INTRODUCTION
The optimal duration of antibiotic treatment in community acquired
pneumonia (CAP) is not well established: discrepancies exist between the
different guidelines published to date1,2,3. In 2007,
IDSA / ATS included a minimum treatment of 5 days, provided the patient
remains free of fever for 48-72 hours and without more than one
criterion of clinical instability4. Recently published
updated guidelines keep the same recommendation5.
The negative impact of the overuse of antibiotics is well known. In this
regard, an increase in nasopharyngeal carriers of penicillin-resistantStreptococcus pneumoniae has been observed with the use of
low-dose beta-lactams for more than 5 days in children. The
unnecessarily prolonged use of antibiotics has been associated with a
greater incidence of resistance, a higher number of adverse effects,
worse adherence to treatment, and a higher cost6-9.
Several studies have been published with the aim of evaluating the
safety of reducing the duration of antibiotic treatment in patients with
CAP10-13. In a recent meta-analysis involving five
clinical trials involving adults with mild-to-moderate CAP comparing the
same types of antibiotic, short 3 to 7 day regimens of antibiotics were
compared to 7 to 10 day regimens. The authors did not observe
significant differences in terms of cure rate, mortality and adverse
effects14. Surprisingly, a new meta-analysis comparing
≤ 6 day versus ≥ 7 day regimens, observed a lower mortality rate in the
shorter compared to the long regimen group (RR 0.52, 95% confidence
interval [CI] 0.33 -0.82), with similar cure and relapse rates in
both groups15. When evaluating only the most severe
patients, mortality was 2.2% in the group with a shorter regimen
compared to 4.7% in the long regimen group.
On the other hand, the use of certain biomarkers such as procalcitonin
(PCT) has been shown to be useful in reducing the duration of antibiotic
treatment. In a study carried out with critically ill patients with CAP,
an algorithm was implemented for the suspension of antibiotics in the
event of a PCT reduction of at least 80% or with values of less than
0.5 ug / L16. The authors observed an absolute
difference of 2.7 days (95% CI 1.4-4.1, P <0.0001)
between the group with which the PCT algorithm was implemented versus
the control group, with a higher number of antibiotic-free days seen in
the first group.
Recently, our working group published the positive
results17 of a clinical trial designed to validate the
IDSA / ATS criteria on the duration of antibiotic treatment in patients
admitted for CAP. The median number of days with antibiotic in the
control group was 10 as opposed to 5 in the intervention group, while
the short-term clinical cure rate was similar for both groups. However,
the impact that such a reduction may have on the long-term prognosis of
these patients, as well as its effect on systemic inflammation, remains
unknown.
The goal of the present study is to assess the impact in the long term
of a reduction of antibiotic treatment in patients admitted for CAP. The
method was to evaluate complications that occurred up to one year later
in patients that had been included in a clinical trial for the
validation of the IDSA / ATS criteria for the duration of antibiotic
treatment.