DUHS Adult Antimicrobial Duration Guidelines

Criteria & Principles

Duration recommendations are provided as a general guideline for therapy (IV or PO) with a goal of minimizing unintended consequences to the patient. Patient specific factors should influence duration decisions and transition to oral therapy.   

Please see this link to better understand the literature supporting antimicrobials durations of therapy: https://www.bradspellberg.com/shorter-is-better

Please refer to the DUHS Adult and Pediatric Pharmacy Policy for Antimicrobial Duration of Therapy page for details about the policy allowing pharmacists to revise antimicrobial stop dates.

Treatment

Duration

​INFECTION	TARGETED DURATION (IV OR PO)
Genitourinary infections (Bacterial)
Catheter-associated urinary tract infection, Complicated urinary tract infection (comorbidities, pregnancy, prolonged symptoms, history of pyelonephritis within 1 year, hospital-acquired infection)	7 days, if prompt resolution of symptoms 10 days, if delayed response 3 days, if female aged ≤ 65 years, no upper urinary tract symptoms, and after catheter is removed
Acute uncomplicated cystitis	Nitrofurantoin: 5 days Trimethoprim/sulfamethoxazole: 3 days Fluoroquinolones: 3 days Βeta-lactams: 7 days
Aute pyelonephritis	Ciprofloxacin or trimethoprim/sulfamethoxazole: 7 days Βeta-lactams: 10-14 days* *Shorter durations (e.g., 7-10 days) may be considered in patients with rapid clinical response and initial IV therapy
Prostatitis	4-6 weeks
Genitourinary infections (Candida species)
Vulvovaginal candidiasis	Fluconazole 150 mg once
Asymptomatic candiduria	Treatment not recommended unless patient is high risk (e.g.,Neutropenic, low birth weight neonates, or undergoing invasive urologic procedures)
Symptomatic candiduria	Fluconazole: 14 days Fluconazole-resistant strain: amphotericin B x 1-7 days or flucytosine x 7 days
Pyelonephritis	14 days
Respiratory tract infections
Bacterial rhinosinusitis	5 days
Streptococcal pharyngitis	Beta-lactam, clindamycin, clarithromycin: 10 days Azithromycin: 5 days
COPD exacerbation	No change in character of sputum: no antibiotics 5 days if increase in volume and purulence of sputum
Community-acquired pneumonia (CAP)	5 days - should be afebrile for 48-72 h and have ≤1 CAP-associated sign of clinical instability
HAP/VAP	7 days
Skin and skin structure infections
Cellulitis, uncomplicated	5 days
Cellulitis, complicated	7 days
Diabetic foot infections
Soft tissue only, mild	1 week, or less if clinical signs and symptoms of infection have resolved
Soft tissue only, moderate	1 week
Soft tissue only, severe	2 weeks
Osteomyelitis
Amputation	No residual infected bone and tissue: 24 – 48 hours after amputation Residual infected bone and tissue: 4 – 6 weeks
Staphylococcus aureus	6 weeks May consider additional 1 – 3 months of rifampin-based PO combo therapy; longer for chronic infection or if debridement not performed
Other bacterial pathogens	3-6  weeks from last major operative debridement
Septic arthritis	3 weeks; may switch to PO at 7 days
Intra-abdominal infections	4 days following source control and resolved clinical signs of infection resolved; refer to the Intra-abdominal infections page for further guidance
Clostridioides difficile	Discontinue offending antibiotic (if receiving and possible), then treat x 10 days
Catheter-related bloodstream infection, uncomplicated, if fever resolves within 72 hours, immunocompetent, no hardware, and no evidence of endocarditis or suppurative thrombophlebitis
Short-term catheter (in situ < 14 days) ​​Catheters should be removed in all cases ​​Day 1 is the first day on which negative blood cultures are obtained
Coagulase-negative staphylococci	5 days
Enterococcus species	7 days
Gram negative bacilli	7 days
Staphylococcus aureus, Staphylococcus lugdunensis, or Candida species	ID consult required; typical duration: ≥ 14 days
Long-term catheter or port (in situ > 14 days); see Antibiotic Lock Therapy Policy for information on antibiotic locks Catheter should be removed for S. aureus or Candida species Catheter may be retained for coagulase-negative staphylococci, Enterococcus species, or Gram negative bacilli; if clinical deterioration or persisting bacteremia occurs, the catheter should be removed and complicated bacteremia ruled out ​Day 1 is the first day on which negative blood cultures are obtained
Coagulase-negative staphylococci	10 days; if catheter retained, use antibiotic lock therapy in combination
Enterococcus species	7 days; if catheter retained, use antibiotic lock therapy in combination
Gram negative bacilli	7 days; if catheter retained, use antibiotic lock therapy in combination 10 days
Staphylococcus aureus, Staphylococcus lugdunensis, or Candida species	ID consult required S. aureus or S. lugdunensis uncomplicated 2 weeks, complicated 4-6 weeks Candida species 14 days
Endocarditis	Strongly recommend ID consult; ID consult required for S. aureus, S. lugdunensis, or fungal bloodstream infections
Meningitis
Neisseria meningitidis or Haemophilus influenzae	7 days
Staphylococcus aureus	14 days
Streptococcus pneumoniae	10 days
Streptococcus agalactiae	14 days
Aerobic Gram negative bacilli	21 days
Listeria monocytogenes	≥ 21 days
Brain abscess, subdural empyema, spinal epidural abscess	≥ 4 weeks

 

References

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2. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation 2005; 111; e394-e434.
3. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011 Oct; 53(7): e25-e76.
4. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012 Apr; 54(8): e72-e112.
5. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31(5):431-55.
6. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52(5): e103-e120.
7. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010; 50: 625-663.
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9. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011 Feb 1; 52(3): e18-e55.
10. Mandell GL, Bennett JE, Dolin R. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases 7th ed. Philadelphia: Churchill Livingstone Elsevier, 2010.
11. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44: S27-72.
12. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 49: 1-45.
13. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America 2012; 1-17.
14. Sharp VJ, Takacs EB, Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician 2010; 82(4): 397-406.
15. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010; 50: 133-164.
16. Stevens DL, Bisno AL, Chambers HF. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005; 41: 1373-1406.
17. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39: 1267-1284.
18. Fox MT, Melia MT, Same RG, et al. A Seven-Day Course of Trimethoprim-Sulfamethoxazole May Be as Effective As a Seven-Day Course of Ciprofloxacin for the Treatment of Pyelonephritis. Am J Med 2017;130(7):842-845.