Steven M. Opal, MD
In critically ill patients with hospital-acquired pneumonia (HAP), does shorter duration of antibiotic therapy improve outcomes compared with longer duration?
Included studies compared 2 fixed durations of antibiotic therapy (short vs prolonged) or protocol-guided antibiotic therapy to reduce treatment duration with standard care in critically ill patients ≥ 16 years of age who were diagnosed with HAP. Patients with hematologic cancer, chemically induced immune suppression, or HIV or AIDS were excluded where possible. Primary outcomes were mortality, recurrence of pneumonia, and antibiotic use.
MEDLINE (to Feb 2011); Cochrane Central Register of Controlled Trials (Cochrane Library, Issue 1, 2011); EMBASE/Excerpta Medica, LILACS, and Web of Science (to March 2011); metaRegister of Controlled Trials; ClinicalTrials.gov; Database of Abstracts of Reviews of Effects; grey literature; conference abstracts; and reference lists were searched for randomized controlled trials (RCTs). 8 RCTs (n = 1703, mean age range 54 to 67 y, 50% to 75% men) met the selection criteria; 5 had adequate random sequence generation, 5 had adequate allocation concealment, and none was blinded. We only report comparisons that included > 1 study.
Meta-analysis showed that fixed-duration short- and prolonged courses of antibiotic therapy did not differ for mortality or overall recurrence of pneumonia; fixed short-course therapy increased risk for recurrence of HAP caused by nonfermenting gram-negative bacilli (NF-GNB) (Table) but not by methicillin-resistant Staphylococcus aureus (MRSA) or non-NF-GNB/MRSA. Serum procalcitonin (PCT)-guided discontinuation of antibiotics did not differ from standard care for mortality (Table) but reduced duration of antibiotic therapy (3 RCTs, n = 308, mean difference −3.2 d, CI −4.5 to −2.0).
In critically ill patients with hospital-acquired pneumonia, interventions to shorten duration of antibiotic therapy reduce its use and do not affect mortality. Fixed short-course therapy may increase risk for recurrence of pneumonia due to nonfermenting gram-negative bacilli.
*NF-GNB = nonfermenting gram-negative bacilli; NS = not significant; other abbreviations defined in Glossary. RRI, RRR, NNH, and CI calculated from data in article using a random-effects model.
Opal SM. Review: Short-course antibiotics in hospital-acquired pneumonia do not affect mortality. Ann Intern Med. ;156:JC3–13. doi: 10.7326/0003-4819-156-6-201202210-02013
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Published: Ann Intern Med. 2012;156(6):JC3-13.
Hospital Medicine, Hospital-Acquired Infections, Infectious Disease, Pneumonia, Pulmonary/Critical Care.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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