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Article pour les cliniciens

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La durée du traitement antibiotique pour la pneumonie acquise en communauté: un essai clinique randomisé multicentrique.

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• Uranga A
• Espana PP
• Bilbao A
• Quintana JM
• Arriaga I
• Intxausti M, et al.

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Commentaires cliniques (en anglais)

Emergency Medicine

Important paper for admitting services; less relevant for EM as the patient population was admitted to hospital.

Hospital Doctor/Hospitalists

Patients have always been told to complete their antibiotic course, and now we know better (sort of). Good step towards better antibiotic stewardship.

Hospital Doctor/Hospitalists

Thoughtful and useful study in that it adds to my confidence in following the current IDSA/ATS guidelines that shorter antibiotic therapy is as good as longer treatment for CAP - as it has now been shown for a variety of other infections as well. Helpful that the study included sicker patients with PSI classes IV -V, who did better with shorter courses of antibiotics. Most of the patients were taking quinolones, so readers need to decide how this affects applicability to their own patients.

Hospital Doctor/Hospitalists

The investigators randomized patients >=18 years hospitalized with community acquired pneumonia (radiologic or clinical diagnosis) at 5 days of therapy to continue antibiotics until vital signs are stable (temperature <=37.8 C x 48 hours, SBP >=90 mm Hg, HR <= 100 bpm, RR <=24 bpm, O2 sat >=90% or PaO2>=60 mm Hg on room air), or duration as defined by routine clinical practice. The researchers excluded patients with immunosuppression (e.g., HIV), atypical infection (e.g., Pseudomonas), infection outside the lungs, prior antibiotic use, specific lower-acuity groups (nursing home, subacute care, palliative care). The team estimated 142 patients in each arm to have 80% power to detect a difference in the symptom score of 3 points. 137/150 control patients and 146/162 intervention patients were included. There were no significant differences between the groups. This study may encourage physicians to consider symptom-based antibiotic durations instead of pre-specified durations.

Infectious Disease

This paper is interesting but also troubling. If our null hypothesis is that patients do better with longer courses of treatment for CAP as determined by their doctors, this paper has not fully succeeded in disproving it. The differences between the outcomes were small, but the sample size was also small and we cannot rule out a modest benefit for longer treatment based solely on the efficacy data. If we ignore the p values and look at the actual outcomes, the NNT for clinical success at day 10 is roughly 11-12. There was no difference in the CAP symptom scale. On the whole, the study is plausible, but the multiplicity of measurements/outcomes makes this ambitious but small study a bit hard to understand. It would be reasonable to treat the "average" patient (i.e., the kind in this study) with 5 days of antibiotics, assuming that things are improving at day 5 and follow-up is good. Is this the last word for sicker patients? Perhaps not.

Infectious Disease

It's important to know that we can limit antibiotic duration and help prevent antibiotic associated complications.

Internal Medicine

The population relevant to heme-Onc practice was excluded.

Internal Medicine

Being an internist, I see quite a number of CAP in my daily practice. This article just grants me more evidence for my practice. In the end, the physician's clinical judgement is what matters most

Internal Medicine

We have been awaiting an RCT on this topic for decades.

Internal Medicine

The most important finding of the study supports length of antibiotic treatment to be guided by clinical stability (which was about 70% of the patients in the intervention group at day 5). The high proportion of fluoroquinolone treatment makes it less generalizable to other antibiotic choices.