Written by Mary Marschner
Spoon Feed
For a patient with bacteremia, with notable exclusions below, a 7-day course of antibiotics is noninferior to the traditional 14-day course.
Two weeks notice… bacteremia can now be treated for only 1 week
Bacteremia is a common cause of illness and hospitalization. Prior to this trial, a 14-day course of antibiotics was standard of care for bacteremia.
Since antibiotics were discovered after World War I, they have become an important tool to fight illness and extend life. The right antibiotic is almost like magic; patients tend to feel better within 24-48 hours, and even severely ill patients can be saved. However, antibiotics come with risks and side effects. How often and how long we treat is important as we fight emerging resistance.
The BALANCE trial was a multicenter noninferiority randomized controlled trial involving 3,608 hospitalized patients across 74 hospitals in seven countries. It compared 7-day versus 14-day antibiotic regimens for bloodstream infections, excluding cases with S. aureus, severe immunosuppression, or infections necessitating prolonged therapy (i.e. osteomyelitis, endocarditis, prosthetic infection, septic arthritis, abscess without drainage or prosthetic heart valve). 90-day mortality was 14.5% in the 7-day group versus 16.1% in the 14-day group (difference –1.6%; 97.5%CI –4.0 to 0.8), confirming noninferiority. These findings support shorter antibiotic courses to reduce exposure without compromising outcomes.
My only real critique is that 20% of patients assigned to a 7-day course received additional days of antibiotics, and there was no subgroup analysis on these patients to help guide us on when to extend duration or for how long.
How does this change my practice?
This study has absolutely changed my practice. For a simple bacteremia (considering exclusions), I now prescribe 7 days of antibiotics rather than 14 days. However, I also don’t feel bad for extending the course if I’m not convinced they are getting better. Vigilance is still needed when caring for bacteremic patients; the 90-day mortality is around 15%, and ~2% have recurrence of bacteremia with 7- or 14-day courses.
Source
Antibiotic Treatment for 7 versus 14 Days in Patients with Bloodstream Infections. N Engl J Med. 2025 Mar 13;392(11):1065-1078. doi: 10.1056/NEJMoa2404991. Epub 2024 Nov 20. PMID: 39565030.
