Shorter is better: The case for short antibiotic courses for common infections in solid organ transplant recipients

Abstract

Background: Prolonged antibiotics are associated with toxicity, selection for resistant organisms, and secondary infections such as Clostridioides difficile colitis. Emerging clinical data suggest that short courses of antibiotics can be used for common bacterial infections among immune competent patients, but for many randomized controlled trials (RCTs), immunocompromised patients, including solid organ transplant recipients (SOTRs), have been excluded.Methods: Peer-reviewed publications were identified through PubMed and Embase searches. Results:We review data examining shorter antibiotic courses among immunocompetent and immunocompromised patients and the rationale for use of short antibiotic courses in SOTRs. Conclusion:There are known harms associated with antibiotics and, when studied, existing data do not demonstrate harm associated with shorter courses of antibiotics among SOTRs. Furthermore, several RCTs did include some immune compromised patients and found shorter therapy to result in similar clinical efficacy with diminished adverse effects. Shorter antibiotic durations should be considered in SOTRs, and questions of antibiotic duration among SOTRs should be prioritized for study in clinical trials.

Bring it on again: antimicrobial stewardship in transplant infectious diseases: updates and new challenges

“… 27 , 28 , 31 , 32 Imlay and Spellberg recently published additional details based on communication with Yahav et al, 27 reporting that of 40 KT recipients, there was no difference in a composite outcome among those receiving 7 vs. 14 days of therapy (62% vs 68%). 30 Data for shorter antibiotic courses for gram-negative bacteremia in neutropenic patients with hematological malignancy or SCT are more variable. A retrospective cohort study of 206 neutropenic patients with hematologic malignancy or SCT with documented gram-negative bacteremia including Pseudomonas found no difference in a composite outcome among those receiving shorter duration (<10 days of therapy) of antibiotics compared to longer durations (either 11–14 days or >15 days).…”

Antibiotic Stewardship in Surgical Departments

“…It is very important that the AS team first presents evidence on the efficacy and benefits of shorter antibiotic courses. They may face the frustration that there is no definite proof of the efficacy of shorter regimens; however, the proof on this subject is mounting, including studies in patients who are immunosuppressed [1,84]. In the long term, new evidence will alter prescribing practices, which will represent a cultural shift [1,8,84].…”

Controlling infections in hospitalized pretransplant candidates

“…In the general population, data increasingly support shorter duration of antibiotics as equally efficacious to longer duration [10]. While most studies exclude pretransplant patients, studies in kidney transplant recipients and in non-SOT immunocompromised patients suggest that shorter courses of antibiotics have similar efficacy to longer courses with less antibiotic exposure [11 ▪▪ ]. Patients with prior receipt of antimicrobials have increased risk of developing infection with resistant organisms and, in some studies, higher posttransplant mortality [12,13].…”

“…Pretransplant patients are at increased risk for colonization with organisms such as Pseudomonas , methicillin resistant Staphylococcus aureus (MRSA), vancomycin resistant Enterococcus (VRE) and extended spectrum beta-lactamase-producing organisms [11 ▪▪ ,12,14]. Knowledge of colonizing flora can assist in developing posttransplant and peri-operative prophylactic regimens.…”