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5MinuteConsult Journal Club

Ten Days is TOO Long for Antibiotics

Reference:

Lee RA, Centor RM, Humphrey LL, et al. Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of Physicians. Ann Intern Med. 2021 Apr 6. doi: 10.7326/M20-7355. Epub ahead of print. PMID: 33819054.

Study Summary:

The American College of Physicians issued their Best Practice guidelines on the use of antibiotics in the outpatient setting. They note 10% of outpatient visits result in an antibiotic prescription, with 30% of those being for inappropriate reasons and when used for an appropriate diagnosis, for too long. The two most common diagnoses where inappropriately used are acute bronchitis and sinusitis. They estimate adverse events occur in 20% of the antibiotic prescriptions, ranging from antibiotic-induced rashes (often confused with allergic reactions) to C. difficile, MRSA, and the worsening of the epidemic of antibiotic resistance.

Recommendations:

Best Practice Advice 1: COPD exacerbations

Limit antibiotic treatment duration to 5 days with acute uncomplicated bronchitis (presence of increased sputum purulence in addition to increased dyspnea, and/or increased sputum volume)

Best Practice Advice 2: Community-acquired pneumonia:

Prescribe antibiotics for a minimum of 5 days; use beyond 5 days of antibiotics should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation

Best Practice Advice 3: UTI

For women (18-50 years) with uncomplicated bacterial cystitis, prescribe nitrofurantoin for 5 days, trimethoprim– sulfamethoxazole (TMP–SMZ) for 3 days, or fosfomycin as a single dose

For men and women with uncomplicated pyelonephritis, prescribe fluoroquinolones (5 to 7 days) or TMP–SMZ (14 days) based on antibiotic susceptibility


Best Practice Advice 4: Non-purulent cellulitis

Use a 5- to 6-day course of antibiotics active against streptococci in patients able to self-monitor and who have close follow-up


Conclusion

Become excellent stewards of all prescriptions, especially antibiotics. Prescribe appropriately, explain the side effects of overuse, and learn to say “NO” to patients’ demands by treating low risk, most likely viral infections like bronchitis and sinusitis aggressively with symptomatic care and close follow-up.


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Urinary Tract Infection (UTI) in Females; Pneumonia, Bacterial; Chronic Obstructive Pulmonary Disease and Emphysema; Cellulitis; Sinusitis; Bronchitis, Acute

Contributed by Frank J. Domino, MD, April 28, 2021

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