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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Host, Organism, And Source Framework
- Antibiotic duration decisions hinge on three domains: host, organism, and source.
- Clinicians should nudge treatment length based on stability, bug risk, and source control.
Titrate Duration To Clinical Response
- Start with the patient's clinical response when choosing duration and shorten if they improve quickly.
- Extend treatment for delayed clearance, instability, hardware, or immunocompromise.
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.