Dr Chih-Cheng Lai, MD, PhD
Consultant, Intensive Care Medicine,
Kaohsiung Veterans General Hospital Tainan Branch

There are several factors to be considered before deciding a suitable agent, dosage and duration of antimicrobial regimen for the treatment of any infection. These include the site of infection, pharmacokinetic, efficacy and safety profile of the agent, and its cost-effectiveness.¹ Another major factor that should be top of mind is the risk of developing antimicrobial-resistance (AMR), recently listed by the World Health Organization as one of the ten threats to global health.²

Inappropriate prescribing of antimicrobials is well recognized to be one of the factors contributing to AMR.^3,4 The potential impact of using abbreviated courses of antimicrobial as an approach to AMR prevention has been investigated;^5–7 the use of a high dose antimicrobial over a shorter antimicrobial course may be an effective strategy for managing infection while minimising the risk of AMR.⁸

Dr Chih-Cheng Lai – an expert in infectious diseases from the Kaohsiung Veterans General Hospital Tainan Branch – shares insights on the use of abbreviated courses versus conventional regimens of antimicrobial therapy.

Q1: Decades of research have provided us with numerous choices of antimicrobial agents and regimens. In your experience, what are the major factors influencing physicians’ choice of antimicrobial regimens for acute bacterial infections?

A1: Many factors can influence the physician’s choice of antimicrobial regimen for an acute bacterial infection. Antibiotic susceptibility, clinical efficacy, tissue penetration, side effects and cost are the major factors in selecting an appropriate antibiotic agent and regimen in the treatment of an infectious disease.¹

Q2: Earlier this year, a group of experts including yourself published a meta-analysis comparing the use of high-dose, short-course levofloxacin versus a conventional regimen in treating acute bacterial infections.⁸ What were the main findings of the study?

A2: A high-dose, short-course levofloxacin regimen can exhibit similar clinical efficacy and microbiologic eradication rate as a conventional regimen in the treatment of acute bacterial infections.⁸ These infections include community-acquired pneumonia, complicated urinary tract infection, acute pyelonephritis and acute sinusitis. In addition, the high-dose, short-course levofloxacin regimen was as well-tolerated as the conventional regimen.⁸

Q3: What are the potential benefits of high-dose, short-course regimens in comparison with conventional regimens?

A3: A high-dose, short-course regimen can reduce the duration of therapy. This can mean shorter hospital stays and lower hospitalisation costs than those cost by a conventional regimen. In addition, a higher dose antibiotic means that the peak concentration is increased, thereby, enhancing microbiologic eradication and potentially reducing the risk of resistant strains emerging.

Q4: Based on your clinical experience, what might be the barriers to physicians adopting the high-dose, short-course regimen in managing acute bacterial infections?

A4: Studies investigating the usefulness of high-dose, short course regimen in the treatment of severe infections are limited. Thus, there are concerns among physicians about the efficacy and safety of high-dose, short-course regimens for patients with severe infections.

Q5: In your opinion, what can be done to raise awareness and increase the adoption of high-dose, short-course antibiotic regimens for bacterial infections?

A5: We need more evidence on the benefits of high-dose, short-course antibiotic regimens in the treatment of severe bacterial infections. Increased use of these regimens in clinical practice could mean reduced treatment costs. The cost of hospitalization can be expensive and short-course regimens may help to reduce hospital stay and lower hospitalisation costs. Most importantly, physicians should be informed that the clinical efficacy of high-dose, short-course is similar as conventional regimens.

References

1. Leekha S, et al. Mayo Clin Proc 2011;86:156–167.
2. World Health Organization. Ten threats to global health in 2019. Available at: https://www.who.int/emergencies/ten-threats-to-global-health-in-2019. Accessed 1 August 2016.
3. Kmietowicz Z. BMJ 2018;360:
4. Chua KP, et al. BMJ 2019;364:
5. Anderson VR, Perry CM. Drugs 2008;68:535–565.
6. Vaughn VM, et al. Ann Intern Med doi:10.7326/M18-3640. [Epub ahead of print]
7. Spellberg B, Rice LB. Ann Intern Med doi:10.7326/M19-1509. [Epub ahead of print]
8. Chen CW, et al. IDR 2019;12:1353–1361.