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Short vs long-course antibiotic therapy in pyelonephritis: a comparison of systematic reviews and guidelines for the SIMI choosing wisely campaign

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Abstract

Background

The Italian Society of Internal Medicine (SIMI) Choosing Wisely Campaign has recently proposed, among its five items, to reduce the prescription of long-term intravenous antibiotics if not indicated. The aim of our study was to assess the available evidences on optimal duration of antibiotic treatment in pyelonephritis through a systematic review of secondary studies.

Materials and methods

We searched for all guidelines on pyelonephritis and systematic reviews assessing the optimal duration of antibiotic therapy in this type of infection. We compared the recommendations of the three most cited and recent guidelines on the topic of interest. We extracted data of non-duplicated RCT from the selected systematic reviews and performed meta-analyses for clinical and microbiological failure. A trial sequential analysis (TSA) was also achieved to identify the need for further evidence.

Results

We identified 4 systematic reviews, including data from 10 non-duplicated RCTs (1536 patients). The meta-analysis showed a higher rate of clinical cure for short-course antibiotic treatment (RR for clinical failure 0.70, 95% CI [0.53–0.94]). No significant difference in the rate of microbiological failure (RR 1.06, 95% CI [0.75–1.49]) was observed. In terms of clinical cure, the TSA suggests that current evidence is sufficient to consider short course at least as effective as long-course treatment. Selected guidelines recommend considering shorter courses, but do not cite most of the published RCTs.

Conclusions

Short-course antibiotic treatment is at least as effective as longer courses for both microbiological and clinical success in the treatment of acute uncomplicated pyelonephritis.

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Acknowledgements

We would like to thank all the members of the SIMI Choosing Wisely Group for their help in the writing of this article.

Author information

Authors and Affiliations

  1. Università Degli Studi Di Milano, Milan, Italy

    Luca Erba, Ludovico Furlan, Alice Monti & Elisa Marsala

  2. UOC Pronto Soccorso E Medicina D’Urgenza, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy

    Giulia Cernuschi, Monica Solbiati & Giorgio Costantino

  3. Department of Internal Medicine, Santa Croce and Carle General Hospital, Cuneo, Italy

    Christian Bracco

  4. Medicina Interna, Università Degli Studi Di Firenze, AOU Careggi, Firenze, Italy

    Giulia Bandini

  5. Dipartimento Delle Professioni Sanitarie, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy

    Monica Pecorino Meli

  6. Dipartimento Di Scienze Biomediche E Cliniche “L. Sacco”, Università Degli Studi Di Milano, Milan, Italy

    Giovanni Casazza

  7. Dipartimento Di Medicina Interna, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy

    Nicola Montano

  8. Dipartimento Di Scienze Cliniche E Di Comunità, Università Degli Studi Di Milano, Milan, Italy

    Nicola Montano & Giorgio Costantino

  9. Dipartimento Di Pronto Soccorso E Medicina D’Urgenza, Azienda Ospedaliera Universitaria Di Udine, Udine, Italy

    Rodolfo Sbrojavacca

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  1. Luca Erba
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Correspondence to Luca Erba.

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Erba, L., Furlan, L., Monti, A. et al. Short vs long-course antibiotic therapy in pyelonephritis: a comparison of systematic reviews and guidelines for the SIMI choosing wisely campaign. Intern Emerg Med 16, 313–323 (2021). https://doi.org/10.1007/s11739-020-02401-4

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