Core IM | Internal Medicine Podcast #195 Antibiotic Duration & BALANCE Trial: Beyond Journal Club with NEJM Group
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Dec 10, 2025 Dr. Manali Nigam, an editorial fellow at the New England Journal of Medicine and neurologist at Mass General Brigham, dives into the complexities of antibiotic duration for bacteremia. They dissect the BALANCE trial, revealing how host, organism, and infection source affect treatment courses. Discover why seven days may often suffice, while situations like S. aureus or osteomyelitis demand longer therapy. With a focus on evidence-based practice, Nigam emphasizes the importance of tailored treatment plans despite the push for shorter defaults.
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Organism Changes Risk, Especially S. Aureus
- Different organisms carry different endocarditis and complication risks that alter duration choice.
- Staphylococcus aureus demands special caution and longer, individualized management.
Source Dictates Treatment Length
- Source of bacteremia alters necessary duration dramatically from cellulitis to osteomyelitis.
- Some sources (e.g., cellulitis) may need very short courses; osteomyelitis needs prolonged therapy.
Trials Favor Shorter Courses Broadly
- Multiple RCTs across infections increasingly support shorter antibiotic courses as noninferior.
- Prior trials (STOP-IT, gram-negative bacteremia trials) paved the way for shorter defaults.