Vancouver IM LMR

Thanks to Connor Booker (PharmD Clinical PGY1) and Rosanne Thalakada (PharmD, Clinical Pharmacy Specialist with ASPIRES) for presenting on the duration of antibiotic therapy in CAP

Here are the slides from the presentation for your reference.

Key takeaways:

1. New ASPIRES recommendations for community acquired pneumonia:
   • Mild CAP (CRB65 score 0-1): Amoxicillin 500-1000 mg po tid (pen allergy with no severe reaction: cefuroxime 500 mg po bid-tid; severe penicillin and cefuroxime allergy: doxycycline po bid)
     • Duration = 3-5 days
   • Moderate CAP (CRB65 of 2): Amoxicillin-clavulanate 875-125 mg po bid OR cefuroxime 500 mg po bid-tid (If unable to tolerate PO, ceftriaxone 1 g IV daily. For atypical coverage, can add azithromycin 500 mg po/iv daily x 3 days or doxycycline 100 mg po bid. If penicillin/cefuroxime/ceftraixone allergic can use moxifloxacin 400 mg po/iv daily)
     • Duration = 3-5 days
   • Severe CAP (CRB65 3-4)
     • Ceftriaxone 1-2 grams daily IV + azithromycin 500 mg PO/IV x 3 days (or doxycycline 100 mg po bid)
     • If ceftriaxone allergic/severe allergy to beta-lactams: Moxifloxacin 400 mg po/iv daily
     • If MRSA suspected, add vancomycin 15 mg/kg IV
     • Duration 3-7 days
2. BC Provincial Antimicrobial Clinical Expert (PACE) group recommended in 2023 for minimum of 3 days therapy for hospitalized CAP of any severity provided the patient meets clinical stability criteria before stopping therapy.
   • Clinical stability criteria:
     • Stop abx on day 3: Afebrile on day 3, SBP > 90, HR < 100, RR < 24, O2 > 90% on room air (or baseline home O2)
     • Stop abx on day 5: Afebrile x 48 hours, no more than 1 CAP-associated sign of clinical instability on day 5 of therapy (SBP < 90, HR > 100, RR > 24, O2 < 90% on room air)
   • Duration should be 7 days for all other cases without complications eg abscess, empyema.
3. Evidence for shorter duration of therapy for CAP
   • Dinh et al. 2021 PTC study – hospitalized patients (non-ICU) given abx for 3 days and meeting clinical stability criteria after 3 days, comparing placebo x 5 days vs additional 5 days of antibiotics (amox-clav) showed non-inferiority for outcomes of LOS, clinical cure and mortality
   • Furukawa et al 2023 – systematic review and meta analysis of RCTs (non-ICU patients) comparing short vs long course showing short treatment duration (3-9 days) likely non-inferior to standard treatment duration (10 days) for adults with CAP who achieve clinical stability.