Short Versus Longer Antibiotic Duration for Community-Acquired Pneumonia : A Multicenter Target Trial Emulation
George Doumat1, David Ratz2, Jennifer K Horowitz3
1Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas (G.D.).
Background:
Shorter antibiotic courses for community-acquired pneumonia (CAP) may reduce adverse effects and resistance. However, real-world data supporting very short durations remain limited.
Objective:
To evaluate the safety and effectiveness of 3- to 4-day versus 5-day or more antibiotic durations in hospitalized patients with CAP who achieve clinical stability by day 3 (afebrile, no new oxygen, and stable vital signs).
Design:
Observational emulation of a target trial.
Setting:
67 Michigan hospitals between 2017 and 2024.
Patients:
Adults hospitalized (non-intensive care unit) with CAP who received 3 days of antibiotics, were clinically stable by antibiotic day 3, and met the strict eligibility criteria of the Pneumonia Short Treatment trial.
Intervention:
0 to 1 additional days of antibiotic treatment versus 2 or more days of additional antibiotic treatment (that is, shorter [3 to 4 days] vs. longer [≥5 days] total antibiotic duration).
Measurements:
The main outcome was 30-day all-cause mortality. Other outcomes included 30-day hospital readmission, urgent health care visits, and Clostridioides difficile infection.
Results:
Among 55 517 hospitalized patients with CAP, 5620 (10.1%) ultimately met eligibility criteria for short-course therapy after comorbidity, clinical stability, and treatment duration criteria were applied. Median age of eligible patients was 68.2 years, and 54.3% were men. Median antibiotic duration was 7 days, with only 7.9% (444 of 5620) receiving 3 to 4 days. Thirty-day adjusted risk ratios for short- versus long-course antibiotic therapy were 0.89 for mortality (95% CI, 0.01 to 2.25), 1.07 for readmission (CI, 0.81 to 1.42), 0.94 for urgent visit (CI, 0.70 to 1.28), and 1.01 for C difficile infection (CI, 0.18 to 5.68).
Limitation:
Few short-duration patients and potential residual confounding.
Conclusion:
Only 10.1% of inpatients with CAP met the strict eligibility criteria for short-course therapy. The short- and longer-course antibiotic treatment groups had similar mortality rates, and there was little difference in benefits and harms.
Primary Funding Source:
Blue Cross Blue Shield of Michigan and Blue Care Network.
Insights
Shorter antibiotic courses for community-acquired pneumonia (CAP) showed similar outcomes to longer courses in a real-world study. This suggests reduced antibiotic exposure may be safe and effective for eligible patients.
Area of Science:
- Infectious Diseases
- Clinical Medicine
- Pharmacology
Background:
- Shorter antibiotic courses for community-acquired pneumonia (CAP) could decrease adverse effects and resistance.
- Real-world data on very short antibiotic durations for CAP are limited.
Purpose of the Study:
- To assess the safety and effectiveness of 3- to 4-day antibiotic durations compared to 5-day or longer durations.
- To evaluate outcomes in hospitalized CAP patients who achieved clinical stability by day 3.
Main Methods:
- Observational study emulating a target trial in 67 Michigan hospitals (2017-2024).
- Included non-ICU hospitalized adults with CAP meeting strict eligibility criteria for short-course therapy.
- Compared 3- to 4-day total antibiotic duration (short-course) versus ≥5 days (long-course).
Main Results:
- Of 55,517 CAP patients, only 10.1% met eligibility for short-course therapy.
- Short-course (3-4 days) vs. long-course (≥5 days) showed similar 30-day mortality (aRR 0.89), readmission (aRR 1.07), urgent visits (aRR 0.94), and C. difficile infection (aRR 1.01).
- Median antibiotic duration was 7 days; only 7.9% received 3-4 days.
Conclusions:
- A small proportion of hospitalized CAP patients met strict criteria for very short antibiotic courses.
- Short-course antibiotic therapy demonstrated comparable safety and effectiveness to longer courses for eligible patients.
- Findings suggest potential for reduced antibiotic exposure in select CAP patients, though residual confounding is possible.
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