Shorter Courses of Antibiotics May Sometimes Be Better in the Long Run

NOVEMBER 18, 2016
For many years, prescribers have instructed patients to finish their entire course of antibiotics even after they start feeling better. However, recent study results have shown that longer durations of antibiotics are not always beneficial. The question many patients and prescribers are starting to ask is whether or not shorter courses are superior. The idea behind finishing the full course of antibiotics was that it was thought to increase the chance of curing the infection, as well as decrease the risk of antibiotic resistance. New study results, though, have shown that shorter course antibiotics are equally efficacious, and in some cases, may be preferred in certain disease processes. It’s important to recognize that not all patients, nor all infections are to be treated equally. Infection type, severity, potential for relapse, immune status, and antibiotic choice are all factors that should be considered prior to determining the duration of therapy. The following list details the duration of treatment and describes when shorter antibiotic courses may be appropriate.
 
Acute sinusitis1:
  • Many cases are viral and cannot be treated by antibiotics
  • According to the Infectious Disease Society of America’s guidelines, the duration of treatment for bacterial infections should be 5 to 10 days
  • A meta-analysis completed in Britain determined that a 5-day course is as effective as a 10-day course
Acute Otitis Media2,3:
  • Some cases are self-limiting and viral; therefore, recommend pain relievers such as acetaminophen
  • Treatment guidelines vary from 5 to 10 days depending on age and severity
  • Children <2 years of age, who’ve had recurrent infections, and who’ve had ruptured eardrums should receive 10 days of therapy
  • Uncomplicated infections ≥2 years of age should receive 3 days or fewer
  •  
Uncomplicated Adult Urinary Tract Infections (UTI)4,5:
  • 3-day courses are equally effective as 5- to 10-day treatment courses
  • Encourage practitioners and patients to use trimethoprim/sulfamethoxazole for 3 days and nitrofurantoin for 5 days
  • Note: patients with complicated UTIs, patients who are pregnant, and elderly patients will still require longer lasting courses
Cellulitis6:
  • Uncomplicated infections can be treated with a 5-day course versus a 10-day course
  • Complicated infections or immunosuppressed should receive longer courses (typically 10 days or longer)
Strep Throat7:
  • Group A strep will require 10 days of amoxicillin/penicillin
  • Alternative to 10-day oral treatment is a one-time intramuscular dose of benzathine penicillin G 
  • 10-day treatment with a first-generation cephalosporin for all patients except anaphylactic penicillin allergic patients
  • 5 days of azithromycin in patients with an anaphylactic allergy to penicillin
****Note: strep throat should be treated with the appropriate antibiotic and for a longer duration to prevent complications such as rheumatic fever***
 
There are many benefits to using shorter courses of antibiotics. By limiting the normal flora to antibiotic exposure, this lowers the risk of antibiotic resistance. Shorter courses may be cheaper for some patients in addition to increasing the likelihood of adherence. Due to a decreased exposure to antibiotics, the number of unwanted adverse effects is also lowered.
 
Although some disease processes can be treated with shorter courses, it’s important to recognize when shorter courses are inappropriate.
 
References
1. 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):72-112. doi: 10.1093/cid/cir1043.
2. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013;131(3): 964-999.
3. Effectiveness of shortened course (<3 days) of antibiotics for treatment of acute otitis media in children: a systematic review of randomized controlled trials. 2009.  World Health Organization website. http://apps.who.int/iris/bitstream/10665/44177/1/9789241598446_eng.ped?ua=1&ua=1. Accessed November 4, 2016.
4. 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 Disease Society of America and the European Society for Microbiology and Infections Diseases. Clin Infect Dis. 2011;52(5):103-120. doi: 10.1093/cid/ciq257.
5. Genao L, Buhr GT. Urinary tract infections in older adults residing in long-term care facilities. Ann Longterm Care. 2012;20:33-38.
6. 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):147-159. doi: 10.1093/cid/ciu296.
7. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guidelines for the diagnosis and management of group a streptococcal pharyngitis: 2012 update by the Infections Diseases Society of America. Clin Infect Dis. 2012;55(10):86-102. doi: 10.1093/cid/cis629.



Nicole Leimbach, PharmD
Nicole Leimbach, PharmD, is a recent Texas Tech University Health Sciences Center School of Pharmacy graduate with emphasis in the areas of patient care and counseling. While in pharmacy school, she was the chairperson for numerous health fair events through the American Pharmacists Association. Her strong clinical pharmacy background combined with her history as a competitive and professional tennis player gives her unique perspective to help patients live healthier lives.
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