BALANCE trial (N=3,631): 7 vs 14 days for gram-negative bacteremia was non-inferior for 90-day mortality (difference -1.6%, 95% CI -4.0 to 0.8) with 5 more antibiotic-free days. BLING III (N=7,202): Continuous infusion beta-lactams showed clinical cure 55.7% vs 50.0% (p<0.001). JAMA Bayesian meta-analysis (N=9,108, 18 RCTs): mortality RR 0.86 (95% CrI 0.72-0.98) with 99.1% posterior probability of benefit.
The evidence for shorter antibiotic courses is now overwhelming for most common infections including CAP (3-5 days), gram-negative bacteremia (7 days), intra-abdominal infections with source control (4 days), and bone/joint infections (IV-to-PO switch after 1 week). Extended/continuous infusion beta-lactams maximize time above MIC in critically ill patients, with the JAMA meta-analysis providing high-certainty evidence of mortality benefit.
| Name | Pmid | Finding |
|---|---|---|
| BALANCE | 39565030 | 7 vs 14 days for gram-negative bacteremia: non-inferior for 90-day mortality, 5 more antibiotic-free days |
| BLING III | 38864155 | Continuous vs intermittent beta-lactam infusion: clinical cure 55.7% vs 50.0% (p<0.001) |
| JAMA Meta-Analysis | 38864162 | Mortality RR 0.86 (95% CrI 0.72-0.98), 99.1% posterior probability of benefit |
| MERCY | 37326473 | 28-day mortality: no significant difference; potentially underpowered |
| STOP-IT | 25992746 | 4 days adequate for intra-abdominal infection with source control |
| OVIVA | 30699315 | Oral step-down after 1 week IV is non-inferior for bone/joint infections |
| Infection | Traditional | Evidence_based | Key_evidence |
|---|---|---|---|
| Community-acquired pneumonia | 7-14 days | 3-5 days | ATS/IDSA 2019; Annals IM 2026 (PMID 41974005) |
| HAP/VAP | 14-21 days | 7 days | ATS/IDSA 2016 |
| Gram-negative bacteremia | 14 days | 7 days | BALANCE trial (PMID 39565030) |
| Intra-abdominal (source controlled) | 10-14 days | 4 days | STOP-IT (PMID 25992746) |
| Uncomplicated cellulitis | 10-14 days | 5-6 days | Hepburn 2004 (PMID 15302637) |
| Complicated UTI/pyelonephritis | 10-14 days | 5-7 days | IDSA 2025 (PMID 41419448) |
| Bone and joint infections | 6 weeks IV | 6 weeks (IV to early PO switch) | OVIVA (PMID 30699315) |
ATS/IDSA 2019 supports short-course CAP therapy. IDSA 2025 cUTI guideline explicitly recommends shorter courses. Surviving Sepsis Campaign now provides a weak recommendation for prolonged beta-lactam infusion. BALANCE trial (NEJM 2024) is the largest RCT on antibiotic duration for bacteremia.
Combined reference card covering two complementary stewardship strategies. Key PMIDs: BALANCE 39565030, BLING III 38864155, JAMA meta-analysis 38864162, MERCY 37326473, STOP-IT 25992746, OVIVA 30699315.