Shorter Courses of Antibiotics May Be Better

Shorter Courses of Antibiotics May Sometimes Be Better in the Long Run –  Nicole Leimbach – Nov 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.

Unless they are suffering from pain.

Then they are treated according to national standardized rules with no regard for individual differences.

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 sinusitis:

  • 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 Media:

  • 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.

Author: 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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3 thoughts on “Shorter Courses of Antibiotics May Be Better

  1. Laura P. Schulman, MD, MA

    At this time in history, it’s critical to practice good antibiotic stewardship. The actual threat of multiply resistant organisms is much higher than the public is allowed to know.

    The suggestion that two or three days of antibiotic therapy would ever be a good idea is terrifying. Any pathogens present would be given enough of a “taste” of the drug to select for resistant germs, but not high enough tissue MICs to kill them. Even if there weren’t sufficient resistant bugs to start a clinical infection, they could easily produce plasmids that could pass the resistance gene on to “friendly” bacteria like E. Coli.

    I don’t want to write a book here, but this is my take-home message: If one’s index of suspicion for infection meets threshold, treat with minimum 5 days. If in doubt, treat with watchful waiting and anticipatory guidance.

    This article makes me grit my teeth. Ruptured eardrums? No need to treat with oral antibiotics unless there is associated sinusitis/pneumonia. We use antibiotic ear drops for that! Amoxacillin for strep???? Nope. It’s not effective for strep because it doesn’t achieve a high enough tissue MIC in vivo. Guess what? You really do have to study basic science to be a decent clinician!

    Zyp, this article gave me lots to gripe about…thanks! Hope I didn’t upset you. This is one of my pet peeves, obviously….

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      I’m not so sure either way. Taking antibiotics longer selects for the very most resilient and virulent to survive – fewer, but stronger.

      I guess it’s a general problem with antibiotics whether short or long term, so any use is detrimental. But, of course, they are handed out like candy by docs (to game patient satisfaction surveys) and our livestock are pumped full of them (more to gain weight/$$ than to prevent disease).

      Liked by 1 person

      Reply
      1. Laura P. Schulman, MD, MA

        Actually, longer courses of abx do the OPPOSITE. The stronger bugs tend to hide out in tissues that have decreased oxygen, like diseased sinuses. Longer courses provide time for tissue MICs (Mean Inhibitory Concentrations) to become bacteriocidal, while giving the immune system time to mount attack via tissue macrophages. It’s well known science! Problem is, we’re living in an age where “quick-and-dirty” is all the modern squirrel-mind can wrap itself around.

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