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Evidence Based Review on Optimal Duration of Antibiotic Therapy for Bacterial Infections to Support Antimicrobial Stewardship Recommendations

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Evidence Based Review on Optimal Duration of Antibiotic Therapy for Bacterial Infections to Support Antimicrobial Stewardship Recommendations Evidence based review on optimal duration of antibiotic therapy for bacterial infections to support antimicrobial stewardship recommendations Maria Diletta Pezzani, Giorgia Be, Paolo Cattaneo, Amina Zaffagnini, Federico Gobbi, Paola Rodari, Zeno Bisoffi, Evelina Tacconelli Infectious Diseases Unit, Department of Diagnostic and Public Health, University of Verona, Italy; Infectious Diseases Unit, IRCCS Sacro Cuore Don Calabria, Negrar, Italy WHO Secretariat Nicola Magrini, Secretary of the Expert Committee on Selection and Use of Essential Medicines; Innovation, Access and Use, Department of Essential Medicines and Health Products 1 Abbreviations AAUS: Asian Association of Urinary Tract Infection and Sexually Transmitted Infection AMC: Amoxicillin-clavulanate AMN: Aminoglicosides AMX: Amoxicillin ASP: Antimicrobial stewardship programmes BLA: Beta lactam agents BLBLI: Beta lactam beta-lactamase inhibitors BSI: Bloodstream infections BZP: Benzylpenicillin CAP: Community acquired pneumonia CEPH: Cephalosporines cUTI: Complicated UTI CYS: Cystitis DOX: Doxicycline EAU: European urological association EML: Essential medicine list EMLc: Essential medicine list children ESBL: Extended spectrum beta-lactamases FOS: Fosfomycin FQL: Fluoroquinolomes HIC: High income countries IDSA: Infectious diseases society of America LIC: Low income countries LMIC: Low-middle income countries MCL: Macrolides MRSA: Methycillin resistant Staphylococcus aureus NTF: Nitrofurantoin PHA: Pharingitis PYN: Pyelonephritis RHI: Rhinosinusitis RTI: Respiratory tract infections SEIMC: Spanish Society of Clinical Microbiology and Infectious Diseases TMP: Trimethoprim TMX: Trimethoprim-sulfamethoxazole UMIC: Upper middle income countries UTI: Urinary tract infections uUTI: Uncomplicated UTI VAP: Ventilator associated pneumonia WHO: World health organization 2 Background Duration of antibiotic therapy plays a pivotal role in antimicrobial stewardship programme (ASP) within the global effort to optimize antibiotic use and reduce resistance. An appropriate antibiotic use together with a treatment course as short as possible can positively affects patient care and the health-system by reducing the frequency of adverse events and development of resistance (at patient and ecological levels) and associated healthcare costs. Recommendations of an optimal duration of therapy needs to balance between efficacy (clinical and/or microbiological) and risk of adverse events (tolerability, relapses, emergence and spread of resistance). Historically recommendations on duration of antibiotic therapy were based on fairly arbitrary extension of days of treatment (magic numbers like 7, 10 and 14 days) rather than on reliable evidence with the main aim to minimise failures and avoid undertreatment. The dominant concept, before the progressive worldwide increase in the incidence of antibiotic-resistant infections, was to treat long beyond the clinical improvement, based on the evidence from infections as tuberculosis where resistance can occur spontaneously under treatment with inappropriate dosing or monotherapy. That concept accomplished both the desire to reduce relapses and the belief that antimicrobial resistance could be prevented by a prolonged antibiotic course. For example, recommendations suggested 14 days to treat pyelonephritis, 10-14 days for community acquired pneumonia (CAP), and 21-28 for bloodstream infections (BSI). However, since early 2000s, to reduce the selective pressure driving resistance it has been frequently questioned whether a short course of antibitics could be as effective as a longer one in both in adult and pediatric populations. Now in the time of evidence based medicine, recommendations on duration of antibiotic therapy must to be based on non-inferiority clinical studies focusing on old and new antibiotic classes with the appropriate sample size and design in order to be generalised to different epidemiological settings and inform antibiotic policy and stewardship. In last years, several studies mostly addressing BSI and respiratory tract infections (RTI) have been completed to assess effectiveness of shortened antibiotics course with controversial results.1-5 A recent retrospective multicenter cohort study found no differences in 30-day all cause mortality between 6-10 days and 11-16 days therapy in adults with monomicrobial enterobacteriaceae bacteremia. Important to note that and adequate source control was a pre- requsiite for short treatement and less than 1% of study patients had inadequate source control. 1 () In a multicenter randomized control trial (RCT), hemodynamically stable inpatients with GN bacteremia and controlled focus of infections received 7 versus 14 days of antibiotic therapy. The primary outcome at 90 days including all-cause mortality; relapse, suppurative or distant complications and re-admission or extended hospitalization (>14 days) did not vary significantly between the two trial’s arms. 2 Opposite findings were reported from a retrospective cohort study which assessed the effectiveness of 7–10 days versus >10 days of antibiotic therapy for uncomplicated Gram- negative BSI. Patients were comparable in most demographic and baseline characteristics but risk of treatment failure was higher in patients receiving short compared to long courses of antibiotics. 3 The Community-Acquired Pneumonia Organization (CAPO) International Cohort Study compared patients who were treated with antibiotic therapy for a total duration of 5 days or less (SCT Group) versus longer than 5 days (LCT Group). At 30-day follow-up no deaths occurred in the SCT group while 8 patients (0.7%) in the LCT group died and there was no difference in the rate of rehospitalizations (11%) at 30 days after discharge. After controlling for confounding, a short duration of antibiotic 3 therapy was not associated to adverse outcomes. 5 A multicenter, noninferiority RCT included 312 patients admitted with CAP and compared 5 days of therapy versus longer duration of treatment. In the intent-to-treat analysis, clinical success was 48.6% in the control group and 56.3% in the intervention group at day 10 and 88.6% in the control group and 91.9% in the intervention group at day 30. 6 In pediatric infections McCullan and coworkers recently reviewed the evidence for duration of therapy and for de- escalation from intravenous to oral in 36 paediatric infections.7 The database was used to develop evidence based guidance to duration of therapy without specifying type and classes of antibiotics. With the increasing and spread of antimicrobial resistant infections, strategies optimizing the length of antibiotic therapy may be an essential component of ASP and should evaluate whether different recommendations are needed for antibiotic resistant infections. For example the majority of guidelines on UTI suggest that the choice has to be based on local ecology and provide a threshold for resistance rates. A recent review highlighted how guidelines on empirical antibiotic use did not routinely consider resistance patterns in their recommendations thus rendering the interpretation difficult especially for decison-makers.8 The Section 6 of the Essential Medicines List covers anti-infective medicines and antibacterial medicines in sections 6.2.1 (beta-lactam medicines) and 6.2.2 (other antibacterials) have been recently reviewed and updated. This revision addresses Objective 4 of the WHO’s Global Action Plan on Antimicrobial Resistance to “optimize the use of antimicrobial medicines in human and animal health”. Within this context and increase reports of antibiotic-resistant infections in LMIC, the WHO Expert Committee on Selection and Use of Essential Medicine recommended to explore the evidence-base for duration of antibiotic therapy for the diseases inldued in the EML List and if duration was different in case of etiological agent resistant to antibiotic(s). The specific objective of this study is to perform an evidence-based review on duration of treatment of bacterial infections in adults and children and to assess if recommendations vary in case of infections caused by resistant bacteria. The review will focus on the following four infection syndromes (as currently listed in the EML): pharyngitis (PHA), rhinosinusitis (RHI), community-acquired pneumonia (CAP) and UTI. The results will be used to explore indications to future integration on duration of therapy in the EML report and/or dedicated WHO guidance documents on duration of therapy within antimicrobial stewardship interventions in both high income countries (HIC) and low income countries (LIC). Methods This document is a summary of a rapid systematic literature review and inventory of available relevant evidence- based guidelines and of systematic reviews on treatment of bacterial community-acquired pneumonia (CAP), UTI, pharyngitis (PHA), and rhinosinusitis (RHI) in children and adult population. Design: Existing evidence-based clinical practical guidelines (CPG) were identified by (1) a systematic search in Pubmed/Medline (search strategy reported in point #3) with publication date from 1 January 2013 to 30 November 2018. The 5 year period has been selected in order to include only CPG based on the most recent epidemiological scenario in terms of type and duration of antibiotic therapy. The evidence has been explored in the last 15 years through analysis of systematic reviews and meta-analyses (see following paragraph); (2) a grey literature search using Google, followed by a screening of the reference lists included
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