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Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study

BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7554.1355 (Published 08 June 2006) Cite this as: BMJ 2006;332:1355

Right approach - but wrong clientele

Editor – The study by el Moussaoui et al addresses the important but
unresolved question of the optimal therapy duration of community-acquired
pneumonia (CAP) – an issue of significant clinical, microbiological, and
economical impact (1). CAP trials with short course treatment schedules
are rare and mostly focus on newly developed costly drugs such as new
quinolones, macrolides, and ketolides (2-4). Studies using more cost
effective first line drugs for adults with mild to moderate CAP are
lacking. Therefore, the above mentioned study comparing different
amoxicillin schedules is useful. Patients were treated as inpatients with
i.v. amoxicillin. Those who improved after three days were randomly
assigned to oral amoxicillin or placebo for five days. Both groups had
similar outcomes. Unfortunately, the study’s impact on clinical practice
will be low because most of the patients enrolled could have been treated
in the outpatient setting with oral antibiotics. According to European and
US guidelines, CAP patients with a pneumonia severity index (PSI) of
>90 (class IV and V) should be treated as inpatients (5,6). Only 15 of
the 121 (12 %) patients in the study met this criterion. Median PSI scores
of 18 and 39 for the 3-day and 8-day treatment groups, respectively,
further underline that mainly individuals with mild CAP were included. In
addition, the exclusion of patients with a PSI score >110 has to be
criticized for being an additional constraint within PSI class IV.

Clearly, further studies with a more consistent design have to follow
before aminopenicillins can be applied for shorter durations in patients
with CAP.

Literature

1. el Moussaoui R, de Borgie CA, van den Broek P, Hustinx WN, Bresser
P, van den Berk GE, Poley JW, van den Berg B, Krouwels FH, Bonten MJ,
Weenink C, Bossuyt PM, Speelman P, Opmeer BC, Prins JM. Effectiveness of
discontinuing antibiotic treatment after three days versus eight days in
mild to moderate-severe community acquired pneumonia: randomised, double
blind study. BMJ 2006;332:1355-7. (10 June.)

2. Shorr AF, Khashab MM, Xiang JX, Tennenberg AM, Kahn JB.
Levofloxacin 750-mg for 5 days for the treatment of hospitalized Fine Risk
Class III/IV community-acquired pneumonia patients. Respir Med 2006;May 24
(online publication)

3. File TM Jr. Clinical efficacy of newer agents in short-duration
therapy for community-acquired pneumonia. Clin Infect Dis 2004;39:S159-64.

4. Tellier G, Niederman MS, Nusrat R, Patel M, Lavin B. Clinical and
bacteriological efficacy and safety of 5 and 7 day regimens of
telithromycin once daily compared with a 10 day regimen of clarithromycin
twice daily in patients with mild to moderate community-acquired
pneumonia. J Antimicrob Chemother 2004;54:515-23.

5. Mandell LA, Bartlett JG, Dowell SF, File TM Jr, Musher DM, Whitney
C; Infectious Diseases Society of America. Update of practice guidelines
for the management of community-acquired pneumonia in immunocompetent
adults. Clin Infect Dis 2003;37:1405-33.

6. Woodhead M, Blasi F, Ewig S, Huchon G, Ieven M, Ortqvist A,
Schaberg T, Torres A, van der Heijden G, Verheij TJ; European Respiratory
Society; European Society of Clinical Microbiology and Infectious
Diseases. Guidelines for the management of adult lower respiratory tract
infections. Eur Respir J 2005;26:1138-80.

Competing interests:
None declared

Competing interests: No competing interests

29 August 2006
Thomas Weitzel
Consultant in Infectious Diseases
Sven Gläser, Consultant in Respiratory Medicine, Norbert Suttorp, Professor in Internal Medicine, Respiratory Medicine and Infectious Diseases
Charité - University Medicine Berlin, 13353 Berlin