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Shorter courses of antibiotics for community-acquired pneumonia at least as good as longer courses
Clinical Question
Are shorter courses of antibiotic therapy as effective for community-acquired pneumonia as longer courses?
Bottom line
This methodology in this study was a bit lacking. I would have preferred that the authors not include any nonrandomized trials, and they should have done a subgroup analysis for higher quality trials using the more standard Cochrane Collaboration Risk of Bias tool. That said, the results consistently favored shorter courses of antibiotics for patients with community-acquired pneumonia (CAP) with regard to clinical cure, mortality, and adverse effects. 1a-
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Self-funded or unfunded
Setting: Various (meta-analysis)
Synopsis
The authors searched PubMed, EMBASE, clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials to find trials that randomized patients to shorter (6 or fewer days) or longer (7 or more days) durations of antibiotic therapy for CAP. The reporting of this meta-analysis is not great, with a very short methods section and a nonstandard quality assessment. The authors included 2 nonrandomized trials, but the other 19 included studies were randomized. Approximately half were not double-blinded, and most did not report allocation concealment. Some studies compared different durations of the same antibiotic; others compared, for example, a 5-day course of azithromycin with a longer course of levofloxacin. For the outcome of clinical cure, there was no difference between groups for 5 studies (n = 1600 patients) that used the same antibiotic (relative risk [RR] 1.0; 95% CI 0.97 - 1.02) and 13 studies (n = 1695 patients) that used different antibiotics (RR 1.0; 0.96 - 1.04). The same was true for 2 studies (n = 774 patients) that compared a single dose of azithromycin with a longer course of the same drug. For mortality, 7 studies (n = 2028 patients) found a lower risk of death for courses of 3 to 5 days versus 7 or more days (2.4% vs 4.6%; RR 0.56; 0.35 - 0.90). Serious adverse events were also less likely with short courses of antibiotics (RR 0.73; 0.55 - 0.97). There was no difference in the likelihood of relapse, but the confidence interval was broad due to the relatively small number of studies that reported this outcome (RR 0.67; 0.30 - 1.46).
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA