The ShortversusLong Antibiotic Course for Pleural Infection Management (SLIM) randomised controlled open-label trial

Abstract

IntroductionBased on expert opinion the length of antibiotic treatment for pleural infection in adults is typically recommended to be a minimum of four weeks. This clinical trial aimed to assess whether shorter antibiotic courses lead to more treatment failures than standard longer courses.MethodsIn an open-label randomised controlled trial adult patients with pleural infection who were medically treated and stabilised within 14 days of admission were randomised to either a short antibiotic course (total course 14–21 days) or a long antibiotic course (total course 28–42 days). Patients were excluded if their baseline RAPID score was >4 (high-risk category). The primary outcome was the incidence of treatment failure by 6 weeks post admission. Secondary outcomes were total length of antibiotic treatment, proportion of patients who resumed normal activity levels within 6 weeks post admission, time from discharge to resuming normal activity levels and the incidence of antibiotic-related adverse reactions.ResultsBetween September 2020 and October 2021 50 patients (35 (70%) males, mean age 46±13.7 years), were recruited to the trial and randomly assigned to the short course group (n=25) or the long course group (n=25) with outcome data available for 24 patients in each study group. Treatment failure occurred in 4 (16.7%) patients in the short course group and 3 (12.5%) patients in the long course group. In the intention-to-treat analysis the odds ratio for treatment failure in the long course group was 0.714 (95% CI 0.142–3.600, p=0.683). The median duration of antibiotic treatment in the short course group was 20.5 [18–22.5] days compared to 34.5 [32–38] days in the long course group (p <0.001). There were no statistically significant differences in the other outcomes.ConclusionIn medically treated adult patients with pleural infection a long course of antimicrobial therapy did not lead to less treatment failures in comparison to a shorter course. These findings need to be confirmed in a larger multi-centre trial.

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

“…In 2021, a study examining short versus long antibiotic courses for treating infections revealed no difference in effectiveness but found that longer durations were linked to more hospital admissions due to complications [ 39 ]. Research on 4 million cases in England indicated that prescriptions of 8–15 days had higher risks compared to shorter treatments.…”

Medical treatment of pleural infection: antibiotic duration and corticosteroid usefulness

“…SLIM was an open label, RCT of adults with pleural infection that aimed to compare the efficacy and safety of a short antibiotic course to those of a long antibiotic course [ 9 ]. Eligibility required hospital admission due to community- or hospital-acquired pleural infection, low-to-intermediate RAPID (renal, age, purulence, infection source, dietary factors) score ( i.e.…”

“…Until recently, no randomised controlled trial (RCT) had ever assessed the appropriate duration of antibiotics in pleural infection, and therefore, an antibiotic course of at least 3 weeks was usually administered, based on extrapolation of data for the treatment of lung abscess [ 3 ]. This is why the publication of two recent trials (Optimal Duration of Antibiotics in Parapneumonic Effusions (ODAPE) and Short versus Long antibiotic course for pleural Infection Management (SLIM)) evaluating the efficacy of shorter antibiotic courses in pleural infection has gathered great interest [ 9 , 10 ]. Regarding medical treatment beyond antibiotics, the intense pleural inflammation that characterises pleural infection has raised the hypothesis of a possible benefit from the use of anti-inflammatory drugs.…”

Infective Pleural Effusions—A Comprehensive Narrative Review Article

“…Treatment failure occurred in 16.7% of patients in the short-course group and 12.5% of patients in the long-course group. In the intention-to-treat analysis, the odds ratio for treatment failure in the long-course group was 0.714 (95% CI 0.142–3.600, p = 0.683) [ 48 ]. The ODAPE trial was a noninferiority double-blind randomized control trial assessing a 2-week versus 3-week antibiotic strategy, and it showed excellent success rates in the group treated with a 2-week course, provided successful drainage and clinical stability had been achieved [ 49 ].…”