More than two-thirds of patients hospitalised with pneumonia were prescribed with excess duration of antibiotic therapy, reports a retrospective cohort study conducted in 43 hospitals in Michigan, United States.¹

Antibiotics overprescribing is frequently encountered in healthcare institutions across the globe,^2-4 and is well known to contribute to the global health threat called antimicrobial resistance (AMR).⁵ AMR is widely observed including in patients with pneumonia; common pneumonia-causing bacteria such as Streptococcus pneumoniae, Haemophilus influenzae and Klebsiella pneumoniae have been found to resist several classes of antibiotics.^2,3 The emergence of these antibiotic-resistant strains has made treating pneumonia increasingly challenging. Measures to prevent the increase of AMR focus on controlling antibiotic overprescribing, including the unnecessarily long duration of antibiotic use.

In a recent study, Vaughn et al. examined predictors and outcomes associated with excess duration of antibiotic treatment among hospitalised patients with pneumonia.¹ The study revealed that 67.8% of the patients received excessive antibiotic therapy, and 93.2% of the total excess duration of antibiotic were prescribed as medication after discharge. The analysis included almost 6,500 patients.¹ Excessive duration of antibiotic use were more likely to be found in patients who had respiratory culture or non-culture diagnostic testing, longer hospital stay, high-risk antibiotic use in the last 90 days, community-acquired pneumonia and undocumented treatment duration at discharge.¹

The high rate of excessive antibiotic use may reflect inadequate level of awareness against antimicrobial resistance.  The authors mentioned that conventional, longer courses of antibiotics are commonly preferred by physicians due to concerns of relapse or progression with short courses of antibiotic.¹ This cautious mindset may have led physicians to prescribe unnecessary longer duration of antibiotics. To the contrary, however, recent studies – including more than 45 randomised controlled trials – have demonstrated that a short course of antibiotic therapy may be as efficacious as a long course of antibiotic therapy. ^6-9

Thus, in an editorial accompanying the above study, experts, Dr Brad Spellberg and Dr Loius B. Rice advocate the implementation of prescribing short courses of antibiotics over conventional therapy, supporting the efforts to increase awareness against AMR with a series of commentaries called ‘Antibiotic mantra – Shorter is better’.^8-10

Apart from being equally effective with a reduced risk of AMR, a shorter duration of treatment also reduces the cost of treatment as well as the duration of hospitalisation, especially for antibiotics that must be administered intravenously.¹¹ In addition, it also reduces the probability of missed doses, hence, increasing patient’s adherence. In one of his editorials, Dr Spellberg also highlighted that reduced exposure to antibiotics intrinsically reduces risk of adverse events.¹⁰

The benefits of short courses of antibiotics are well documented and its role in addressing the emergence of AMR is crucial in preserving antibiotics’ effectiveness against pathogens. However, the current level of awareness among healthcare professional regarding this matter is still inadequate. Educational initiatives for physicians on the evidence and benefits of short courses of antibiotics should be reinforced.

References

1. Vaughn VM, et al. Intern. Med. 2019. doi:10.7326/M18-3640. [Epub ahead of print]
2. World Health Organization. Antimicrobial resistance: global report on surveillance. 2014. Available at: https://www.who.int/drugresistance/documents/surveillancereport/en/. Accessed 8 August 2019.
3. Schrag SJ, et al. Communicable Diseases Cluster. (‎2001)‎. Resistant pneumococcal infections: the burden of disease and challenges in monitoring and controlling antimicrobial resistance. Available at: https://apps.who.int/iris/handle/10665/66846. Accessed 8 August 2019.
4. Kmietowicz Z. BMJ 2018;360:
5. Llor C, Bjerrum L. Therapeutic Advances in Drug Safety 2014;5:229–241.
6. Tansarli GS, Mylonakis E. Antimicrob Agents Chemother 2018;62:e00635-18.
7. Chen CW, et al. Infect Drug Resist 2019;12:1353–1361.
8. Spellberg B. JAMA Intern Med 2016;176:
9. Spellberg B, Rice LB. Ann Intern Med doi:10.7326/M19-1509. [Epub ahead of print]
10. Spellberg B. J Hosp Med 2018;13:361-362.
11. Opmeer BC, et al. J Antimicrob Chemother 2007;60:;1131–1136.