Clinical Question: In patients hospitalized for treatment of community-acquired pneumonia, can treatment be stopped after three days if the patient has substantially improved?

Setting: Inpatient (any location)

Study Design: Randomized controlled trial (double-blinded)

Allocation: Uncertain

Synopsis: The treatment of pneumonia for seven to 10 days is based on tradition, not scientific evidence. The researchers conducting this study challenged the status quo by enrolling 119 adults with mild to moderate-severe community-acquired pneumonia with a severity index score of 110 or less. On admission, all patients were started on intravenous amoxicillin, the preferred empiric treatment in the Netherlands. After 72 hours of treatment, patients who showed improvement in symptoms, had a temperature lower than 100.4° F (38° C), and could take oral medication were randomized to treatment with placebo or amoxicillin 750 mg three times daily for five days. Using modified intention-to-treat analysis, after 10 days, 89 percent of patients in both groups were clinically cured. In follow-up at 28 days, clinical cure rates were also similar between the two approaches, as were bacteriologic and radiologic success rates. This study was designed to find a difference in success rates of at least 10 percent.

There are some notable limitations to this study. First, the patients in the short-treatment group had a median age of 54 years compared with 60 years in the eight-day group, and these younger patients may have been more likely to respond to the short course, possibly skewing the results. Second, the study was conducted in the Netherlands, where resistance patterns may be different than in other countries. Finally, the study was conducted in nine hospitals over three years, which is less than five patients per hospital per year recruited into the study. Given the imbalance in age and this sparse representation, these patients could be highly selected and not representative of the typical patient admitted to a community hospital.

Bottom Line: In patients who respond well to initial treatment, stopping antibiotic therapy after three days is just as effective as continuing treatment for the standard eight days. (Level of Evidence: 1b)