HN Summary
• Growing evidence shows that shorter courses of antibiotics are just as effective as longer regimens for many common infections, while helping reduce antimicrobial resistance.
• National and provincial guidelines support reduced treatment durations for conditions such as ear infections, pneumonia, COPD exacerbations, urinary tract infections and cellulitis, without compromising patient outcomes.
• Physicians and pharmacists play a critical role in antimicrobial stewardship by aligning prescribing practices with current evidence to improve patient safety and preserve antibiotic effectiveness.
Antimicrobial resistance (https://www.who.int/health-topics/antimicrobial-resistance) is a global patient safety and public health concern. One strategy to address this is the implementation of antimicrobial stewardship – e.g., Shorter antibiotic courses are often just as effective as longer-term ones. In this article, we will highlight five common infections where shorter courses improve antimicrobial resistance without compromising cure rates, with evidence from Choosing Wisely Canada (https://choosingwiselycanada.org/), the Association of Medical Microbiology and Infectious Disease (AMMI) Canada (https://ammi.ca/en/), and Ontario Health guidelines (https://www.ontario.ca/page/ontario-public-health-standards-requirements-programs-services-and-accountability).
Acute Otitis Media
Acute otitis media is one of the most common pediatric infections, with age being the key determinant of therapy duration. Current evidence demonstrates that in children over 2 years of age, a 5-day amoxicillin regimen provides equivalent clinical cure to longer treatment duration. On the other hand, for children aged 6 months to 2 years, a 10-day antibiotic course is recommended. These durations reflect antibiotic prescribing guidelines from the Cold Standard (https://choosingwiselycanada.org/toolkit/the-cold-standard/), the AMMI Canada, and Ontario Health. The key takeaway is that standardizing shorter therapy for older children can reduce unnecessary antibiotic exposure without compromising recovery.
Community-Acquired Pneumonia (CAP)
Among respiratory infections, community-acquired pneumonia (CAP) has seen the most changes in recommended treatment duration. A large body of evidence, including recent trials comparing 3 days versus 8 days of therapy, shows that short courses, typically 5 days or less, are equally effective for low-severity pneumonia. Overall, a treatment duration of 5 days for CAP is supported by the Cold Standard (https://choosingwiselycanada.org/toolkit/the-cold-standard/), the AMMI Canada, and Ontario Health.
Acute Exacerbation of COPD
It is important to note that acute exacerbations of Chronic Obstructive Pulmonary Disease (COPD) are often triggered by viruses. Bacteria are typically secondary causes. If acute exacerbations are associated with a bacterial infection, then evidence has shown that antibiotic courses of 5 days were just as effective as longer regimens across all antibiotic classes. In general, acute exacerbations of COPD are managed with inhalers (e.g., bronchodilators), anti-inflammatory therapy (e.g., steroids), and removal or management of reversible underlying causes (e.g., environmental factors or other medical conditions). A 5-day course is recommended by the Cold Standard (https://choosingwiselycanada.org/toolkit/the-cold-standard/), if antibiotic use is indicated.
Urinary Tract Infections (UTI): Cystitis or Lower UTI
For cystitis or lower UTI, short durations of antibiotic therapy, particularly for non-pregnant female adult patients, are well supported by evidence – for instance, ranging from the option of 1-day use of Fosfomycin to a 5-day course of Nitrofurantoin. On the other hand, in male adults, a 7-day therapy is recommended, as cystitis may be more complicated in this patient population. In addition, AMMI Canada has published an educational toolkit on the management of asymptomatic bacteriuria (i.e., bacteria in the urine but with no symptoms) in long-term care residents called “Symptom Free Pee: Let It Be” (https://ammi.ca/wp-content/uploads/2021/09/AC-Brief-poster_Eng_8.5x11_colour.pdf), supporting a national antimicrobial stewardship initiative to prevent inappropriate antibiotic use.
Cellulitis
Current evidence suggests that 5-7 days of antibiotic therapy is appropriate for most cases of outpatient uncomplicated non-purulent or purulent cellulitis. Treatment may be extended to 7-10 days in patients with slow clinical response, severe disease, large abscesses, or suspected antibiotic resistance. The management of cellulitis provides an example of why re-examining a traditional 10-14-day regimen for an infection is essential for embracing antimicrobial stewardship.
Takeaway Message
The message from recent evidence is clear: Use shorter duration of antimicrobial therapy. Physicians and pharmacists play a key role in antimicrobial stewardship by ensuring antibiotic durations align with current guidelines and evidence. Through medication reviews and patient counselling, pharmacists can often identify unnecessarily prolonged antibiotic courses and collaborate with prescribers to optimize therapy. Clinicians can play a crucial role in combatting antimicrobial resistance, improving patient safety, and advancing stewardship goals across the healthcare system.
Other Resources
To learn more about duration of antimicrobial therapy in common infections, readers are encouraged to review the following resources:
• From Choosing Wisely Canada: The Cold Standard (https://choosingwiselycanada.org/toolkit/the-cold-standard/)
• From the University of British Columbia Continuing Professional Development (UBC CPD): Duration of Antimicrobial Therapy for Common Infections in Primary Care
• From the Journal of the Association of Medical Microbiology and Infectious Disease Canada:)
Jenna Yu Xie Zhang and Mona Mollaeizadeh are PharmD Students at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor, Teaching Stream, at the Leslie Dan Faculty of Pharmacy and Department of Psychiatry, University of Toronto.