Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the ACP guidance on reducing duration of antibiotic treatment for common infections
2. Describe the reasoning behind limiting the duration of antibiotic use in the context of resistance

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from through , participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Read Disclaimer & Fine Print

SUMMARY:

The American College of Physicians (ACP) addresses the use of antibiotics for common infections (COPD, community-acquired pneumonia, UTIs, and cellulitis). Evidence-based, the overall purpose of this document is to “describe appropriate use of shorter durations of antibiotic therapy for common bacterial infections seen in both inpatient and outpatient health care settings.”

KEY POINTS:

• Antibiotics/antimicrobials are prescribed in 10% of all outpatient PCP visits
  • 30% of these prescriptions are unnecessary and continue for longer than needed
  • Overuse causes antibiotic resistance and “adverse events” in 20% of patients | Considered a national threat by ACP and the CDC
• Current guidelines support shortening the duration of antibiotic use
  • However, to prevent antibiotic resistance, many physicians prescribe longer courses of treatment, irrespective of the condition (around 10 days)
• Resistance
  • Evidence shows that there is no correlation between shorter course of antibiotics and increased resistance
  • Due to “natural selection,” resistance is more likely to occur with longer course therapy

COPD Exacerbation and Acute Uncomplicated Bronchitis

Bronchitis

• Antibiotics are not recommended unless there is suspicion of pneumonia

COPD

• Antibiotics are recommended due to high risk of underlying bacterial infection
• Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends
  • Treating COPD with antibiotics if an underlying bacterial infection is suspected (such as increased sputum volume or purulence)
  • 5 to 7 days of therapy

Community-Acquired Pneumonia

• Antibiotics are recommended for a minimum of 5 days (American Thoracic Society/IDSA guideline)
  • However, when determining length of treatment, consider validated measures of clinical stability (e.g., resolution of vital sign abnormalities, ability to eat, and normal mentation)
• Evidence suggests that every additional day of treatment is associated with a 5% increased risk for an “adverse event”

Uncomplicated Cystitis and Pyelonephritis

• UTIs
  • Most common bacterial infection that presents for medical attention
  • Infectious cystitis primarily caused by Escherichia coli (75% of bacterial cases)
• Therapy durations based on antibiotic type
  • Nitrofurantoin: 5 days
  • TMP–SMX: 3 days
  • Fosfomycin: Single dose
• Fluoroquinolones
  • 3-day administration
  • Due to adverse events, reserve use for patients with history of resistant organisms
• Pyelonephritis
  • IDSA/ESCMID (European Society of Clinical Microbiology and Infectious Diseases) guideline only addresses female patient
  • Recommendation (not hospitalized): Oral fluoroquinolone for 7 days or TMP–SMX for 14 days | TMP–SMX should not be used as the only therapy without “culture and susceptibility testing in pyelonephritis”
  • Some clinical trials have showed that fluroquinolones can effectively be reduced to 5 days (cure rate of 93%; noninferior studies comparing 5-day course to 10-day course)
  • Recommendations for a shorter course of TMP–SMX are not yet determined | More clinical trials are needed

Note: UTIs in pregnant women, complicated UTIs (related to “structural or functional abnormalities” in the urinary tract), and acute bacterial prostatitis are not covered in this best practice statement

Nonpurulent Cellulitis

• Nonpurulent cellulitis usually caused by methicillin-resistant Staphylococcus aureus (MRSA) and streptococci
• IDSA guideline (2014)
  • Recommends that “patients should receive antibiotics for uncomplicated cellulitis but that clinicians should consider extending treatment if the infection has not improved after 5 days”
• NICE (2019)
  • Recommends treatment for 5 to 7 days
• More studies are needed to further clarify the best duration of antibiotic treatment for soft tissue infections (SSTIs)

Note: Purulent SSTIs such as furuncles, carbuncles, and abscesses, usually require incision and drainage and are not addressed in this document

Learn More – Primary Sources:

Annals of Internal Medicine: Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of Physicians

Related ObG Topics:

Diagnosis and Management of Stable COPD

Guideline for the Treatment of Community-Acquired Pneumonia: Outpatient Diagnosis and Management

Uncomplicated Cystitis: When to Culture, How to Treat and Recommended Prevention Strategies