Optimal duration of antibiotic treatment for community-acquired pneumonia in adults: a systematic review and duration-effect meta-analysis

Abstract

ObjectivesTo find the optimal treatment duration with antibiotics for community-acquired pneumonia (CAP) in adults.DesignSystematic review and duration-effect meta-analysis.Data sourcesMEDLINE, Embase and CENTRAL through 25 August 2021.Eligibility criteriaAll randomised controlled trials comparing the same antibiotics used at the same daily dosage but for different durations for CAP in adults. Both outpatients and inpatients were included but not those admitted to intensive care units. We imposed no date, language or publication status restriction.Data extraction and synthesisData extraction by two independent reviewers. We conducted a random-effects, one-stage duration-effect meta-analysis with restricted cubic splines. We tested the non-inferiority with the prespecified non-inferiority margin of 10% examined against 10 days . The primary outcome was clinical improvement on day 15 (range 7–45 days). Secondary outcomes: all-cause mortality, serious adverse events and clinical improvement on day 30 (15–60 days).ResultsWe included nine trials (2399 patients with a mean (SD) age of 61.2 (22.1); 39% women). The duration-effect curve was monotonic with longer duration leading to a lower probability of improvement, and shorter treatment duration (3–9 days) was likely to be non-inferior to 10-day treatment. Harmful outcome curves indicated no association. The weighted average percentage of the primary outcome in the 10-day treatment arms was 68%. Using that average, the absolute clinical improvement rates of the following durations were: 3-day treatment 75% (95% CI: 68% to 81%), 5-day treatment 72% (95% CI: 66% to 78%) and 7-day treatment 69% (95% CI: 61% to 76%).ConclusionsShorter treatment duration (3–5 days) probably offers the optimal balance between efficacy and treatment burden for treating CAP in adults if they achieved clinical stability. However, the small number of included studies and the overall moderate-to-high risk of bias may compromise the certainty of the results. Further research on the shorter duration range is required.PROSPERO registration numberCRD 42021273357.

Shorter and Longer Antibiotic Durations for Respiratory Infections: To Fight Antimicrobial Resistance—A Retrospective Cross-Sectional Study in a Secondary Care Setting in the UK

“…However, the conclusions are tempered by the small number of studies and the potential for bias. Additional research is necessary, especially for patients with severe illness [ 42 ]. This study does not provide sufficient evidence to support the superiority of shorter antibiotic treatment durations over longer ones.…”

Controversies in the management of community-acquired pneumonia in adults

“… 6 , 7 Recent meta-analyses of randomised controlled trials (RCTs) have also demonstrated that a duration of therapy of 7 days or shorter is equivalent to 7 to 14 days of antibiotic therapy, which was historically considered standard for CAP. 12 , 27 - 29 Shortening the standard duration has many potential benefits including a reduced risk of antibiotic-associated harms (including adverse events and antimicrobial resistance), improved adherence to therapy, and lower healthcare costs. 27 Longer durations of therapy are recommended for complicated infections (e.g.…”

“… 12 , 27 - 29 Shortening the standard duration has many potential benefits including a reduced risk of antibiotic-associated harms (including adverse events and antimicrobial resistance), improved adherence to therapy, and lower healthcare costs. 27 Longer durations of therapy are recommended for complicated infections (e.g. pneumonia complicated by empyema or infective endocarditis) and for directed therapy to treat certain pathogens such as Mycobacterium tuberculosis .…”

Diagnostic and Prognostic Roles of Procalcitonin and Other Tools in Community-Acquired Pneumonia: A Narrative Review

“…A systematic review and Bayesian meta-analysis pointed out that a gram stain was adequately accurate to diagnose S. pneumoniae and H. influenzae in those with CAP [29]. With good-quality specimens, it can form a basis of clinical actions for specified antibiotic therapies for certain pathogens.…”

“…Five-day treatment and longer antibiotic courses for CAP resulted in similar clinical and microbiological responses and exhibited comparable safety profiles [109]. However, recent analyses pointed out that a shorter treatment duration (3-5 days) probably offers the optimal balance between efficacy and treatment burden for treating CAP in adults if they achieved clinical stability [29].…”