For a given clinical infection:
- Goal is selection of the right drug, in the right dose for the right period of time.
- Past traditional treatment durations were based on observational studies, expert opinion, and FDA approved “ gold
standard” regimens. - This Table summarizes the duration of therapy suggested for selected common clinical settings. See specific syndromes for detail regarding the settings listed here.
- Most are the traditional durations used in Guidelines or drug package inserts or expert opinion
- If the traditional gold standard duration was found non-inferior to a shorter regimen in one or more Randomized
Clinical Trials (RCT), the validating number of RCTs is shown. - Pertinent “Shorter is Better” references: Clin Microbiol Infect, doi.org/10.1016/j.cmi.2022.08.024; Ann Intern Med 2021 174:822
- NOTE: Whatever duration is selected, cessation of therapy requires evidence of “source control” as manifest by
resolution of clinical signs and symptoms plus trending, or resolved, biomarkers of inflammation (Inf.Dis.Clin.No.Amer. 2017; 31:435).- biomarkers include the following clinical signs: body temperature < 37.7°C for ≥ 24 hours, mean arterial blood pressure above 65 mm Hg for ≥ 24 hours, respiratory rate < 20 breaths/min and oxygen saturation above 90% on room air.
Type of Infection
- Selected infections: bacteremia, bone, CNS, meningitis, ear, gastrointestinal, genital, heart, joint, kidney, lung, muscle, peritoneum, pharynx, prostate, sinuses, skin, systemic.
| Site | Diagnosis | Duration of Therapy | Comments |
|---|---|---|---|
| Bacteremia | Gram-negative (GNB) bacteremia with removable focus (no endocarditis) | 7-14 days | Equal efficacy in 3 RCT |
| Bone | Osteomyelitis, adult, acute | 42-56 days | In patients with uncomplicated vertebral osteomyelitis, 6 weeks as efficacious as 12 weeks (Lancet 2015;385:875) |
| Osteomyelitis, adult, chronic | 42 days | As effective as 84 days in patients with vertebral osteomyelitis (Lancet 2015;385: 875) | |
| Child, acute, Staph, Strep, enterobacterales | 21-28 days until ESR normal | For all osteomyelitis in children even though there are some data that support 21 days if resolution of signs and symptoms and normalization of biomarkers (J Paediatr Child Health 2013;49:760) | |
| Child, acute, Meningococcal, Haemophilus | 14-21 days | ||
| CNS: Meningitis | N. meningitidis | 7 days | In children, relapses seldom occur until 3 or more days after the end of therapy |
| H. influenzae | 7 days | ||
| S. pneumoniae | 10-14 days | ||
| L. monocytogenes, Streptococcus sp. (Group B), Coliforms | 21 days | Longer if immunocompromised patient | |
| Ear | Otitis media with effusion | 10 days (age < 2 yrs)5-7 days (age ≥ 2 yrs) | |
| Gastrointestinal | Bacillary dysentery (Shigellosis) or traveler’s diarrhea | 1 dose, but up to 3 days if no response | |
| Typhoid fever (S. typhi):Uncomplicated | Azithromycin x 5-7 days (child/adolescent)Ceftriaxone x 7-14 days Fluoroquinolone x 7-10 daysChloramphenicol x 14 days | ||
| H. pylori | 14 days | ||
| C. difficile | 10 days | ||
| Genital | Pelvic inflammatory disease | 14 days | |
| Heart | Pericarditis (purulent) | 28 days | Until resolution of signs and symptoms and normalization of biomarkers |
| Joint | Arthritis, septic, non-gonococcal, adult | 14-28 days | |
| Arthritis, septic, non-gonococcal, child | 10-14 days | Contingent upon resolution of signs and symptoms and normalization of biomarkers | |
| Arthritis, disseminated, gonococcal | 7 days | CDC recommended minimum duration of therapy; a longer duration may be indicated based on clinical response. | |
| Kidney | Cystitis, acute | 3 days (fluoroquinolone or TMP-SMX), 5 days (Nitrofurantoin) 1 day (Fosfomycin) | |
| Pyelonephritis, acute | 7 days (Ciprofloxacin) 5 days (Levofloxacin) | 8 RCT | |
| Asymptomatic bacteriuria | No treatment unless pregnancy or urologic surgery | ||
| Intra-abdominal | Peritonitis, secondary | 4-7 days (with source control) | 1 RCT |
| Lung: | Pneumonia, pneumococcal, CAP | 3-5 days vs. 5-14 days | Equal efficacy in 14 RCT |
| Pneumonia, Gram negative, e.g., Pseudomonas, VAP | 7-8 days vs. 10-15 days | Equal efficacy in 2 meta-analyses of 6 RCTs: Cochrane Database Syst Rev. 2015 Aug 24;2015(8):CD007577; Chest. 2013 Dec;144(6):1759-1767 | |
| Pneumonia, staphylococcal | 21-28 days (variable, until biomarkers normalize) | ||
| Pneumonia, legionella | 7-10 days | ||
| Pneumonia, chlamydia, mycoplasma | Azithromycin 1 dose vs. 3 days 5 vs. 10 days | No difference in Azithro regimen. Equal efficacy in 2 RCT | |
| Lung abscess | 28-42 days (but variable) | ||
| Muscle | Gas gangrene, clostridial | 10 days depending on severity | |
| Peritoneum | Peritonitis from bowel flora | 4-8 days | Immunocompetent with source control: N Engl J Med 372:1996, 2015; N Engl J Med 372:2062, 2015 |
| Pharynx | Strep pharyngitis | Grp A: 10 days (Penicillin VK), 5 days (oral Cephalosporin or Azithromycin)Grp C/G: 5 days | |
| Diphtheria (membranous) | 14 days (Penicillin G, Erythromycin) If carrier: 1 dose (Penicillin G), 7-10 days (Erythromycin) | ||
| Prostate | Prostatitis, chronic | 30-90 days (TMP-SMX) 28-42 days (FQ) | |
| Sinuses | Sinusitis, acute bacterial | 3-7 days vs. 6-10 days | Most common etiology of acute sinusitis is a respiratory virus. Equal efficacy in 12 RCT |
| Skin | Cellulitis | 5-7 days | |
| Systemic | Brucellosis | 42 days | Duration varies with specific site(s) of infection |
| Rocky Mountain Spotted Fever | Until afebrile 2 days | ||
| Tularemia | 7-21 days | MMWR 58:744, 2009 |