Short-Course Antibiotics for Cellulitis Led to More Longer-Term Relapses
Antibiotic stewardship programs often look at ways to reduce duration of antibiotic prescriptions without affecting outcomes. A new study warns that, even if antibiotic reduction appears to work in the short term, the relapse rate could be greater in the long term for some patients with some infections. Here are more details.
MADRID, SPAIN – While shorter courses of antibiotics can sometimes be beneficial, reducing overuse of the drugs while having the same clinical outcomes, that is not always the case.
Research recently presented at the 28th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) points out that cellulitis patients treated with a six-day course of intravenous antibiotic flucloxacillin instead of a 12-days course had greater rates of relapse at 90 days post- treatment, despite having similar short-term results.
A study team from the Netherlands points out that the recommended antibiotic treatment duration for patients hospitalized with cellulitis is 10-14 days, which is primarily based on expert recommendations.
The researchers sought to determine if six days of antibiotic treatment would be non-inferior to 12 days in patients hospitalized with cellulitis. Their randomized, double-blind, placebo-controlled non-inferiority trial enrolled from 11 Dutch hospitals. Participants were 248 adult patients admitted with cellulitis and treated with intravenous flucloxacillin, with optional oral step-down. Most, 66%, were male, and the mean age was 63; 24% of the patients had diabetes.
After six days of treatment, participants who had improved substantially -- defined as being without fever and having a lower cellulitis severity score -- were randomized between an additional six days of oral flucloxacillin or placebo.
Targeted as the primary outcome was cure by day 14 without relapse by day 28. A modified cure assessment and the relapse rate by day 90 were included in secondary outcomes. The trail, which occurred between Aug. 26, 2014, and June 29, 2017, was ended early because of slow recruitment.
Results indicate that, after 28 days, 49.3% of participants in the 12-day group and 50.7% in the 6-day group were cured without relapse by day 28 (absolute risk reduction 1.4 percentage points, 95% CI: -14.8 to 17.5). With the modified cure assessment, 74.6% and 71.0% participants in the 12-day and 6-day groups, respectively, were cured without relapse after 28 days (absolute risk reduction of -3.6, 95% CI: -18.1 to 11).
After initial cure without relapse, day 90 relapse rates were higher in the six-day group than in the 12-day group, however. ."Patients with a shorter course of therapy showed significantly faster and more frequent relapses by day 90," said lead author Dr. Duncan Rowan Cranendonk, adding that the results show that "short-term outcomes are not everything."
While earlier studies have shown no differences in outcome between shorter and standard therapy duration in young healthy outpatients, that appears not to be the case in older patients.
"Our trial is the exact opposite; we had elderly hospitalized patients with a lot of comorbidity," Cranendonk said. "This is the population clinicians are likely to see, but unfortunately, therapy cannot be shortened within this population.