 5 days of non-aminoglycoside-based therapy for adults with pyelonephritis and found similar outcomes (77).
The 2011 practice guidelines from the IDSA and the European Society for Microbiology and Infectious Diseases recommended a minimum 7-day course of antibiotics (if using fluoroquinolones) in the setting of uncomplicated pyelonephritis (without septic shock or abscesses) in women who rapidly respond to therapy. However, other than fluoroquinolones, for which 7 days of treatment was shown to be sufficient, there were limited data on shorter durations with other classes of antibiotics; therefore, a 10- to 14-day course was recommended if other antibiotic classes are used (66). The NICE guidelines, also vary treatment duration according to class of antimicrobial, with 7 days for fluoroquinolones (consider safety issues), and 7 to 10 days for ß-lactams (78). Rising rates of resistance and safety issues (especially with fluoroquinolones) emphasize the critical importance of proper diagnosis and cultures as well as prompt re-evaluation in the event of a slow response to therapy. Some experts have suggested an initial intravenous dose of an aminoglycoside, ceftriaxone, or ertapenem, especially if oral β-lactams are planned as definitive therapy.
Children
Pyelonephritis in children refers to the clinical syndrome of fever and symptoms compatible with UTI (eg, dysuria, incontinence, urgency) with pyuria and an abnormal urinalysis. No RCTs specifically examining duration of therapy in children with febrile UTIs (presumed pyelonephritis) have been published. A 2014 Cochrane review determined that 10 to 14 days of therapy was appropriate for clinical success (79). A more recent 2019 study of almost 800 children with febrile UTI reported similar outcomes with courses of 6 to 9 days versus ≥10 days of therapy. However, children with urologic abnormalities had more treatment failures with short courses (80). An RCT conducted in neonates with gram-negative bacteremia, of which 69% had a urinary tract source, reported that those treated with 7 days of antibiotics had non-inferior outcomes to those treated for 14 days (81). In children older than 1 month, treatment durations for bacteremia associated with pyelonephritis have not been the subject of an RCT. A recent retrospective cohort study of pyelonephritis has too few cases of associated bacteremia to determine duration of therapy (80). The Canadian Pediatric Society practice point recommends a 7-10 day course (72).
AMMI Canada recommendations
A 7-day course of a fluoroquinolone (ciprofloxacin or levofloxacin) is likely adequate for the treatment of uncomplicated pyelonephritis in men and non-pregnant women with no underlying anatomic abnormalities and rapid response to an antibiotic to which the pathogen is susceptible, as these antibiotics attain high renal concentrations. If β-lactam agents (ie, cephalosporins, aminopenicillins, or trimethoprim-sulfamethoxazole) are given based on susceptibilities, longer courses of 10 to 14 days should be considered.
In persons with underlying comorbidities (eg, diabetes, anatomic abnormalities of the urinary tract, urinary tract outflow obstruction or renal calculi, recurrent pyelonephritis, immunocompromising conditions) or slow response to therapy, durations of 10 to 14 days or longer are recommended.
If outpatient therapy is being contemplated at presentation, empiric therapy with 1 dose of intramuscular or intravenous aminoglycoside, ceftriaxone, or ertapenem can be considered. Adequate follow-up of the patient and the ability to modify treatment based on pathogen susceptibility should be assured.
The same principles for duration apply to children older than 2 months of age who have an uncomplicated febrile UTI (not associated with a bacteremia or meningitis), where recommended durations range from 7 to 10 days. Children with no underlying renal abnormalities and non-bacteremic UTI who have a rapid response to therapy should receive a minimum of 7 days of effective therapy. Longer durations will likely be required in the event of a slow response to therapy or underlying renal structural abnormalities, and treatment should be individualized. Aminoglycosides attain high renal concentrations and may be given as an initial empiric therapeutic dose if consideration is being given to outpatient therapy. In children, fluoroquinolones should be reserved for pathogens resistant to other agents.
Skin and Soft Tissue Infections
Purulent and non-purulent cellulitis
Cellulitis in patients who are neutropenic, cellulitis associated with bites (animal or human), periorbital swelling caused by complicated sinusitis, and cellulitis associated with chronic ulcers, deeper infections (such as necrotizing fasciitis), or fish or water exposure are beyond the scope of this practice point. Additionally, cellulitis should be differentiated from venous stasis, erythema migrans caused by Lyme disease, cutaneous herpes infections, and subperiosteal abscesses associated with childhood acute osteomyelitis.
Acute cellulitis is most commonly caused by S. pyogenes (usually a non-purulent cellulitis characterized primarily by rapid onset pain, erythema, and swelling without abscesses) or S. aureus (usually a purulent cellulitis characterized by abscesses or pus that is visible or can be expressed from the site). There may be some overlap in these presentations in persons with underlying dermatitis.
One RCT of patients with uncomplicated cellulitis (outpatients and inpatients) concluded that, despite some residual erythema, 5 days of therapy resulted in similar cure rates compared with 10 days (82). In a study involving patients admitted to hospital with cellulitis, there appeared to be more readmissions in the shorter (6 d) duration group, suggesting that some hospitalized patients may have more extensive disease requiring longer durations of therapy to prevent relapse (83). In cases of recurrent cellulitis, consideration should be given to penicillin prophylaxis and other supportive measures (84). IDSA guidelines recommend 5 days of therapy for uncomplicated non-purulent cellulitis; however, the duration should be extended to 10 days if the infection has not improved within the 5-day period or if the patient is hospitalized for more severe or extensive disease (85).
Purulent cellulitis can be accompanied by folliculitis or tender, erythematous, often fluctuant nodules or boils and is caused by S. aureus in the majority of cases. IDSA guidelines recommend incision and drainage of cutaneous abscesses (85). Two subsequent RCTs, with a majority of cases caused by methicillin-resistant S. aureus (MRSA), concluded that antimicrobial therapy for 7 to 10 days along with incision and drainage was superior to incision and drainage alone (86,87). These conclusions, however, may not apply to small (<2-cm) abscesses caused by methicillin-susceptible S. aureus (MSSA), which may only need incision and drainage.
AMMI Canada recommendations
Duration of therapy for uncomplicated, non-purulent cellulitis for adults and children is 5 to 7 days. Skin abscesses should undergo incision and drainage with culture of pus. Antimicrobial therapy should be considered if the abscess is large (>2 cm) or if MRSA is suspected. If antibiotics are prescribed, the recommended duration is 7 days. Hospitalized patients with more extensive disease may need longer courses of 10 days.
Bone and Joint Infections
Adults
An RCT of patients with vertebral osteomyelitis showed similar outcomes for 6 versus 12 weeks of antibiotic therapy (88). A non-inferiority trial of 154 adult patients with native joint septic arthritis (64% hand and wrist) randomly assigned patients to 2 or 4 weeks of antibiotic therapy post-surgical drainage and reported similar outcomes for both groups (ie, the shorter duration was non-inferior). However, the findings may not be applicable to large joints such as hips and knees, since these joints were underrepresented in the study (89). Appropriate surgical source control including drainage of joint fluid is paramount to reducing morbidity from joint infections. Management of prosthetic joint infections or septic arthritis due to Neisseria gonorrhoeae is outside the scope of this practice point.
Guidelines currently recommend a 6-week course of antimicrobials for acute native vertebral osteomyelitis, commonly due to S. aureus (90). There are no current guidelines from North American or European organizations for other native joint infections or for osteomyelitis at other sites. In 2006, the British Society for Antimicrobial Chemotherapy, in conjunction with other specialty societies, recommended 2 weeks of intravenous therapy, followed by a further 4 weeks of oral therapy; however, they acknowledged that there exists little evidence for this recommendation (91). Shorter durations of 3 to 4 weeks could be considered for non–S. aureus septic arthritis with a susceptible pathogen and adequate surgical drainage.
Children
In children, multiple studies have determined that shortening the duration of antimicrobial therapy to 3 to 4 weeks is likely sufficient to treat acute (symptom duration <4 wk), uncomplicated (rapid clinical response to therapy and rapid decline in C-reactive protein) hematogenous osteoarticular infections, which are likely due to MSSA or Kingella kingae (92–94). Treatment duration for osteomyelitis caused by MRSA or other pathogens has not been systematically studied, but it is very likely to be longer (4–6 wk), as these patients often have complicated infections.
The CPS practice point on acute hematogenous osteomyelitis recommends a total of 3 to 4 weeks of therapy with step-down to oral therapy for uncomplicated osteomyelitis. Acute osteoarticular infections caused by MRSA or other pathogens will need a more individualized approach (95). Similar recommendations are outlined in European guidelines (96).
AMMI Canada recommendations
Uncomplicated vertebral osteomyelitis should be treated for 6 weeks. There are less data available for native joint septic arthritis (excludes N. gonorrhoeae). Once source control has been achieved, septic arthritis of native joints involving the hand and fingers can be treated for 2 weeks, whereas infection of larger joints will require 4 weeks of treatment. In children, duration of therapy for acute hematogenous osteoarticular infections is usually 3 to 4 weeks, with longer courses reserved for complicated infections.
Bacteremia
Staphylococcus aureus bacteremia
Bacteremia caused by S. aureus is common, is always considered pathologic, and must be treated and managed appropriately. The source of infection may be associated with an implantable or intravascular line or a detectable focus of infection such as osteoarticular infection or infective endocarditis. All prosthetic devices or intravascular catheters should be removed, if possible, to effect cure, and an echocardiogram is recommended as part of the assessment for endocarditis.
Current data support treatment of uncomplicated S. aureus bacteremia with 14 days of intravenous antimicrobials from the first negative blood culture. Uncomplicated bacteremia is defined as S. aureus bacteremia without evidence of infective endocarditis, using echocardiography, or metastatic sites of infection (clinically or other imaging modalities), rapid (3 d) sterilization of blood cultures and rapid (<72 h) defervescence after appropriate antibiotics, and absence of prosthetic devices (97).
Newborns with S. aureus bacteremia treated less than 14 days are also more likely to have relapse of infection (81). Persistent S. aureus bacteremia beyond 72 hours despite adequate therapy may indicate endovascular or other deep-seated infection requiring prolonged therapy (usually 4–6 wk) (98). Accumulating data indicate improved outcomes and lower mortality in patients with S. aureus bacteremia whose management includes infectious diseases consultation (99,100).
AMMI Canada recommendations
Fourteen days of intravenous antimicrobials is required for cases of uncomplicated S. aureus bacteremia (see the previous section for important caveats) or for those associated with a central line, provided the catheter has been removed. However, many cases are either associated with a source (eg, musculoskeletal infection, abscesses) or complications (eg, endocarditis) and require 4 to 6 weeks of therapy. Therefore, most cases of S. aureus bacteremia should be managed in conjunction with infectious diseases consultation or input.
In healthy children, MSSA bacteremia associated with uncomplicated acute hematogenous osteomyelitis should be treated with 3 to 4 weeks of antibiotics, with intravenous to oral conversion as per recommendations (see section on osteoarticular infections).
Enterobacterales bacteremia
Adults
Bacteremia associated with pyelonephritis, generally caused by Enterobacteriaceae (such as E. coli or Klebsiella), has been traditionally treated with 7 to 14 days of antibiotics. In a meta-analysis of outcomes in 7,695 patients treated with shorter (≤7 d) versus longer courses of antibiotics, there were no differences in clinical outcomes, microbiologic cure, or mortality between the two groups (101). Subsequent to this meta-analysis, several RCTs of 7 to 8 versus 14 to 15 days of antibiotics in patients with gram-negative bacteremia (of which the majority had a urinary tract source) found that the shorter course was non-inferior to the longer course with respect to clinical outcomes (102–104). A more recent meta-analysis that compared ≤10 to >10 days of therapy in patients with bacteremia showed no differences in clinical or microbiologic cure or in mortality; however, there were only 4 studies available to assess this specific duration (105). In an observational study, when source control had been achieved, investigators found that patients with Pseudomonas bacteremia treated with a median of 9 days of therapy (interquartile range 8–10) had similar odds of recurrent infection and death as patients who received a median of 16 days (interquartile range 14–17) (106). A recent RCT in adults that evaluated 7 versus 14 days versus a C-reactive protein–guided duration study for gram-negative bacteremia found no significant differences in clinical outcomes between groups with very few recurrences (107).
Children
Definitive studies of duration of treatment for Enterobacterales bacteremia in children are not available. Although this practice point does not apply to infants younger than 2 months of age, the possibility of secondary meningitis should be considered in infants in the setting of Enterobacterales bacteremia, and, if clinically warranted, a lumbar puncture should be performed to exclude meningitis. Treatment duration and management for secondary meningitis or primary sources of infection (eg, abdominal abscesses) are beyond the scope of this practice point.
AMMI Canada recommendations
For bacteremia caused by Enterobacterales in adults, there appears to be wide variation in duration of antimicrobial therapy; however, emerging literature would support a 7-day course for uncomplicated bacteremias from pyelonephritis or from a source that has been successfully controlled. Duration of therapy for Enterobacterales bacteremia in children should follow guidelines for the specific pathogen and clinical diagnosis, being careful to exclude meningitis, especially in infants.
Central line–associated bacteremia
Bacteremia caused by coagulase-negative staphylococci associated with an intravascular device that has been removed has generally been treated with antibiotics for 5 to 7 days after catheter removal (108,109). Shorter durations of <5 days can be considered in circumstances with early catheter removal and where rapid response is seen (110).
Catheter-associated central line infections caused by Enterobacterales should include catheter removal followed by 7 to 14 days of antimicrobial therapy (109,110). Similar durations of therapy are recommended for implantable venous access devices, provided they are removed, source control is in place, and the infection is not caused by S. aureus (111).
AMMI Canada recommendations
Compared with uncomplicated S. aureus catheter-related bacteremias, which require 14 days of therapy, uncomplicated central line–associated Enterobacterales bacteremias can be treated for 7 days after catheter removal. If the pathogen is a coagulase-negative Staphylococcus, a shorter duration of 5 days following removal of the intravascular catheter is recommended, especially if there is early catheter removal and good clinical response.
Conclusions
Antibiotics are societal resources, and the emerging potential impact of losing these precious resources is enormous, as detailed in a recent Canadian report (12). Notwithstanding the societal benefits of using fewer antimicrobials, shortening durations of antibiotic therapy for individual patients is increasingly recommended as a better practice choice. Clinicians should be aware of new data and current guidelines and recommendations and adjust their practices accordingly to provide the best patient care while preserving antibiotics for future use.
Acknowledgements:
AMMI Canada is grateful to the following members for additional expert review of the document: Dr Nick Daneman (Sunnybrook Health Sciences Centre), Dr Dominik Mertz (McMaster University, Hamilton Health Sciences), Dr Neil Rau (University of Toronto, Halton Healthcare and Humber River Hospital), Dr Shaqil Peermohamed (University of Saskatchewan), and Dr Joan Robinson (University of Alberta) as well as the Infectious Diseases and Immunization Committee of the Canadian Paediatric Society.
*Members of the Antimicrobial Stewardship and Resistance Committee (ASRC) of AMMI Canada
•
Edith Blondel-Hill
•
Paul Bonar
•
John Conly
•
Peter Daley
•
Bruce Dalton
•
Linda Dresser
•
Greg German
•
Yoav Keynan
•
Tim Lau
•
Andrew Morris
•
Caroline Nott
•
David Patrick
•
Joanne Salmon
•
Yvonne Shevchuk
•
Genevieve Soucy
•
Daniel Thirion
Registry and the registration no. of the study/trial:
N/A
Funding:
No funding was received for this work.
Peer Review:
This manuscript has been peer reviewed.
Animal studies:
N/A
References
1. Livorsi D, Comer A, Matthias MS, Perencevich EN, Bair MJ. Factors influencing antibiotic-prescribing decisions among inpatient physicians: A qualitative investigation. Infect Control Hosp Epidemiol. 2015;36(9):1065–72. https://doi.org/10.1017/ice.2015.136. Medline: 26078017
2. McDonnell Norms Group. Antibiotic overuse: the influence of social norms. J Am Coll Surg. 2008;207(2):265–75. https://doi.org/10.1016/j.jamcollsurg.2008.02.035. Medline: 18656057
3. Tillett WS, McCormack JE, Cambier MJ. The treatment of lobar pneumonia with penicillin. J Clin Invest. 1945;24(4):589–94. https://doi.org/10.1172/JCI101640. Medline: 16695250
4. Spellberg B, Rice LB. Duration of antibiotic therapy: Shorter Is better. Ann Intern Med. 2019;171(3):210-1. https://doi.org/10.7326/M19-1509. Medline: 31284302
5. Aliberti S, Giuliani F, Ramirez J, Blasi F; DURATION Study Group. How to choose the duration of antibiotic therapy in patients with pneumonia. Curr Opin Infect Dis. 2015;28(2):177–84. https://doi.org/10.1097/QCO.0000000000000140. Medline: 25692271
6. Wald-Dickler N, Spellberg B. Short-course antibiotic therapy-Replacing Constantine Units with “Shorter is better.” Clin Infect Dis. 2019;69(9):1476–9. https://doi.org/10.1093/cid/ciy1134. Medline: 30615129
7. Royer S, DeMerle KM, Dickson RP, Prescott HC. Shorter versus longer courses of antibiotics for infection in hospitalized patients: a systematic review and meta-analysis. J Hosp Med. 2018 ;13(5):336–42. https://doi.org/10.12788/jhm.2905
8. Hanretty AM, Gallagher JC. Shortened courses of antibiotics for bacterial infections: a systematic review of randomized controlled trials. Pharmacotherapy. 2018;38(6):674–87. https://doi.org/10.1002/phar.2118. Medline: 29679383
9. Pouwels KB, Hopkins S, Llewelyn MJ, Walker AS, McNulty CA, Robotham JV. Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines. BMJ. 2019;364:440. https://doi.org/ 10.1136/bmj.l440. Medline: 30814052
10. Esposito S, Esposito I, Leone S. Considerations of antibiotic therapy duration in community- and hospital-acquired bacterial infections. J Antimicrob Chemother. 2012;67(11):2570–5. https://doi.org/ 10.1093/jac/dks277. Medline: 22833640
11. Versporten A, Zarb P, Caniaux I, et al. Antimicrobial consumption and resistance in adult hospital inpatients in 53 countries: results of an internet-based global point prevalence survey. Lancet Glob Health. 2018;6(6):e619–29. https://doi.org/10.1016/S2214-109X(18)30186-4
12. Council of Canadian Academies. When Antibiotics Fail. Ottawa: the Expert Panel on the Potential Socio-Economic Impacts of Antimicrobial Resistance in Canada, Council of Canadian Academies; 2019.
13. Bonomo RA, Burd EM, Conly J, et al. Carbapenemase-producing organisms: a global scourge. Clin Infect Dis. 2018;66(8):1290–7. https://doi.org/10.1093/cid/cix893. Medline: 29165604
14. Bhalodi AA, van Engelen TSR, Virk HS, Wiersinga WJ. Impact of antimicrobial therapy on the gut microbiome. J Antimicrob Chemother. 2019 Jan 1;74:i6–15. https://doi.org/10.1093/jac/dky530. Medline: 30690540
15. Baxter R, Ray GT, Fireman BH. Case-control study of antibiotic use and subsequent Clostridium difficile-associated diarrhea in hospitalized patients. Infect Control Hosp Epidemiol. 2008;29(1):44–50. https://doi.org/10.1086/524320. Medline: 18171186
16. Bell BG, Schellevis F, Stobberingh E, Goossens H, Pringle M. A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance. BMC Infect Dis. 2014;14(1):13. https://doi.org/10.1186/1471-2334-14-13. Medline: 24405683
17. Hecker MT, Aron DC, Patel NP, Lehmann MK, Donskey CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med. 2003;163(8):972–8. https://doi.org/10.1001/archinte.163.8.972. Medline: 12719208
18. Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a multihospital cohort study. Ann Intern Med. 2019;171(3):153–63. https://doi.org/10.7326/M18-3640. Medline: 31284301
19. Spellberg B. The maturing antibiotic mantra: “Shorter is still better.” J Hosp Med. 2018;13(5):361–2. https://doi.org/10.12788/jhm.2904. Medline: 29370317
20. Rice LB. The Maxwell Finland Lecture: For the duration-rational antibiotic administration in an era of antimicrobial resistance and Clostridium difficile. Clin Infect Dis. 2008;46(4):491–6. https://doi.org/10.1086/526535. Medline: 18194098
21. Pulcini C, Binda F, Lamkang AS, et al. Developing core elements and checklist items for global hospital antimicrobial stewardship programmes: a consensus approach. Clin Microbiol Infect. 2019;25(1):20–5. https://doi.org/10.1016/j.cmi.2018.03.033. Medline: 29625170
22. Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials. Br J Clin Pharmacol. 2009;67(2):161–71. https://doi.org/10.1111/j.1365-2125.2008.03306.x. Medline: 19154447
23. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152:S1–39. https://doi.org/10.1177/0194599815572097. Medline: 25832968
24. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72–112. https://doi.org/10.1093/cid/cis370
25. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-80. https://doi.org/10.1542/peds.2013-1071. Medline: 23796742
26. Le Saux N, Robinson JL, Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Management of acute otitis media in children six months of age and older. Paediatr Child Health. 2016;21(1):39–50. https://doi.org/10.1093/pch/21.1.39. Medline: 26941560
27. Tähtinen PA, Laine MK, Huovinen P, Jalava J, Ruuskanen R, Ruohola A. A placebo-controlled trial of antimicrobial treatment for acute otitis media. N Engl J Med. 2011;364:116–26. https://doi.org/10.1056/NEJMoa1007174. Medline: 21226577
28. Hoberman A, Paradise JL, Rockette HE, et al. Shortened antimicrobial treatment for acute otitis media in young children. N Engl J Med. 2016;375(25): 2446–56. https://doi.org/10.1056/NEJMoa1606043. Medline: 28002709
29. Falagas ME, Vouloumanou EK, Matthaiou DK, Kapaskelis AM, Karageorgopoulos DE. Effectiveness and safety of short-course vs long-course antibiotic therapy for group a beta-hemolytic streptococcal tonsillopharyngitis: A meta-analysis of randomized trials. Mayo Clin Proc. 2008;83(8):880–9. https://doi.org/10.4065/83.8.880. Medline: 18674472
30. Skoog Ståhlgren G, Tyrstrup M, Edlund C, et al. Penicillin V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci: Randomised controlled, open label, non-inferiority study. BMJ. 2019;367. https://doi.org/10.1136/bmj.l5337. Medline: 31585944
31. Sauve L, Forrester AM, Top DA, Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Group A streptococcal (GAS) pharyngitis: A practical guide to diagnosis and treatment Paediatrics & Child Health. (In Press)
32. National Institute for Health and Care Excellence. Sore throat (acute): antimicrobial prescribing. NICE guideline [NG84]. London: BMJ Publishing Group Limited; 2018.
33. Tansarli GS, Mylonakis E. Systematic review and meta-analysis of the efficacy of short-course antibiotic treatments for community-acquired pneumonia in adults. Antimicrob Agents Chemother. 2018;62(9):e00365–18. https://doi.org/10.1128/AAC.00635-18. Medline: 29987137
34. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45–67. https://doi.org/10.1164/rccm.201908-1581ST. Medline: 31573350
35. Greenberg D, Givon-Lavi N, Sadaka Y, Ben-Shimol S, Bar-Ziv J, Dagan R. Short-course antibiotic treatment for community-acquired alveolar pneumonia in ambulatory children: a double-blind, randomized, placebo-controlled trial. Pediatr Infect Dis J. 2014;33(2):136–42. https://doi.org/10.1097/INF.0000000000000023. Medline: 23989106
36. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:e25–76. https://doi.org/10.1093/cid/cir531. Medline: 21880587
37. Le Saux N, Robinson JL, Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Uncomplicated pneumonia in healthy Canadian children and youth: Practice points for management. Paediatr Child Health. 2011;16(7):417–20. https://doi.org/10.1093/pch/16.7.417. Medline: 22851898
38. National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing NICE guideline[NG138]. London: BMJ Publishing Group Limited; 2019.
39. Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61–111. https://doi.org/10.1093/cid/ciw353. Medline: 27418577
40. Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. 2003;290(19):2588–98. https://doi.org/ 10.1001/jama.290.19.2588. Medline: 14625336
41. Dimopoulos G, Poulakou G, Pneumatikos IA, Armaganidis A, Kollef MH, Matthaiou DK. Short- vs long-duration antibiotic regimens for ventilator-associated pneumonia: a systematic review and meta-analysis. Chest. 2013;144(6):1759–67. https://doi.org/10.1378/chest.13-0076. Medline: 23788274
42. Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J. 2017;50(3):1700582. https://doi.org/10.1183/13993003.00582-2017. Medline: 28890434
43. Martin-Loeches I, Rodriguez AH, Torres A. New guidelines for hospital-acquired pneumonia/ventilator-associated pneumonia: USA vs. Europe. Curr Opin Crit Care. 2018;24(5):347–52. https://doi.org/10.1097/MCC.0000000000000535. Medline: 30063491
44. Global Initiative for Chronic Obstructive Lung Disease. Pocket Guide to COPD Diagnosis, Management, and Prevention. 2019. https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-POCKET-GUIDE-DRAFT-v1.7-14Nov2018-WMS.pdf (Accessed 06 03, 2020)
45. Stolbrink M, Amiry J, Blakey JD. Does antibiotic treatment duration affect the outcomes of exacerbations of asthma and COPD? A systematic review. Chron Respir Dis. 2018;15(3):225–40. https://doi.org/10.1177/1479972317745734. Medline: 29232988
46. El Moussaoui R, Roede BM, Speelman P, Bresser P, Prins JM, Bossuyt PMM. Short-course antibiotic treatment in acute exacerbations of chronic bronchitis and COPD: a meta-analysis of double-blind studies. Thorax. 2008;63(5):415–22. https://doi.org/10.1136/thx.2007.090613. Medline: 18234905
47. Hopkinson NS, Molyneux A, Pink J, Harrisingh MC; Guideline Committee (GC). Chronic obstructive pulmonary disease: diagnosis and management: summary of updated NICE guidance. BMJ. 2019;366:4486. https://doi.org/10.1136/bmj.l4486. Medline: 31358491
48. Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017;49(3):1600791. https://doi.org/10.1183/13993003.00791-2016. Medline: 28298398
49. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Heal Syst Pharm. 2013;70(3):195–283. https://doi.org/10.2146/ajhp120568. Medline: 23327981
50. Berriós-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784–91. https://doi.org/10.1001/jamasurg.2017.0904. Medline: 28467526
51. Branch-Elliman W, O’Brien W, Strymish J, Itani K, Wyatt C, Gupta K. Association of duration and type of surgical prophylaxis with antimicrobial-associated adverse events. JAMA Surg. 2019;154(7):590–8. https://doi.org/10.1001/jamasurg.2019.0569. Medline: 31017647
52. Yudin MH, van Schalkwyk J, Van Eyk N. Antibiotic therapy in preterm premature rupture of the membranes. J Obstet Gyaenecol Can. 2009;31(9):863–7. https://doi.org/10.1016/S1701-2163(16)34305-5
53. World Health Organization. Global guidelines for the prevention of surgical site infection, second edition. Geneva: WHO Press; 2018.
54. Smaill FM, Grivell RM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Syst Rev. 2014;2014(10):CD007482. https://doi.org/10.1002/14651858.CD007482.pub3. Medline: 25350672
55. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 199: Use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2018;132(3):e103–19.
56. Ban KA, Minei JP, Laronga C, et al. Executive summary of the American College of Surgeons/Surgical Infection Society surgical site infection guidelines-2016 update. Surg Infect (Larchmt). 2017;18(4):379–82. https://doi.org/10.1089/sur.2016.214. Medline: 28541808
57. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(2): 133–64. https://doi.org/10.1086/649554. Medline: 20034345
58. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015;372(21):1996–2005. https://doi.org/10.1056/NEJMoa1411162. Medline: 25992746
59. Montravers P, Tubach F, Lescot T, et al. Short-course antibiotic therapy for critically ill patients treated for postoperative intra-abdominal infection: the DURAPOP randomised clinical trial. Intensive Care Med. 2018;44(3):300–10. https://doi.org/10.1007/s00134-018-5088-x. Medline: 29484469
60. Tinusz B, Szapáry L, Paládi B, et al. Short-course antibiotic treatment is not inferior to a long-course one in acute cholangitis: a systematic review. Dig Dis Sci. 2019;64(2):307–15. https://doi.org/10.1007/s10620-018-5327-6. Medline: 30368681
61. Mazuski JE, Tessier JM, May AK, et al. The surgical infection society revised guidelines on the management of intra-abdominal infection. Surg Infect (Larchmt). 2017;18(1):1–76. https://doi.org/10.1089/sur.2016.261. Medline: 28085573
62. Gomi H, Solomkin JS, Schlossberg D, et al. Tokyo guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):3–16. https://doi.org/10.1002/jhbp.560. Medline: 29878697
63. Mayumi T, Okamoto K, Takada T,et al. Tokyo guidelines 2018: management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):96–100. https://doi.org/10.1002/jhbp.519. Medline: 29090868
64. Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):1611–5. https://doi.org/10.1093/cid/ciz021. Medline: 31506700
65. AMMI CANADA. Symptom-free pee: Let it be. https://www.ammi.ca/?ID=127 (Accessed 06 03, 2020)
66. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103–20. https://doi.org/10.1093/cid/cir102
67. Huttner A, Kowalczyk A, Turjeman A, et al. Effect of 5-day nitrofurantoin vs single-dose fosfomycin on clinical resolution of uncomplicated lower urinary tract infection in women. JAMA. 2018;319(17): 1781–9. https://doi.org/10.1001/jama.2018.3627. Medline: 29710295
68. Falagas ME, Vouloumanou EK, Samonis G, Vardakas KZ. Fosfomycin. Clin Microbiol Rev. 2016;29(2): 321–47. https://doi.org/10.1128/CMR.00068-15. Medline: 26960938
69. Tandan M, Cormican M, Vellinga A. Adverse events of fluoroquinolones vs. other antimicrobials prescribed in primary care: a systematic review and meta-analysis of randomized controlled trials. Int J Antimicrob Agents. 2018;52(5):529–40. https://doi.org/10.1016/j.ijantimicag.2018.04.014. Medline: 29702230
70. Gorelik E, Masarwa R, Perlman A, et al. Fluoroquinolones and cardiovascular risk: a systematic review, meta-analysis and network meta-analysis. Drug Saf. 2019;42(4):529–38. https://doi.org/10.1007/s40264-018-0751-2. Medline: 30368737
71. Drekonja DM, Rector TS, Cutting A, Johnson JR. Urinary tract infection in male veterans treatment patterns and outcomes. JAMA Intern Med. 2013; 173(1):62–8. https://doi.org/10.1001/2013.jamainternmed.829. Medline: 23212273
72. Robinson JL, Finlay JC, Lang ME, Bortolussi R, Canadian Paediatric Society, Infectious Diseases and Immunization Committee, Community Paediatrics Committee. Urinary tract infections in infants and children: diagnosis and management. Paediatr Child Health. 2014;19(6):315–25. https://doi.org/10.1093/pch/19.6.315. Medline: 25332662
73. Eliakim-Raz N, Yahav D, Paul M, Leibovici L. Duration of antibiotic treatment for acute pyelonephritis and septic urinary tract infection-- 7 days or less versus longer treatment: systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother. 2013;68(10):2183–91. https://doi.org/10.1093/jac/dkt177. Medline: 23696620
74. van Nieuwkoop C, van der Starre WE, Stalenhoef JE, et al. Treatment duration of febrile urinary tract infection: a pragmatic randomized, double-blind, placebo-controlled non-inferiority trial in men and women. BMC Med. 2017 Dec 3;15(1):70. https://doi.org/10.1186/s12916-017-0835-3. Medline: 28366170
75. Kyriakidou KG, Rafailidis P, Matthaiou DK, Athanasiou S, Falagas ME. Short-versus long-course antibiotic therapy for acute pyelonephritis in adolescents and adults: a meta-analysis of randomized controlled trials. Clin Ther. 2008;30(10):1859–68. https://doi. org/10.1016/j.clinthera.2008.10.007. Medline: 19014841
76. Sandberg T, Skoog G, Hermansson AB, et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012;380(9840):484–90. https://doi.org/ 10.1016/S0140-6736(12)60608-4
77. Elbaz M, Zadka H, Weiss-Meilik A, Ben-Ami R. Effectiveness and safety of an institutional aminoglycoside-based regimen as empirical treatment of patients with pyelonephritis. J Antimicrob Chemother. 2020;75(8):2307-13.https://doi.org/ 10.1093/jac/dkaa148. Medline: 32451549
78. National Institute for Health and Care Excellence. Pyelonephritis (acute): antimicrobial prescribing. London: BMJ Publishing Group Limited; 2018.
79. Strohmeier Y, Hodson EM, Willis NS, Webster AC, Craig JC. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev. 2014;28(7):CD003772. https://doi.org/10.1002/14651858.CD003772.pub4. Medline: 25066627
80. Fox MT, Amoah J, Hsu AJ, Herzke CA, Gerber JS, Tamma PD. Comparative effectiveness of antibiotic treatment duration in children with pyelonephritis. JAMA Netw Open. 2020;3(5):e203951. https://doi.org/10.1001/jamanetworkopen.2020.3951. Medline: 32364593
81. Chowdhary G, Dutta S, Narang A. Randomized controlled trial of 7-Day vs. 14-Day antibiotics for neonatal sepsis. J Trop Pediatr. 2006;52(6):427–32. https://doi.org/10.1093/tropej/fml054.
82. Cranendonk DR, Opmeer BC, van Agtmael MA, et al. Antibiotic treatment for 6 days versus 12 days in patients with severe cellulitis: a multicentre randomized, double-blind, placebo-controlled, non-inferiority trial. Clin Microbiol Infect. 2020;26(5):606–12. https://doi.org/10.1016/j.cmi.2019.09.019. Medline: 31618678
83. Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC. Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med. 2004;164(15):1669–74. https://doi.org/10.1001/archinte.164.15.1669. Medline: 15302637
84. Chlebicki MP, Oh CC. Recurrent cellulitis: risk factors, etiology, pathogenesis and treatment. Curr Infect Dis Rep. 2014;16(9):422. https://doi.org/10.1007/s11908-014-0422-0. Medline: 24980389
85. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10–52. https://doi.org/10.1093/cid/ciu296. Medline: 24947530
86. Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim–sulfamethoxazole versus placebo for uncomplicated skin abscess. N Engl J Med. 2016;374(9):823–32. https://doi.org/10.1056/NEJMoa1507476. Medline: 26962903
87. Daum RS, Miller LG, Immergluck L, et al. A placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J Med. 2017;376(26):2545–55. https://doi.org/10.1056/NEJMoa1607033. Medline: 28657870
88. Bernard L, Dinh A, Ghout I, et al. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Lancet. 2015;385(9971):875–82. https://doi.org/10.1016/S0140-6736(14)61233-2
89. Gjika E, Beaulieu J-Y, Vakalopoulos K, et al. Two weeks versus four weeks of antibiotic therapy after surgical drainage for native joint bacterial arthritis: a prospective, randomised, non-inferiority trial. Ann Rheum Dis. 2019;78(8):1114–21. https://doi.org/10.1136/annrheumdis-2019-215116. Medline: 30992295
90. Berbari EF, Kanj SS, Kowalski TJ, et al. 2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clin Infect Dis. 2015;61(6):e26–46. https://doi.org/10.1093/cid/civ482. Medline: 26229122
91. Coakley G, Mathews C, Field M, et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology (Oxford). 2006;45(8):1039–41. https://doi.org/10.1093/rheumatology/kel163a. Medline: 16829534
92. Peltola H, Pääkkönen M, Kallio P, Kallio MJT; Osteomyelitis-Septic Arthritis Study Group. Short- versus long-term antimicrobial treatment for acute hematogenous osteomyelitis of childhood: prospective, randomized trial on 131 culture-positive cases. Pediatr Infect Dis J. 2010;29(12):1123–8. https://doi.org/10.1097/INF.0b013e3181f55a89. Medline: 20842069
93. Jagodzinski NA, Kanwar R, Graham K, Bache CE. Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children. J Pediatr Orthop. 2009;29(5):518–25. https://doi.org/10.1097/BPO.0b013e3181ab472d. Medline: 19568027
94. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015;169(2):120–8. https://doi.org/10.1001/jamapediatrics.2014.2822. Medline: 25506733
95. Le Saux N. Diagnosis and management of acute osteoarticular infections in children. Paediatr Child Health. 2018;23(5):336–43. https://doi.org/10.1093/pch/pxy049. Medline: 30653632
96. Saavedra-Lozano J, Falup-Pecurariu O, Faust SN, Girschick H, Hartwig N, Kaplan S, et al. Bone and joint infections. Pediatr Infect Dis J. 2017 Aug;36(8):788–99. https://doi.org/10.1097/INF.0000000000001635. Medline: 28708801
97. Chong YP, Moon SM, Bang K-M, et al. Treatment duration for uncomplicated staphylococcus aureus bacteremia to prevent relapse: Analysis of a prospective observational cohort study. Antimicrob Agents Chemother. 2013;57(3):1150–6. https://doi.org/10.1128/AAC.01021-12. Medline: 23254436
98. Holland TL, Arnold C, Fowler VG. Clinical management of staphylococcus aureus bacteremia: A review. JAMA. 2014;312(13):1330–41. https://doi.org/10.1001/jama.2014.9743. Medline: 25268440
99. Pragman AA, Kuskowski MA, Abraham JM, Filice GA. Infectious disease consultation for Staphylococcus aureus bacteremia improves patient management and outcomes. Infect Dis Clin Pract (Baltim Md). 2012; 20(4):261–7. https://doi.org/10.1097/IPC.0b013e318255d67c. Medline: 23049234
100. Sherbuk JE, McManus D, Topal JE, Malinis M. Improved mortality in Staphylococcus aureus bacteremia with the involvement of antimicrobial stewardship team and infectious disease consultation. Infect Control Hosp Epidemiol. 2019;40(8):932–5. https://doi.org/10.1017/ice.2019.136. Medline: 31196239
101. Havey TC, Fowler RA, Daneman N. Duration of antibiotic therapy for bacteremia: a systematic review and meta-analysis. Crit Care. 2011;15(6):R267. https://doi.org/10.1186/cc10545. Medline: 22085732
102. Yahav D, Franceschini E, Koppel F, et al. Seven versus 14 days of antibiotic therapy for uncomplicated gram-negative bacteremia: a noninferiority randomized controlled trial. Clin Infect Dis. 2019;69(7):1091–8. https://doi.org/10.1093/cid/ciy1054. Medline: 30535100
103. Daneman N, Rishu AH, Pinto R, et al. 7 versus 14 days of antibiotic treatment for critically ill patients with bloodstream infection: a pilot randomized clinical trial. Trials. 2018;19(1):111. https://doi.org/10.1186/s13063-018-2474-1. Medline: 29452598
104. Chotiprasitsakul D, Han JH, Cosgrove SE, et al. Comparing the outcomes of adults with Enterobacteriaceae bacteremia receiving short-course versus prolonged-course antibiotic therapy in a multicenter, propensity score-matched cohort. Clin Infect Dis. 2018;66(2):172–7. https://doi.org/10.1093/cid/cix767. Medline: 29190320
105. Tansarli GS, Andreatos N, Pliakos EE, Mylonakis E. A Systematic review and meta-analysis of antibiotic treatment duration for bacteremia due to Enterobacteriaceae. Antimicrob Agents Chemother. 2019;63(5):e02495–18. https://doi.org/10.1128/AAC.02495-18. Medline: 30803971
106. Fabre V, Amoah J, Cosgrove SE, Tamma PD. Antibiotic therapy for Pseudomonas aeruginosa bloodstream infections: How long is long enough? Clin Infect Dis. 2019;69(11):2011–4. https://doi.org/10.1093/cid/ciz223. Medline: 30882137
107. Von Dach E, Albrich WC, Brunel AS, et al. Effect of C-reactive protein-guided antibiotic treatment duration, 7-day treatment, or 14-day treatment on 30-day clinical failure rate in patients with uncomplicated gram-negative bacteremia: a randomized clinical trial. JAMA. 2020;323(21):2160–9. https://doi.org/10.1001/jama.2020.6348. Medline: 32484534
108. Chesshyre E, Goff Z, Bowen A, Carapetis J. The prevention, diagnosis and management of central venous line infections in children. J Infect. 2015;71(S1):59–75. https://doi.org/10.1016/j.jinf.2015.04.029. Medline: 25934326
109. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49(1):1–45. https://doi.org/10.1086/ 599376. Medline: 19489710
110. Hebeisen UP, Atkinson A, Marschall J, Buetti N. Catheter-related bloodstream infections with coagulase-negative staphylococci: Are antibiotics necessary if the catheter is removed? Antimicrob Resist Infect Control. 2019;8(1):21. https://doi.org/10.1186/s13756-019-0474-x. Medline: 30719282
111. Lebeaux D, Fernández-Hidalgo N, Chauhan A, et al. Management of infections related to totally implantable venous-access ports: challenges and perspectives. Lancet Infect Dis. 2014;14(2):146–59. https://doi.org/10.1016/S1473-3099(13)70266-4
Information & Authors
Information
Published In
Official Journal of the Association of Medical Microbiology and Infectious Disease Canada
Volume 6 • Number 3 • September 2021
Pages: 181 - 197
Copyright
2021 AMMI Canada.
History
Published ahead of print: 15 September 2021
Published in print: September 2021
Published online: 27 September 2022
Keywords:
Mots-clés :
Authors
Contributors:
Conceptualization, NL, JG; Methodology, NL, JG; Validation, NL, JG; Investigation, NL, JG; Resources, NL, JG; Data Curation, NL, JG; Writing – Original Draft, NL, JG; Writing – Review & Editing, NL, JG, AMR committee; Visualization, NL, JG; Supervision, NL, JG; Project Administration, NL, JG.
Disclosures:
The authors have nothing to disclose.
Ethics Approval:
N/A
Informed Consent:
N/A
Metrics & Citations
Metrics
Related Content
Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
Download article citation data for:
Journal of the Association of Medical Microbiology and Infectious Disease Canada 2021 6:3, 181-197
Journal of the Association of Medical Microbiology and Infectious Disease Canada 2021 6:3, 181-197