RCT

BALANCE

Antibiotic Treatment for 7 versus 14 Days in Patients with Bloodstream Infections

NEJM, 2025 · Multicenter randomized noninferiority trial (n=3608)

Clinical question

Is 7 days of antibiotic therapy noninferior to 14 days for selected hospitalized patients with bloodstream infection?

Population: Hospitalized adults with bloodstream infection, including ICU patients; important exclusions included pathogens/syndromes requiring prolonged treatment and severe immunosuppression
Intervention: 7 days of active antibiotic treatment
Comparator: 14 days of active antibiotic treatment
Primary outcome: All-cause mortality by 90 days
Result: 90-day mortality was 14.5% with 7 days vs 16.1% with 14 days (difference −1.6 percentage points; 95.7% CI −4.0 to 0.8), meeting the prespecified noninferiority criterion.

What the trial found

Seven days was noninferior to 14 days for mortality in the trial's selected bloodstream-infection population.

Current guideline position

Use organism-, source-, host-, and source-control-specific duration rather than a universal bacteremia duration.

Clinical interpretation

Supports shorter therapy for appropriately selected uncomplicated bloodstream infection after source control and clinical improvement; it does not justify 7 days for S. aureus bacteremia, endovascular infection, inadequately controlled foci, or other syndromes that require longer treatment.

Clinical Context & Relevant Topics (1)

Disease Reference

Sepsis

Life-threatening organ dysfunction caused by a dysregulated host response to infection — recognized by an acute rise in SOFA score, not by infection plus fever alone.

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