Summary of antibiotic duration recommendations for bacterial infections from major guidelines
| Infection syndrome . | Major guidelinesa Recommendation, year of publication, [strength of recommendation as stated in the guideline] . | Comments . | |||
|---|---|---|---|---|---|
| US guideline . | UK guideline . | European guideline . | WHO/international guidelines . | ||
| Respiratory tract | |||||
| Acute GAS pharyngotonsillitis | 10 days penicillin or amoxicillin (first line) [Strong recommendation, high evidence], first generation cephalosporin, clindamycin or clarithromycin [strong recommendation, moderate evidence]; 5 days azithromycin (IDSA, 2012) | 5–10 days phenoxymethylpenicillin (first line); 5 days clarithromycin or erythromycin (second line) in adults and children [Very low to low-quality evidence] (NICE, 2018) | Not available | 5 days (low riskb) or 10 days (high riskb) amoxicillin or phenoxymethylpenicillin (first line); 5 days cefalexin or clarithromycin (second line) (AWaRe antibiotic book 2023) | 5 days may be adequate for symptomatic cure; 10 days is associated with higher rates of GAS pharyngeal eradication |
| Otitis media in children | 10 days amoxicillin or amoxicillin/clavulanate (first line) in <2 years or severe symptoms; 7 days first-line antibiotics in 2–5 years with mild or moderate symptoms; 5–7 days first-line antibiotics in >6 years with mild to moderate symptoms (AAP/AAFP, 2013) | 5–7 days amoxicillin (first line), clarithromycin or amoxicillin/clavulanate in 1 month to 17 years, with 7 days reserved for those with severe or recurrent infection [Very low- to low-quality evidence] (NICE, 2018) | 5–10 days [Weak evidence] (Systematic review of guidelines across 17 countries in the EU, 2020) | 5 days amoxicillin (first line) or amoxicillin/clavulanate (AWaRe antibiotic book, 2023) | |
| Acute bacterial sinusitis | In adults, 5–7 days amoxicillin/clavulanate (first line) or doxycycline In children, 10–14 days amoxicillin/clavulanate (first line) [Weak recommendation, low–moderate evidence] (IDSA, 2012) | In adults and children, 5 days phenoxymethylpenicillin or amoxicillin/clavulanate (first line), doxycycline or erythromycin [Moderate to high evidence] (NICE, 2017) | No specific recommendations on antibiotic duration [Weak evidence] (European position paper, 2020) | 5 days amoxicillin (first line), or amoxicillin/clavulanate (AWaRe antibiotic book, 2023) | Longer duration recommended in some guidelines for paediatric patients because shorter course antibiotic has not been studied in this population with randomized trials |
| Community-acquired pneumonia | In adults, 5 days amoxicillin, doxycycline or macrolide (if local pneumococcal resistance is <25%, no comorbidities or risk factors for MRSA or P. aeruginosa) or more until clinical stability; 7 days for MRSA or P. aeruginosa pneumonia [Strong recommendation, moderate evidence] In children, no specific recommendation on antibiotic duration (IDSA, 2019) | In adults and children, 5 days amoxicillin (first line), doxycycline, clarithromycin or erythromycin for mild infections; combine amoxicillin or amoxicillin/clavulanate with doxycycline, clarithromycin or erythromycin for moderate to severe infections (avoid doxycycline in children <12 years) (NICE, 2019) | 8 days or less in responding patient [1 RCT or more, consistent evidence/clear outcome]; (ERS/ESCMID, 2011) Addition of 3–5 days of macrolides to β-lactams in hospitalized patients with severe infections [Conditional recommendation, very low evidence] (ERS/ESICM/ESCMID/ALAT, 2023) | In adults, 5 days amoxicillin or phenoxymethylpenicillin (first line), amoxicillin/clavulanate or doxycycline until clinical stability for mild–moderate infections; cefotaxime or ceftriaxone (first line), or amoxicillin/clavulanate with or without clarithromycin for severe infections In children from areas of low HIV prevalence and no chest indrawing, 3 days amoxicillin for mild to moderate infections; longer treatment until clinical stability with IV amoxicillin, ampicillin, or benzylpenicillin with gentamicin for severe infections (AWaRe antibiotic book, 2023) | |
| Ventilator-associated pneumonia | 7 days [Strong recommendation, moderate evidence] (IDSA, 2016) | Not available | 7–8 days in patients without immunodeficiency, cystic fibrosis, empyema, lung abscess, cavitation or necrotizing pneumonia and with a good clinical response to therapy [Weak recommendation, moderate evidence] (ERS/ESICM/ESCMID/ALAT, 2017) | Not available | |
| Bacterial exacerbation of COPD | Not available | 5 days amoxicillin, doxycycline or clarithromycin (first line), amoxicillin/clavulanate, trimethoprim/sulfamethoxazole or levofloxacin [Low to moderate evidence] (NICE, 2018) | No specific recommendation on antibiotic duration (ERS/ATS, 2017) | 5 days amoxicillin (first line), cefalexin or doxycycline in mild–moderate infections, amoxicillin/clavulanate in severe infections (AWaRe antibiotic book, 2023) | |
| Genitourinary tract | |||||
| Simple cystitis in women | 5 days nitrofurantoin; 3 days trimethoprim/sulfamethoxazole (first line); 3 days trimethoprim or fluoroquinolones; single-dose fosfomycin; 3–7 days pivmecillinam or β-lactam agents [Moderate to good evidence] (IDSA, 2011) | 3 days nitrofurantoin or trimethoprim (first line); 3 days pivmecillinam; single-dose fosfomycin in non-pregnant women >15 years 7 days nitrofurantoin (first line); amoxicillin or cefalexin for pregnant women >11 years [Very low to moderate evidence] (NICE, 2018) | Single-dose fosfomycin; 3–5 days pivmecillinam; 5 days nitrofurantoin [Strong recommendation, 1 RCT or more] (EAU, 2023) | 3–5 days amoxicillin/clavulanate; 5 days nitrofurantoin (preferred); 3 days trimethoprim/ sulfamethoxazole or trimethoprim; consider longer treatment in pregnant women, i.e. 5 days (AWaRe antibiotic book, 2023) | |
| Complicated urinary tract infections (in males, catheter-associated, upper urinary tract involvement) | Catheter-associated: Up to 14 days depending on symptom resolution [Good evidence, expert opinion]; 5 days levofloxacin for mild infections [Moderate evidence, expert opinion]; 3 days for women <65 years without upper tract involvement after indwelling catheter removal [Moderate evidence, 1 well-designed observational study or more] Uncomplicated pyelonephritis: 7 days ciprofloxacin [Good evidence, 1 RCT or more]; 5 days levofloxacin [Moderate evidence, 1 well-designed observational study or more]; 14 days trimethoprim/ sulfamethoxazole [Good evidence, 1 RCT or more] (IDSA, 2010) | Catheter-associated: 7 days nitrofurantoin, trimethoprim, amoxicillin (first line), or pivmecillinam in non-pregnant women and men >16 years if upper tract involvement; 7–10 days cefalexin or amoxicillin/clavulanate; 14 days trimethoprim; or 7 days ciprofloxacin (first line) if upper tract involvement Males: 7 days trimethoprim or nitrofurantoin (first line) for >16 years [Very low to moderate evidence] Acute pyelonephritis in men >16 years: 7–10 days cefalexin or amoxicillin/clavulanate (first line); 14 days trimethoprim; 7 days ciprofloxacin (NICE, 2018) | Catheter-associated: Up to 14 days depending on symptom resolution, indwelling catheter removal; 5 days levofloxacin for mild infections [Strong recommendation, 1 RCT or more] Uncomplicated pyelonephritis: 7 days ciprofloxacin; 5 days levofloxacin; 14 days trimethoprim/ sulfamethoxazole; 10 days cefpodoxime or ceftibuten Males with prostatitis: 14 days (EAU, 2023) | Uncomplicated pyelonephritis: 7 days ciprofloxacin in mild infections; cefotaxime, ceftriaxone and/or amikacin and/or gentamicin in severe infections (AWaRe antibiotic book, 2023) | |
| Bone and joint infections | |||||
| Adult osteomyelitis, septic arthritis and prosthetic joint infection | Osteomyelitis: MRSA: ≥ 8 weeks [Good evidence, 1 well-designed observational study or more] Septic arthritis: MRSA: 3–4 weeks with debridement or drainage [Good evidence, expert opinion] (IDSA, 2011) Prosthetic joint infection: Following debridement and prosthesis retention or 1-stage exchange: Staphylococcus: 2–6 weeks IV antibiotic with rifampicin (extend to 4–6 weeks if rifampicin cannot be used), followed by oral antibiotic with rifampicin for a total of 3 months for hip; 6 months for knee [Good evidence, 1 RCT or more] Other organism(s): 4–6 weeks of IV or highly bioavailable oral antibiotics [Moderate evidence, 1 well-designed observational study or more] Indefinite chronic oral antimicrobial suppression for retained prosthesis [Moderate evidence, expert opinion] Following resection arthroplasty with or without planned staged reimplantation: 4–6 weeks post procedure [Good evidence, 1 well-designed observational study or more] Following amputation and complete removal of infected tissue: 1–2 days post procedure [Poor evidence, expert opinion] (IDSA, 2014) | Osteomyelitis: Staphylococcus: 6 weeks flucloxacillin or clindamycin, or vancomycin or teicoplanin (if MRSA suspected) with fusidic acid or rifampicin for initial 2 weeks Septic arthritis: Staphylococcus: 4–6 weeks Neisseria gonorrhoeae or Gram-negative: 4–6 weeks cefotaxime or ceftriaxone (NICE, 2020) | Septic arthritis: Native joint: 1 to 2 weeks of IV antibiotics followed by 2–4 weeks oral antibiotics [Very low-quality, weak recommendation] After reconstruction of anterior cruciate ligament: 1–2 weeks of IV antibiotics followed by 4–5 weeks of oral antibiotics [Very low-quality, weak recommendation] (EBJIS, 2023) Prosthetic joint infection: 4–6 weeks (Italy, 2006) | Osteomyelitis: 4–6 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin Septic arthritis: 4–6 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin N. gonorrhoeae: 2 weeks (AWaRe antibiotic book, 2023) | |
| Childhood osteomyelitis/septic arthritis | MRSA osteomyelitis: MRSA 4–6 weeks [Good evidence, 1 well-designed observational study or more] MRSA septic arthritis: 3–4 weeks [Good evidence, 1 well-designed observational study or more] (IDSA, 2011) | Not available | Uncomplicated native joint septic arthritis: 2–4 days IV antibiotics with total antibiotic duration of 2–3 weeks (EBJIS, 2023) | Osteomyelitis (with uncomplicated infections) and septic arthritis: 3 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin | |
| Others | |||||
| Bloodstream infections | Varied durations depend on bacterial pathogen, source control and secondary seeding: 4–6 weeks for persistent bacteraemia after catheter removal, complications of infective endocarditis or suppurative thrombophlebitis, complicated staphylococcal bacteraemia, paediatric patients with osteomyelitis [Good evidence] 2 weeks for uncomplicated staphylococcal bacteraemia (exclusion of endocarditis, no implanted prostheses, clearance of follow-up blood cultures 2–4 days after the initial set, defervescence within 72 h effective therapy, and no metastatic sites of infection) [Good evidence (IDSA guideline on intravascular catheter-related infection, 2009; guideline on MRSA infections, 2011) | In neonates, 7 days in early- (first 72 h after birth) and late-onset (after 1st week of birth to 3 months) sepsis if without meningitis, >7 days if not yet recovered or due to the identified pathogen; <7 days in prompt recovery and pathogen identified is common commensal or no pathogen identified (NICE guideline on neonatal infection, 2021) | Varied durations depend on the organism identified, the presence of complications and whether the intravascular catheter has been removed: 4–6 weeks if there is: prolonged or persistent bacteraemia after intravascular catheter removal (i.e. >72 h after removal), endocarditis or suppurative thrombophlebitis, metastatic focus of infection, osteomyelitis in paediatric patients (Ireland, 2014) | Not available | |
| Non-tuberculous meningitis | Neisseria meningitidis: 7 days third-generation cephalosporin (first line), penicillin G, ampicillin, chloramphenicol, fluoroquinolone, aztreonam Haemophilus influenzae: 7 days third-generation cephalosporin (first line), chloramphenicol, cefepime, meropenem, fluoroquinolone Streptococcus pneumoniae: 10–14 days vancomycin plus a third-generation cephalosporin (first line), meropenem, fluoroquinolone Streptococcus agalactiae: 14–21 days ampicillin or penicillin G (first line), third-generation cephalosporin Aerobic Gram-negative bacilli: 21 days third-generation cephalosporin (first line), cefepime, meropenem, aztreonam, fluoroquinolone, trimethoprim/sulfamethoxazole Listeria monocytogenes: ≥21 days ampicillin or penicillin G (first line), trimethoprim/sulfamethoxazole, meropenem [Good evidence, expert opinion] (IDSA, 2004) | >3 months: H. influenzae type B: 10 days ceftriaxone S. pneumoniae: 14 days ceftriaxone Unconfirmed bacterial meningitis: >10 days ceftriaxone <3 months: Group B Streptococcus pneumonia: >14 days cefotaxime or benzylpenicillin with gentamicin for first 5 days Gram-negative bacilli: >21 days cefotaxime L. monocytogenes: 21 days IV amoxicillin or ampicillin and gentamicin for at least the first 7 days Unconfirmed bacterial meningitis: >14 days cefotaxime plus ampicillin or amoxicillin (NICE, 2010 and 2021) | N. meningitidis: 7 days S. pneumoniae: 10–14 days H. influenzae: 7–10 days S. aureus: >14 days [Strong recommendation] L. monocytogenes: >21 days (ESCMID, 2016) | N. meningitidis: 5–7 days S. pneumoniae: 10–14 days Listeria meningitis: 21 days Unknown pathogen: 10 days cefotaxime or ceftriaxone (first line), amoxicillin, ampicillin, benzylpenicillin or chloramphenicol in adults and older children; 3 weeks in neonates <1 month, ampicillin with gentamicin, cefotaxime or ceftriaxone with gentamicin (first line), or meropenem (AWaRe antibiotic book, 2023) | |
| Cellulitis and skin abscesses | Cellulitis: 5 days [Strong recommendation, high evidence] Recurrent cellulitis (>3 episodes a year): 4–52 weeks oral penicillin or erythromycin; or every 2–4 weeks intramuscular benzathine penicillin [Strong recommendation, moderate evidence] Recurrent abscess: 5–10 days [Weak recommendation, low evidence] (IDSA, 2014) | Cellulitis: 5–7 days flucloxacillin (first line), clarithromycin, erythromycin, doxycycline; 7 days amoxicillin/clavulanate (first line) or clarithromycin and metronidazole if infection near eyes or nose (avoid doxycycline in children) [Limited evidence] (NICE, 2019) | Not available | Cellulitis: 5 days amoxicillin/clavulanate, cefalexin or cloxacillin in adults and children (AWaRe antibiotic book, 2023) | |
| Intra-abdominal infections | 4–7 days with adequate source control [Moderate evidence] (IDSA, 2010) | Not available | 2–3 days in localized community-acquired intra-abdominal infections with adequate source control, adapted to the degree of contamination observed intraoperatively [Strong agreement, weak recommendation]; 5–7 days in generalized community-acquired intra-abdominal infections [Strong agreement, weak recommendation] (SRLF, 2015) | <4 days with adequate source control, <7 days in patients with secondary bacteraemia who have undergone adequate source control and are no longer bacteraemic [Weak recommendation, moderate-quality evidence] 4 days in complicated appendicitis, complicated cholecystitis, diffuse peritonitis, small bowel perforation, gastroduodenal ulcer perforation, if source control is adequate in immunocompetent patients without sepsis 3–5 days in acute cholangitis with biliary drainage, or diverticular abscesses (with percutaneous drainage in abscesses >4–5 cm) 5–7 days in uncomplicated diverticulitis in immunocompromised patients or with sepsis (no antibiotics needed for uncomplicated diverticulitis otherwise), or in established intra-abdominal infections where definitive source control procedure is not performed [Weak recommendation, weak-quality evidence] <24 h in patients with traumatic bowel perforations, acute or gangrenous appendicitis/cholecystitis in absence of perforation [Strong recommendation, high-quality evidence], gastroduodenal perforations, ischaemic and non-perforated bowel [Strong recommendation, weak-quality evidence] (SIS, 2017; WSES/GAIS/SIS-E/WSIS/AAST, 2021) | |
| Perioperative prophylaxis | Generally single dose or continuation <24 h after end of surgery, with variations across types of surgical procedures, e.g. no need for prophylaxis in clean orthopaedic procedures not involving implantation of foreign materials [Evidence from well-conducted cohort studies or randomized trials] (IDSA, 2013) | Single dose on starting anaesthesia or earlier for operations in which a tourniquet is used, repeat dose when the operation is longer than the half-life of the antibiotic given (NICE, 2020) | Single dose if surgery lasts <4 h and no significant blood loss, total duration should not exceed 24 h after the end of surgery [Low to moderate evidence] (ECDC, 2013) | Single-dose cefazolin (first line) within 120 min of surgery, add metronidazole if contamination expected (AWaRe antibiotic book, 2023) | |
| Infection syndrome . | Major guidelinesa Recommendation, year of publication, [strength of recommendation as stated in the guideline] . | Comments . | |||
|---|---|---|---|---|---|
| US guideline . | UK guideline . | European guideline . | WHO/international guidelines . | ||
| Respiratory tract | |||||
| Acute GAS pharyngotonsillitis | 10 days penicillin or amoxicillin (first line) [Strong recommendation, high evidence], first generation cephalosporin, clindamycin or clarithromycin [strong recommendation, moderate evidence]; 5 days azithromycin (IDSA, 2012) | 5–10 days phenoxymethylpenicillin (first line); 5 days clarithromycin or erythromycin (second line) in adults and children [Very low to low-quality evidence] (NICE, 2018) | Not available | 5 days (low riskb) or 10 days (high riskb) amoxicillin or phenoxymethylpenicillin (first line); 5 days cefalexin or clarithromycin (second line) (AWaRe antibiotic book 2023) | 5 days may be adequate for symptomatic cure; 10 days is associated with higher rates of GAS pharyngeal eradication |
| Otitis media in children | 10 days amoxicillin or amoxicillin/clavulanate (first line) in <2 years or severe symptoms; 7 days first-line antibiotics in 2–5 years with mild or moderate symptoms; 5–7 days first-line antibiotics in >6 years with mild to moderate symptoms (AAP/AAFP, 2013) | 5–7 days amoxicillin (first line), clarithromycin or amoxicillin/clavulanate in 1 month to 17 years, with 7 days reserved for those with severe or recurrent infection [Very low- to low-quality evidence] (NICE, 2018) | 5–10 days [Weak evidence] (Systematic review of guidelines across 17 countries in the EU, 2020) | 5 days amoxicillin (first line) or amoxicillin/clavulanate (AWaRe antibiotic book, 2023) | |
| Acute bacterial sinusitis | In adults, 5–7 days amoxicillin/clavulanate (first line) or doxycycline In children, 10–14 days amoxicillin/clavulanate (first line) [Weak recommendation, low–moderate evidence] (IDSA, 2012) | In adults and children, 5 days phenoxymethylpenicillin or amoxicillin/clavulanate (first line), doxycycline or erythromycin [Moderate to high evidence] (NICE, 2017) | No specific recommendations on antibiotic duration [Weak evidence] (European position paper, 2020) | 5 days amoxicillin (first line), or amoxicillin/clavulanate (AWaRe antibiotic book, 2023) | Longer duration recommended in some guidelines for paediatric patients because shorter course antibiotic has not been studied in this population with randomized trials |
| Community-acquired pneumonia | In adults, 5 days amoxicillin, doxycycline or macrolide (if local pneumococcal resistance is <25%, no comorbidities or risk factors for MRSA or P. aeruginosa) or more until clinical stability; 7 days for MRSA or P. aeruginosa pneumonia [Strong recommendation, moderate evidence] In children, no specific recommendation on antibiotic duration (IDSA, 2019) | In adults and children, 5 days amoxicillin (first line), doxycycline, clarithromycin or erythromycin for mild infections; combine amoxicillin or amoxicillin/clavulanate with doxycycline, clarithromycin or erythromycin for moderate to severe infections (avoid doxycycline in children <12 years) (NICE, 2019) | 8 days or less in responding patient [1 RCT or more, consistent evidence/clear outcome]; (ERS/ESCMID, 2011) Addition of 3–5 days of macrolides to β-lactams in hospitalized patients with severe infections [Conditional recommendation, very low evidence] (ERS/ESICM/ESCMID/ALAT, 2023) | In adults, 5 days amoxicillin or phenoxymethylpenicillin (first line), amoxicillin/clavulanate or doxycycline until clinical stability for mild–moderate infections; cefotaxime or ceftriaxone (first line), or amoxicillin/clavulanate with or without clarithromycin for severe infections In children from areas of low HIV prevalence and no chest indrawing, 3 days amoxicillin for mild to moderate infections; longer treatment until clinical stability with IV amoxicillin, ampicillin, or benzylpenicillin with gentamicin for severe infections (AWaRe antibiotic book, 2023) | |
| Ventilator-associated pneumonia | 7 days [Strong recommendation, moderate evidence] (IDSA, 2016) | Not available | 7–8 days in patients without immunodeficiency, cystic fibrosis, empyema, lung abscess, cavitation or necrotizing pneumonia and with a good clinical response to therapy [Weak recommendation, moderate evidence] (ERS/ESICM/ESCMID/ALAT, 2017) | Not available | |
| Bacterial exacerbation of COPD | Not available | 5 days amoxicillin, doxycycline or clarithromycin (first line), amoxicillin/clavulanate, trimethoprim/sulfamethoxazole or levofloxacin [Low to moderate evidence] (NICE, 2018) | No specific recommendation on antibiotic duration (ERS/ATS, 2017) | 5 days amoxicillin (first line), cefalexin or doxycycline in mild–moderate infections, amoxicillin/clavulanate in severe infections (AWaRe antibiotic book, 2023) | |
| Genitourinary tract | |||||
| Simple cystitis in women | 5 days nitrofurantoin; 3 days trimethoprim/sulfamethoxazole (first line); 3 days trimethoprim or fluoroquinolones; single-dose fosfomycin; 3–7 days pivmecillinam or β-lactam agents [Moderate to good evidence] (IDSA, 2011) | 3 days nitrofurantoin or trimethoprim (first line); 3 days pivmecillinam; single-dose fosfomycin in non-pregnant women >15 years 7 days nitrofurantoin (first line); amoxicillin or cefalexin for pregnant women >11 years [Very low to moderate evidence] (NICE, 2018) | Single-dose fosfomycin; 3–5 days pivmecillinam; 5 days nitrofurantoin [Strong recommendation, 1 RCT or more] (EAU, 2023) | 3–5 days amoxicillin/clavulanate; 5 days nitrofurantoin (preferred); 3 days trimethoprim/ sulfamethoxazole or trimethoprim; consider longer treatment in pregnant women, i.e. 5 days (AWaRe antibiotic book, 2023) | |
| Complicated urinary tract infections (in males, catheter-associated, upper urinary tract involvement) | Catheter-associated: Up to 14 days depending on symptom resolution [Good evidence, expert opinion]; 5 days levofloxacin for mild infections [Moderate evidence, expert opinion]; 3 days for women <65 years without upper tract involvement after indwelling catheter removal [Moderate evidence, 1 well-designed observational study or more] Uncomplicated pyelonephritis: 7 days ciprofloxacin [Good evidence, 1 RCT or more]; 5 days levofloxacin [Moderate evidence, 1 well-designed observational study or more]; 14 days trimethoprim/ sulfamethoxazole [Good evidence, 1 RCT or more] (IDSA, 2010) | Catheter-associated: 7 days nitrofurantoin, trimethoprim, amoxicillin (first line), or pivmecillinam in non-pregnant women and men >16 years if upper tract involvement; 7–10 days cefalexin or amoxicillin/clavulanate; 14 days trimethoprim; or 7 days ciprofloxacin (first line) if upper tract involvement Males: 7 days trimethoprim or nitrofurantoin (first line) for >16 years [Very low to moderate evidence] Acute pyelonephritis in men >16 years: 7–10 days cefalexin or amoxicillin/clavulanate (first line); 14 days trimethoprim; 7 days ciprofloxacin (NICE, 2018) | Catheter-associated: Up to 14 days depending on symptom resolution, indwelling catheter removal; 5 days levofloxacin for mild infections [Strong recommendation, 1 RCT or more] Uncomplicated pyelonephritis: 7 days ciprofloxacin; 5 days levofloxacin; 14 days trimethoprim/ sulfamethoxazole; 10 days cefpodoxime or ceftibuten Males with prostatitis: 14 days (EAU, 2023) | Uncomplicated pyelonephritis: 7 days ciprofloxacin in mild infections; cefotaxime, ceftriaxone and/or amikacin and/or gentamicin in severe infections (AWaRe antibiotic book, 2023) | |
| Bone and joint infections | |||||
| Adult osteomyelitis, septic arthritis and prosthetic joint infection | Osteomyelitis: MRSA: ≥ 8 weeks [Good evidence, 1 well-designed observational study or more] Septic arthritis: MRSA: 3–4 weeks with debridement or drainage [Good evidence, expert opinion] (IDSA, 2011) Prosthetic joint infection: Following debridement and prosthesis retention or 1-stage exchange: Staphylococcus: 2–6 weeks IV antibiotic with rifampicin (extend to 4–6 weeks if rifampicin cannot be used), followed by oral antibiotic with rifampicin for a total of 3 months for hip; 6 months for knee [Good evidence, 1 RCT or more] Other organism(s): 4–6 weeks of IV or highly bioavailable oral antibiotics [Moderate evidence, 1 well-designed observational study or more] Indefinite chronic oral antimicrobial suppression for retained prosthesis [Moderate evidence, expert opinion] Following resection arthroplasty with or without planned staged reimplantation: 4–6 weeks post procedure [Good evidence, 1 well-designed observational study or more] Following amputation and complete removal of infected tissue: 1–2 days post procedure [Poor evidence, expert opinion] (IDSA, 2014) | Osteomyelitis: Staphylococcus: 6 weeks flucloxacillin or clindamycin, or vancomycin or teicoplanin (if MRSA suspected) with fusidic acid or rifampicin for initial 2 weeks Septic arthritis: Staphylococcus: 4–6 weeks Neisseria gonorrhoeae or Gram-negative: 4–6 weeks cefotaxime or ceftriaxone (NICE, 2020) | Septic arthritis: Native joint: 1 to 2 weeks of IV antibiotics followed by 2–4 weeks oral antibiotics [Very low-quality, weak recommendation] After reconstruction of anterior cruciate ligament: 1–2 weeks of IV antibiotics followed by 4–5 weeks of oral antibiotics [Very low-quality, weak recommendation] (EBJIS, 2023) Prosthetic joint infection: 4–6 weeks (Italy, 2006) | Osteomyelitis: 4–6 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin Septic arthritis: 4–6 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin N. gonorrhoeae: 2 weeks (AWaRe antibiotic book, 2023) | |
| Childhood osteomyelitis/septic arthritis | MRSA osteomyelitis: MRSA 4–6 weeks [Good evidence, 1 well-designed observational study or more] MRSA septic arthritis: 3–4 weeks [Good evidence, 1 well-designed observational study or more] (IDSA, 2011) | Not available | Uncomplicated native joint septic arthritis: 2–4 days IV antibiotics with total antibiotic duration of 2–3 weeks (EBJIS, 2023) | Osteomyelitis (with uncomplicated infections) and septic arthritis: 3 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin | |
| Others | |||||
| Bloodstream infections | Varied durations depend on bacterial pathogen, source control and secondary seeding: 4–6 weeks for persistent bacteraemia after catheter removal, complications of infective endocarditis or suppurative thrombophlebitis, complicated staphylococcal bacteraemia, paediatric patients with osteomyelitis [Good evidence] 2 weeks for uncomplicated staphylococcal bacteraemia (exclusion of endocarditis, no implanted prostheses, clearance of follow-up blood cultures 2–4 days after the initial set, defervescence within 72 h effective therapy, and no metastatic sites of infection) [Good evidence (IDSA guideline on intravascular catheter-related infection, 2009; guideline on MRSA infections, 2011) | In neonates, 7 days in early- (first 72 h after birth) and late-onset (after 1st week of birth to 3 months) sepsis if without meningitis, >7 days if not yet recovered or due to the identified pathogen; <7 days in prompt recovery and pathogen identified is common commensal or no pathogen identified (NICE guideline on neonatal infection, 2021) | Varied durations depend on the organism identified, the presence of complications and whether the intravascular catheter has been removed: 4–6 weeks if there is: prolonged or persistent bacteraemia after intravascular catheter removal (i.e. >72 h after removal), endocarditis or suppurative thrombophlebitis, metastatic focus of infection, osteomyelitis in paediatric patients (Ireland, 2014) | Not available | |
| Non-tuberculous meningitis | Neisseria meningitidis: 7 days third-generation cephalosporin (first line), penicillin G, ampicillin, chloramphenicol, fluoroquinolone, aztreonam Haemophilus influenzae: 7 days third-generation cephalosporin (first line), chloramphenicol, cefepime, meropenem, fluoroquinolone Streptococcus pneumoniae: 10–14 days vancomycin plus a third-generation cephalosporin (first line), meropenem, fluoroquinolone Streptococcus agalactiae: 14–21 days ampicillin or penicillin G (first line), third-generation cephalosporin Aerobic Gram-negative bacilli: 21 days third-generation cephalosporin (first line), cefepime, meropenem, aztreonam, fluoroquinolone, trimethoprim/sulfamethoxazole Listeria monocytogenes: ≥21 days ampicillin or penicillin G (first line), trimethoprim/sulfamethoxazole, meropenem [Good evidence, expert opinion] (IDSA, 2004) | >3 months: H. influenzae type B: 10 days ceftriaxone S. pneumoniae: 14 days ceftriaxone Unconfirmed bacterial meningitis: >10 days ceftriaxone <3 months: Group B Streptococcus pneumonia: >14 days cefotaxime or benzylpenicillin with gentamicin for first 5 days Gram-negative bacilli: >21 days cefotaxime L. monocytogenes: 21 days IV amoxicillin or ampicillin and gentamicin for at least the first 7 days Unconfirmed bacterial meningitis: >14 days cefotaxime plus ampicillin or amoxicillin (NICE, 2010 and 2021) | N. meningitidis: 7 days S. pneumoniae: 10–14 days H. influenzae: 7–10 days S. aureus: >14 days [Strong recommendation] L. monocytogenes: >21 days (ESCMID, 2016) | N. meningitidis: 5–7 days S. pneumoniae: 10–14 days Listeria meningitis: 21 days Unknown pathogen: 10 days cefotaxime or ceftriaxone (first line), amoxicillin, ampicillin, benzylpenicillin or chloramphenicol in adults and older children; 3 weeks in neonates <1 month, ampicillin with gentamicin, cefotaxime or ceftriaxone with gentamicin (first line), or meropenem (AWaRe antibiotic book, 2023) | |
| Cellulitis and skin abscesses | Cellulitis: 5 days [Strong recommendation, high evidence] Recurrent cellulitis (>3 episodes a year): 4–52 weeks oral penicillin or erythromycin; or every 2–4 weeks intramuscular benzathine penicillin [Strong recommendation, moderate evidence] Recurrent abscess: 5–10 days [Weak recommendation, low evidence] (IDSA, 2014) | Cellulitis: 5–7 days flucloxacillin (first line), clarithromycin, erythromycin, doxycycline; 7 days amoxicillin/clavulanate (first line) or clarithromycin and metronidazole if infection near eyes or nose (avoid doxycycline in children) [Limited evidence] (NICE, 2019) | Not available | Cellulitis: 5 days amoxicillin/clavulanate, cefalexin or cloxacillin in adults and children (AWaRe antibiotic book, 2023) | |
| Intra-abdominal infections | 4–7 days with adequate source control [Moderate evidence] (IDSA, 2010) | Not available | 2–3 days in localized community-acquired intra-abdominal infections with adequate source control, adapted to the degree of contamination observed intraoperatively [Strong agreement, weak recommendation]; 5–7 days in generalized community-acquired intra-abdominal infections [Strong agreement, weak recommendation] (SRLF, 2015) | <4 days with adequate source control, <7 days in patients with secondary bacteraemia who have undergone adequate source control and are no longer bacteraemic [Weak recommendation, moderate-quality evidence] 4 days in complicated appendicitis, complicated cholecystitis, diffuse peritonitis, small bowel perforation, gastroduodenal ulcer perforation, if source control is adequate in immunocompetent patients without sepsis 3–5 days in acute cholangitis with biliary drainage, or diverticular abscesses (with percutaneous drainage in abscesses >4–5 cm) 5–7 days in uncomplicated diverticulitis in immunocompromised patients or with sepsis (no antibiotics needed for uncomplicated diverticulitis otherwise), or in established intra-abdominal infections where definitive source control procedure is not performed [Weak recommendation, weak-quality evidence] <24 h in patients with traumatic bowel perforations, acute or gangrenous appendicitis/cholecystitis in absence of perforation [Strong recommendation, high-quality evidence], gastroduodenal perforations, ischaemic and non-perforated bowel [Strong recommendation, weak-quality evidence] (SIS, 2017; WSES/GAIS/SIS-E/WSIS/AAST, 2021) | |
| Perioperative prophylaxis | Generally single dose or continuation <24 h after end of surgery, with variations across types of surgical procedures, e.g. no need for prophylaxis in clean orthopaedic procedures not involving implantation of foreign materials [Evidence from well-conducted cohort studies or randomized trials] (IDSA, 2013) | Single dose on starting anaesthesia or earlier for operations in which a tourniquet is used, repeat dose when the operation is longer than the half-life of the antibiotic given (NICE, 2020) | Single dose if surgery lasts <4 h and no significant blood loss, total duration should not exceed 24 h after the end of surgery [Low to moderate evidence] (ECDC, 2013) | Single-dose cefazolin (first line) within 120 min of surgery, add metronidazole if contamination expected (AWaRe antibiotic book, 2023) | |
Note that these recommendations are meant for when antibiotics are indicated or the decision for prescribing antibiotics has been made. Antibiotics may not be indicated in these infections. When antibiotic names are included without specific bacterial pathogens, they refer to empirical choices stated in the respective guidelines without the need for microbiological cultures. When antibiotic names are not included, they were not mentioned in the guidelines or culture directed antibiotics are required.
WHO AWaRe antibiotic book, WHO Access, Watch, Reserve antibiotic book; AAP, American Academy of Pediatrics; AAFP, American Academy of Family Physicians; ERS, European Respiratory Society; ESICM, European Society of Intensive Care Medicine, ESCMID, European Society of Clinical Microbiology and Infectious Diseases; ALAT, Latin American Thoracic Association; ATS, American Thoracic Society; EAU, European Association of Urology; RCT, randomized controlled trial; EBJIS, European Bone and Joint Infection Society; SRLF, Société de réanimation de langue française; SIS-E, Surgical Infection Society-Europe; WSES, World Society of Emergency Surgery; GAIS, Global Alliance for Infections in Surgery; WSIS, World Surgical Infection Society; AAST, American Association for the Surgery of Trauma.
aFull reference list can be found in the Supplementary material (references).
bRisk of GAS pharyngitis can be estimated by the Centor score+ local prevalence or previous history of rheumatic fever. Centor score is the sum of: presence of fever, absence of cough, tonsillar exudates or swelling, and tender anterior cervical lymphadenopathy, where each criterion is given 1 point (<2 points = low risk, 2–3 moderate risk, >3 high risk of GAS pharyngitis).
Summary of antibiotic duration recommendations for bacterial infections from major guidelines
| Infection syndrome . | Major guidelinesa Recommendation, year of publication, [strength of recommendation as stated in the guideline] . | Comments . | |||
|---|---|---|---|---|---|
| US guideline . | UK guideline . | European guideline . | WHO/international guidelines . | ||
| Respiratory tract | |||||
| Acute GAS pharyngotonsillitis | 10 days penicillin or amoxicillin (first line) [Strong recommendation, high evidence], first generation cephalosporin, clindamycin or clarithromycin [strong recommendation, moderate evidence]; 5 days azithromycin (IDSA, 2012) | 5–10 days phenoxymethylpenicillin (first line); 5 days clarithromycin or erythromycin (second line) in adults and children [Very low to low-quality evidence] (NICE, 2018) | Not available | 5 days (low riskb) or 10 days (high riskb) amoxicillin or phenoxymethylpenicillin (first line); 5 days cefalexin or clarithromycin (second line) (AWaRe antibiotic book 2023) | 5 days may be adequate for symptomatic cure; 10 days is associated with higher rates of GAS pharyngeal eradication |
| Otitis media in children | 10 days amoxicillin or amoxicillin/clavulanate (first line) in <2 years or severe symptoms; 7 days first-line antibiotics in 2–5 years with mild or moderate symptoms; 5–7 days first-line antibiotics in >6 years with mild to moderate symptoms (AAP/AAFP, 2013) | 5–7 days amoxicillin (first line), clarithromycin or amoxicillin/clavulanate in 1 month to 17 years, with 7 days reserved for those with severe or recurrent infection [Very low- to low-quality evidence] (NICE, 2018) | 5–10 days [Weak evidence] (Systematic review of guidelines across 17 countries in the EU, 2020) | 5 days amoxicillin (first line) or amoxicillin/clavulanate (AWaRe antibiotic book, 2023) | |
| Acute bacterial sinusitis | In adults, 5–7 days amoxicillin/clavulanate (first line) or doxycycline In children, 10–14 days amoxicillin/clavulanate (first line) [Weak recommendation, low–moderate evidence] (IDSA, 2012) | In adults and children, 5 days phenoxymethylpenicillin or amoxicillin/clavulanate (first line), doxycycline or erythromycin [Moderate to high evidence] (NICE, 2017) | No specific recommendations on antibiotic duration [Weak evidence] (European position paper, 2020) | 5 days amoxicillin (first line), or amoxicillin/clavulanate (AWaRe antibiotic book, 2023) | Longer duration recommended in some guidelines for paediatric patients because shorter course antibiotic has not been studied in this population with randomized trials |
| Community-acquired pneumonia | In adults, 5 days amoxicillin, doxycycline or macrolide (if local pneumococcal resistance is <25%, no comorbidities or risk factors for MRSA or P. aeruginosa) or more until clinical stability; 7 days for MRSA or P. aeruginosa pneumonia [Strong recommendation, moderate evidence] In children, no specific recommendation on antibiotic duration (IDSA, 2019) | In adults and children, 5 days amoxicillin (first line), doxycycline, clarithromycin or erythromycin for mild infections; combine amoxicillin or amoxicillin/clavulanate with doxycycline, clarithromycin or erythromycin for moderate to severe infections (avoid doxycycline in children <12 years) (NICE, 2019) | 8 days or less in responding patient [1 RCT or more, consistent evidence/clear outcome]; (ERS/ESCMID, 2011) Addition of 3–5 days of macrolides to β-lactams in hospitalized patients with severe infections [Conditional recommendation, very low evidence] (ERS/ESICM/ESCMID/ALAT, 2023) | In adults, 5 days amoxicillin or phenoxymethylpenicillin (first line), amoxicillin/clavulanate or doxycycline until clinical stability for mild–moderate infections; cefotaxime or ceftriaxone (first line), or amoxicillin/clavulanate with or without clarithromycin for severe infections In children from areas of low HIV prevalence and no chest indrawing, 3 days amoxicillin for mild to moderate infections; longer treatment until clinical stability with IV amoxicillin, ampicillin, or benzylpenicillin with gentamicin for severe infections (AWaRe antibiotic book, 2023) | |
| Ventilator-associated pneumonia | 7 days [Strong recommendation, moderate evidence] (IDSA, 2016) | Not available | 7–8 days in patients without immunodeficiency, cystic fibrosis, empyema, lung abscess, cavitation or necrotizing pneumonia and with a good clinical response to therapy [Weak recommendation, moderate evidence] (ERS/ESICM/ESCMID/ALAT, 2017) | Not available | |
| Bacterial exacerbation of COPD | Not available | 5 days amoxicillin, doxycycline or clarithromycin (first line), amoxicillin/clavulanate, trimethoprim/sulfamethoxazole or levofloxacin [Low to moderate evidence] (NICE, 2018) | No specific recommendation on antibiotic duration (ERS/ATS, 2017) | 5 days amoxicillin (first line), cefalexin or doxycycline in mild–moderate infections, amoxicillin/clavulanate in severe infections (AWaRe antibiotic book, 2023) | |
| Genitourinary tract | |||||
| Simple cystitis in women | 5 days nitrofurantoin; 3 days trimethoprim/sulfamethoxazole (first line); 3 days trimethoprim or fluoroquinolones; single-dose fosfomycin; 3–7 days pivmecillinam or β-lactam agents [Moderate to good evidence] (IDSA, 2011) | 3 days nitrofurantoin or trimethoprim (first line); 3 days pivmecillinam; single-dose fosfomycin in non-pregnant women >15 years 7 days nitrofurantoin (first line); amoxicillin or cefalexin for pregnant women >11 years [Very low to moderate evidence] (NICE, 2018) | Single-dose fosfomycin; 3–5 days pivmecillinam; 5 days nitrofurantoin [Strong recommendation, 1 RCT or more] (EAU, 2023) | 3–5 days amoxicillin/clavulanate; 5 days nitrofurantoin (preferred); 3 days trimethoprim/ sulfamethoxazole or trimethoprim; consider longer treatment in pregnant women, i.e. 5 days (AWaRe antibiotic book, 2023) | |
| Complicated urinary tract infections (in males, catheter-associated, upper urinary tract involvement) | Catheter-associated: Up to 14 days depending on symptom resolution [Good evidence, expert opinion]; 5 days levofloxacin for mild infections [Moderate evidence, expert opinion]; 3 days for women <65 years without upper tract involvement after indwelling catheter removal [Moderate evidence, 1 well-designed observational study or more] Uncomplicated pyelonephritis: 7 days ciprofloxacin [Good evidence, 1 RCT or more]; 5 days levofloxacin [Moderate evidence, 1 well-designed observational study or more]; 14 days trimethoprim/ sulfamethoxazole [Good evidence, 1 RCT or more] (IDSA, 2010) | Catheter-associated: 7 days nitrofurantoin, trimethoprim, amoxicillin (first line), or pivmecillinam in non-pregnant women and men >16 years if upper tract involvement; 7–10 days cefalexin or amoxicillin/clavulanate; 14 days trimethoprim; or 7 days ciprofloxacin (first line) if upper tract involvement Males: 7 days trimethoprim or nitrofurantoin (first line) for >16 years [Very low to moderate evidence] Acute pyelonephritis in men >16 years: 7–10 days cefalexin or amoxicillin/clavulanate (first line); 14 days trimethoprim; 7 days ciprofloxacin (NICE, 2018) | Catheter-associated: Up to 14 days depending on symptom resolution, indwelling catheter removal; 5 days levofloxacin for mild infections [Strong recommendation, 1 RCT or more] Uncomplicated pyelonephritis: 7 days ciprofloxacin; 5 days levofloxacin; 14 days trimethoprim/ sulfamethoxazole; 10 days cefpodoxime or ceftibuten Males with prostatitis: 14 days (EAU, 2023) | Uncomplicated pyelonephritis: 7 days ciprofloxacin in mild infections; cefotaxime, ceftriaxone and/or amikacin and/or gentamicin in severe infections (AWaRe antibiotic book, 2023) | |
| Bone and joint infections | |||||
| Adult osteomyelitis, septic arthritis and prosthetic joint infection | Osteomyelitis: MRSA: ≥ 8 weeks [Good evidence, 1 well-designed observational study or more] Septic arthritis: MRSA: 3–4 weeks with debridement or drainage [Good evidence, expert opinion] (IDSA, 2011) Prosthetic joint infection: Following debridement and prosthesis retention or 1-stage exchange: Staphylococcus: 2–6 weeks IV antibiotic with rifampicin (extend to 4–6 weeks if rifampicin cannot be used), followed by oral antibiotic with rifampicin for a total of 3 months for hip; 6 months for knee [Good evidence, 1 RCT or more] Other organism(s): 4–6 weeks of IV or highly bioavailable oral antibiotics [Moderate evidence, 1 well-designed observational study or more] Indefinite chronic oral antimicrobial suppression for retained prosthesis [Moderate evidence, expert opinion] Following resection arthroplasty with or without planned staged reimplantation: 4–6 weeks post procedure [Good evidence, 1 well-designed observational study or more] Following amputation and complete removal of infected tissue: 1–2 days post procedure [Poor evidence, expert opinion] (IDSA, 2014) | Osteomyelitis: Staphylococcus: 6 weeks flucloxacillin or clindamycin, or vancomycin or teicoplanin (if MRSA suspected) with fusidic acid or rifampicin for initial 2 weeks Septic arthritis: Staphylococcus: 4–6 weeks Neisseria gonorrhoeae or Gram-negative: 4–6 weeks cefotaxime or ceftriaxone (NICE, 2020) | Septic arthritis: Native joint: 1 to 2 weeks of IV antibiotics followed by 2–4 weeks oral antibiotics [Very low-quality, weak recommendation] After reconstruction of anterior cruciate ligament: 1–2 weeks of IV antibiotics followed by 4–5 weeks of oral antibiotics [Very low-quality, weak recommendation] (EBJIS, 2023) Prosthetic joint infection: 4–6 weeks (Italy, 2006) | Osteomyelitis: 4–6 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin Septic arthritis: 4–6 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin N. gonorrhoeae: 2 weeks (AWaRe antibiotic book, 2023) | |
| Childhood osteomyelitis/septic arthritis | MRSA osteomyelitis: MRSA 4–6 weeks [Good evidence, 1 well-designed observational study or more] MRSA septic arthritis: 3–4 weeks [Good evidence, 1 well-designed observational study or more] (IDSA, 2011) | Not available | Uncomplicated native joint septic arthritis: 2–4 days IV antibiotics with total antibiotic duration of 2–3 weeks (EBJIS, 2023) | Osteomyelitis (with uncomplicated infections) and septic arthritis: 3 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin | |
| Others | |||||
| Bloodstream infections | Varied durations depend on bacterial pathogen, source control and secondary seeding: 4–6 weeks for persistent bacteraemia after catheter removal, complications of infective endocarditis or suppurative thrombophlebitis, complicated staphylococcal bacteraemia, paediatric patients with osteomyelitis [Good evidence] 2 weeks for uncomplicated staphylococcal bacteraemia (exclusion of endocarditis, no implanted prostheses, clearance of follow-up blood cultures 2–4 days after the initial set, defervescence within 72 h effective therapy, and no metastatic sites of infection) [Good evidence (IDSA guideline on intravascular catheter-related infection, 2009; guideline on MRSA infections, 2011) | In neonates, 7 days in early- (first 72 h after birth) and late-onset (after 1st week of birth to 3 months) sepsis if without meningitis, >7 days if not yet recovered or due to the identified pathogen; <7 days in prompt recovery and pathogen identified is common commensal or no pathogen identified (NICE guideline on neonatal infection, 2021) | Varied durations depend on the organism identified, the presence of complications and whether the intravascular catheter has been removed: 4–6 weeks if there is: prolonged or persistent bacteraemia after intravascular catheter removal (i.e. >72 h after removal), endocarditis or suppurative thrombophlebitis, metastatic focus of infection, osteomyelitis in paediatric patients (Ireland, 2014) | Not available | |
| Non-tuberculous meningitis | Neisseria meningitidis: 7 days third-generation cephalosporin (first line), penicillin G, ampicillin, chloramphenicol, fluoroquinolone, aztreonam Haemophilus influenzae: 7 days third-generation cephalosporin (first line), chloramphenicol, cefepime, meropenem, fluoroquinolone Streptococcus pneumoniae: 10–14 days vancomycin plus a third-generation cephalosporin (first line), meropenem, fluoroquinolone Streptococcus agalactiae: 14–21 days ampicillin or penicillin G (first line), third-generation cephalosporin Aerobic Gram-negative bacilli: 21 days third-generation cephalosporin (first line), cefepime, meropenem, aztreonam, fluoroquinolone, trimethoprim/sulfamethoxazole Listeria monocytogenes: ≥21 days ampicillin or penicillin G (first line), trimethoprim/sulfamethoxazole, meropenem [Good evidence, expert opinion] (IDSA, 2004) | >3 months: H. influenzae type B: 10 days ceftriaxone S. pneumoniae: 14 days ceftriaxone Unconfirmed bacterial meningitis: >10 days ceftriaxone <3 months: Group B Streptococcus pneumonia: >14 days cefotaxime or benzylpenicillin with gentamicin for first 5 days Gram-negative bacilli: >21 days cefotaxime L. monocytogenes: 21 days IV amoxicillin or ampicillin and gentamicin for at least the first 7 days Unconfirmed bacterial meningitis: >14 days cefotaxime plus ampicillin or amoxicillin (NICE, 2010 and 2021) | N. meningitidis: 7 days S. pneumoniae: 10–14 days H. influenzae: 7–10 days S. aureus: >14 days [Strong recommendation] L. monocytogenes: >21 days (ESCMID, 2016) | N. meningitidis: 5–7 days S. pneumoniae: 10–14 days Listeria meningitis: 21 days Unknown pathogen: 10 days cefotaxime or ceftriaxone (first line), amoxicillin, ampicillin, benzylpenicillin or chloramphenicol in adults and older children; 3 weeks in neonates <1 month, ampicillin with gentamicin, cefotaxime or ceftriaxone with gentamicin (first line), or meropenem (AWaRe antibiotic book, 2023) | |
| Cellulitis and skin abscesses | Cellulitis: 5 days [Strong recommendation, high evidence] Recurrent cellulitis (>3 episodes a year): 4–52 weeks oral penicillin or erythromycin; or every 2–4 weeks intramuscular benzathine penicillin [Strong recommendation, moderate evidence] Recurrent abscess: 5–10 days [Weak recommendation, low evidence] (IDSA, 2014) | Cellulitis: 5–7 days flucloxacillin (first line), clarithromycin, erythromycin, doxycycline; 7 days amoxicillin/clavulanate (first line) or clarithromycin and metronidazole if infection near eyes or nose (avoid doxycycline in children) [Limited evidence] (NICE, 2019) | Not available | Cellulitis: 5 days amoxicillin/clavulanate, cefalexin or cloxacillin in adults and children (AWaRe antibiotic book, 2023) | |
| Intra-abdominal infections | 4–7 days with adequate source control [Moderate evidence] (IDSA, 2010) | Not available | 2–3 days in localized community-acquired intra-abdominal infections with adequate source control, adapted to the degree of contamination observed intraoperatively [Strong agreement, weak recommendation]; 5–7 days in generalized community-acquired intra-abdominal infections [Strong agreement, weak recommendation] (SRLF, 2015) | <4 days with adequate source control, <7 days in patients with secondary bacteraemia who have undergone adequate source control and are no longer bacteraemic [Weak recommendation, moderate-quality evidence] 4 days in complicated appendicitis, complicated cholecystitis, diffuse peritonitis, small bowel perforation, gastroduodenal ulcer perforation, if source control is adequate in immunocompetent patients without sepsis 3–5 days in acute cholangitis with biliary drainage, or diverticular abscesses (with percutaneous drainage in abscesses >4–5 cm) 5–7 days in uncomplicated diverticulitis in immunocompromised patients or with sepsis (no antibiotics needed for uncomplicated diverticulitis otherwise), or in established intra-abdominal infections where definitive source control procedure is not performed [Weak recommendation, weak-quality evidence] <24 h in patients with traumatic bowel perforations, acute or gangrenous appendicitis/cholecystitis in absence of perforation [Strong recommendation, high-quality evidence], gastroduodenal perforations, ischaemic and non-perforated bowel [Strong recommendation, weak-quality evidence] (SIS, 2017; WSES/GAIS/SIS-E/WSIS/AAST, 2021) | |
| Perioperative prophylaxis | Generally single dose or continuation <24 h after end of surgery, with variations across types of surgical procedures, e.g. no need for prophylaxis in clean orthopaedic procedures not involving implantation of foreign materials [Evidence from well-conducted cohort studies or randomized trials] (IDSA, 2013) | Single dose on starting anaesthesia or earlier for operations in which a tourniquet is used, repeat dose when the operation is longer than the half-life of the antibiotic given (NICE, 2020) | Single dose if surgery lasts <4 h and no significant blood loss, total duration should not exceed 24 h after the end of surgery [Low to moderate evidence] (ECDC, 2013) | Single-dose cefazolin (first line) within 120 min of surgery, add metronidazole if contamination expected (AWaRe antibiotic book, 2023) | |
| Infection syndrome . | Major guidelinesa Recommendation, year of publication, [strength of recommendation as stated in the guideline] . | Comments . | |||
|---|---|---|---|---|---|
| US guideline . | UK guideline . | European guideline . | WHO/international guidelines . | ||
| Respiratory tract | |||||
| Acute GAS pharyngotonsillitis | 10 days penicillin or amoxicillin (first line) [Strong recommendation, high evidence], first generation cephalosporin, clindamycin or clarithromycin [strong recommendation, moderate evidence]; 5 days azithromycin (IDSA, 2012) | 5–10 days phenoxymethylpenicillin (first line); 5 days clarithromycin or erythromycin (second line) in adults and children [Very low to low-quality evidence] (NICE, 2018) | Not available | 5 days (low riskb) or 10 days (high riskb) amoxicillin or phenoxymethylpenicillin (first line); 5 days cefalexin or clarithromycin (second line) (AWaRe antibiotic book 2023) | 5 days may be adequate for symptomatic cure; 10 days is associated with higher rates of GAS pharyngeal eradication |
| Otitis media in children | 10 days amoxicillin or amoxicillin/clavulanate (first line) in <2 years or severe symptoms; 7 days first-line antibiotics in 2–5 years with mild or moderate symptoms; 5–7 days first-line antibiotics in >6 years with mild to moderate symptoms (AAP/AAFP, 2013) | 5–7 days amoxicillin (first line), clarithromycin or amoxicillin/clavulanate in 1 month to 17 years, with 7 days reserved for those with severe or recurrent infection [Very low- to low-quality evidence] (NICE, 2018) | 5–10 days [Weak evidence] (Systematic review of guidelines across 17 countries in the EU, 2020) | 5 days amoxicillin (first line) or amoxicillin/clavulanate (AWaRe antibiotic book, 2023) | |
| Acute bacterial sinusitis | In adults, 5–7 days amoxicillin/clavulanate (first line) or doxycycline In children, 10–14 days amoxicillin/clavulanate (first line) [Weak recommendation, low–moderate evidence] (IDSA, 2012) | In adults and children, 5 days phenoxymethylpenicillin or amoxicillin/clavulanate (first line), doxycycline or erythromycin [Moderate to high evidence] (NICE, 2017) | No specific recommendations on antibiotic duration [Weak evidence] (European position paper, 2020) | 5 days amoxicillin (first line), or amoxicillin/clavulanate (AWaRe antibiotic book, 2023) | Longer duration recommended in some guidelines for paediatric patients because shorter course antibiotic has not been studied in this population with randomized trials |
| Community-acquired pneumonia | In adults, 5 days amoxicillin, doxycycline or macrolide (if local pneumococcal resistance is <25%, no comorbidities or risk factors for MRSA or P. aeruginosa) or more until clinical stability; 7 days for MRSA or P. aeruginosa pneumonia [Strong recommendation, moderate evidence] In children, no specific recommendation on antibiotic duration (IDSA, 2019) | In adults and children, 5 days amoxicillin (first line), doxycycline, clarithromycin or erythromycin for mild infections; combine amoxicillin or amoxicillin/clavulanate with doxycycline, clarithromycin or erythromycin for moderate to severe infections (avoid doxycycline in children <12 years) (NICE, 2019) | 8 days or less in responding patient [1 RCT or more, consistent evidence/clear outcome]; (ERS/ESCMID, 2011) Addition of 3–5 days of macrolides to β-lactams in hospitalized patients with severe infections [Conditional recommendation, very low evidence] (ERS/ESICM/ESCMID/ALAT, 2023) | In adults, 5 days amoxicillin or phenoxymethylpenicillin (first line), amoxicillin/clavulanate or doxycycline until clinical stability for mild–moderate infections; cefotaxime or ceftriaxone (first line), or amoxicillin/clavulanate with or without clarithromycin for severe infections In children from areas of low HIV prevalence and no chest indrawing, 3 days amoxicillin for mild to moderate infections; longer treatment until clinical stability with IV amoxicillin, ampicillin, or benzylpenicillin with gentamicin for severe infections (AWaRe antibiotic book, 2023) | |
| Ventilator-associated pneumonia | 7 days [Strong recommendation, moderate evidence] (IDSA, 2016) | Not available | 7–8 days in patients without immunodeficiency, cystic fibrosis, empyema, lung abscess, cavitation or necrotizing pneumonia and with a good clinical response to therapy [Weak recommendation, moderate evidence] (ERS/ESICM/ESCMID/ALAT, 2017) | Not available | |
| Bacterial exacerbation of COPD | Not available | 5 days amoxicillin, doxycycline or clarithromycin (first line), amoxicillin/clavulanate, trimethoprim/sulfamethoxazole or levofloxacin [Low to moderate evidence] (NICE, 2018) | No specific recommendation on antibiotic duration (ERS/ATS, 2017) | 5 days amoxicillin (first line), cefalexin or doxycycline in mild–moderate infections, amoxicillin/clavulanate in severe infections (AWaRe antibiotic book, 2023) | |
| Genitourinary tract | |||||
| Simple cystitis in women | 5 days nitrofurantoin; 3 days trimethoprim/sulfamethoxazole (first line); 3 days trimethoprim or fluoroquinolones; single-dose fosfomycin; 3–7 days pivmecillinam or β-lactam agents [Moderate to good evidence] (IDSA, 2011) | 3 days nitrofurantoin or trimethoprim (first line); 3 days pivmecillinam; single-dose fosfomycin in non-pregnant women >15 years 7 days nitrofurantoin (first line); amoxicillin or cefalexin for pregnant women >11 years [Very low to moderate evidence] (NICE, 2018) | Single-dose fosfomycin; 3–5 days pivmecillinam; 5 days nitrofurantoin [Strong recommendation, 1 RCT or more] (EAU, 2023) | 3–5 days amoxicillin/clavulanate; 5 days nitrofurantoin (preferred); 3 days trimethoprim/ sulfamethoxazole or trimethoprim; consider longer treatment in pregnant women, i.e. 5 days (AWaRe antibiotic book, 2023) | |
| Complicated urinary tract infections (in males, catheter-associated, upper urinary tract involvement) | Catheter-associated: Up to 14 days depending on symptom resolution [Good evidence, expert opinion]; 5 days levofloxacin for mild infections [Moderate evidence, expert opinion]; 3 days for women <65 years without upper tract involvement after indwelling catheter removal [Moderate evidence, 1 well-designed observational study or more] Uncomplicated pyelonephritis: 7 days ciprofloxacin [Good evidence, 1 RCT or more]; 5 days levofloxacin [Moderate evidence, 1 well-designed observational study or more]; 14 days trimethoprim/ sulfamethoxazole [Good evidence, 1 RCT or more] (IDSA, 2010) | Catheter-associated: 7 days nitrofurantoin, trimethoprim, amoxicillin (first line), or pivmecillinam in non-pregnant women and men >16 years if upper tract involvement; 7–10 days cefalexin or amoxicillin/clavulanate; 14 days trimethoprim; or 7 days ciprofloxacin (first line) if upper tract involvement Males: 7 days trimethoprim or nitrofurantoin (first line) for >16 years [Very low to moderate evidence] Acute pyelonephritis in men >16 years: 7–10 days cefalexin or amoxicillin/clavulanate (first line); 14 days trimethoprim; 7 days ciprofloxacin (NICE, 2018) | Catheter-associated: Up to 14 days depending on symptom resolution, indwelling catheter removal; 5 days levofloxacin for mild infections [Strong recommendation, 1 RCT or more] Uncomplicated pyelonephritis: 7 days ciprofloxacin; 5 days levofloxacin; 14 days trimethoprim/ sulfamethoxazole; 10 days cefpodoxime or ceftibuten Males with prostatitis: 14 days (EAU, 2023) | Uncomplicated pyelonephritis: 7 days ciprofloxacin in mild infections; cefotaxime, ceftriaxone and/or amikacin and/or gentamicin in severe infections (AWaRe antibiotic book, 2023) | |
| Bone and joint infections | |||||
| Adult osteomyelitis, septic arthritis and prosthetic joint infection | Osteomyelitis: MRSA: ≥ 8 weeks [Good evidence, 1 well-designed observational study or more] Septic arthritis: MRSA: 3–4 weeks with debridement or drainage [Good evidence, expert opinion] (IDSA, 2011) Prosthetic joint infection: Following debridement and prosthesis retention or 1-stage exchange: Staphylococcus: 2–6 weeks IV antibiotic with rifampicin (extend to 4–6 weeks if rifampicin cannot be used), followed by oral antibiotic with rifampicin for a total of 3 months for hip; 6 months for knee [Good evidence, 1 RCT or more] Other organism(s): 4–6 weeks of IV or highly bioavailable oral antibiotics [Moderate evidence, 1 well-designed observational study or more] Indefinite chronic oral antimicrobial suppression for retained prosthesis [Moderate evidence, expert opinion] Following resection arthroplasty with or without planned staged reimplantation: 4–6 weeks post procedure [Good evidence, 1 well-designed observational study or more] Following amputation and complete removal of infected tissue: 1–2 days post procedure [Poor evidence, expert opinion] (IDSA, 2014) | Osteomyelitis: Staphylococcus: 6 weeks flucloxacillin or clindamycin, or vancomycin or teicoplanin (if MRSA suspected) with fusidic acid or rifampicin for initial 2 weeks Septic arthritis: Staphylococcus: 4–6 weeks Neisseria gonorrhoeae or Gram-negative: 4–6 weeks cefotaxime or ceftriaxone (NICE, 2020) | Septic arthritis: Native joint: 1 to 2 weeks of IV antibiotics followed by 2–4 weeks oral antibiotics [Very low-quality, weak recommendation] After reconstruction of anterior cruciate ligament: 1–2 weeks of IV antibiotics followed by 4–5 weeks of oral antibiotics [Very low-quality, weak recommendation] (EBJIS, 2023) Prosthetic joint infection: 4–6 weeks (Italy, 2006) | Osteomyelitis: 4–6 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin Septic arthritis: 4–6 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin N. gonorrhoeae: 2 weeks (AWaRe antibiotic book, 2023) | |
| Childhood osteomyelitis/septic arthritis | MRSA osteomyelitis: MRSA 4–6 weeks [Good evidence, 1 well-designed observational study or more] MRSA septic arthritis: 3–4 weeks [Good evidence, 1 well-designed observational study or more] (IDSA, 2011) | Not available | Uncomplicated native joint septic arthritis: 2–4 days IV antibiotics with total antibiotic duration of 2–3 weeks (EBJIS, 2023) | Osteomyelitis (with uncomplicated infections) and septic arthritis: 3 weeks cloxacillin (first line), amoxicillin/clavulanate, cefazolin, cefotaxime, ceftriaxone or clindamycin | |
| Others | |||||
| Bloodstream infections | Varied durations depend on bacterial pathogen, source control and secondary seeding: 4–6 weeks for persistent bacteraemia after catheter removal, complications of infective endocarditis or suppurative thrombophlebitis, complicated staphylococcal bacteraemia, paediatric patients with osteomyelitis [Good evidence] 2 weeks for uncomplicated staphylococcal bacteraemia (exclusion of endocarditis, no implanted prostheses, clearance of follow-up blood cultures 2–4 days after the initial set, defervescence within 72 h effective therapy, and no metastatic sites of infection) [Good evidence (IDSA guideline on intravascular catheter-related infection, 2009; guideline on MRSA infections, 2011) | In neonates, 7 days in early- (first 72 h after birth) and late-onset (after 1st week of birth to 3 months) sepsis if without meningitis, >7 days if not yet recovered or due to the identified pathogen; <7 days in prompt recovery and pathogen identified is common commensal or no pathogen identified (NICE guideline on neonatal infection, 2021) | Varied durations depend on the organism identified, the presence of complications and whether the intravascular catheter has been removed: 4–6 weeks if there is: prolonged or persistent bacteraemia after intravascular catheter removal (i.e. >72 h after removal), endocarditis or suppurative thrombophlebitis, metastatic focus of infection, osteomyelitis in paediatric patients (Ireland, 2014) | Not available | |
| Non-tuberculous meningitis | Neisseria meningitidis: 7 days third-generation cephalosporin (first line), penicillin G, ampicillin, chloramphenicol, fluoroquinolone, aztreonam Haemophilus influenzae: 7 days third-generation cephalosporin (first line), chloramphenicol, cefepime, meropenem, fluoroquinolone Streptococcus pneumoniae: 10–14 days vancomycin plus a third-generation cephalosporin (first line), meropenem, fluoroquinolone Streptococcus agalactiae: 14–21 days ampicillin or penicillin G (first line), third-generation cephalosporin Aerobic Gram-negative bacilli: 21 days third-generation cephalosporin (first line), cefepime, meropenem, aztreonam, fluoroquinolone, trimethoprim/sulfamethoxazole Listeria monocytogenes: ≥21 days ampicillin or penicillin G (first line), trimethoprim/sulfamethoxazole, meropenem [Good evidence, expert opinion] (IDSA, 2004) | >3 months: H. influenzae type B: 10 days ceftriaxone S. pneumoniae: 14 days ceftriaxone Unconfirmed bacterial meningitis: >10 days ceftriaxone <3 months: Group B Streptococcus pneumonia: >14 days cefotaxime or benzylpenicillin with gentamicin for first 5 days Gram-negative bacilli: >21 days cefotaxime L. monocytogenes: 21 days IV amoxicillin or ampicillin and gentamicin for at least the first 7 days Unconfirmed bacterial meningitis: >14 days cefotaxime plus ampicillin or amoxicillin (NICE, 2010 and 2021) | N. meningitidis: 7 days S. pneumoniae: 10–14 days H. influenzae: 7–10 days S. aureus: >14 days [Strong recommendation] L. monocytogenes: >21 days (ESCMID, 2016) | N. meningitidis: 5–7 days S. pneumoniae: 10–14 days Listeria meningitis: 21 days Unknown pathogen: 10 days cefotaxime or ceftriaxone (first line), amoxicillin, ampicillin, benzylpenicillin or chloramphenicol in adults and older children; 3 weeks in neonates <1 month, ampicillin with gentamicin, cefotaxime or ceftriaxone with gentamicin (first line), or meropenem (AWaRe antibiotic book, 2023) | |
| Cellulitis and skin abscesses | Cellulitis: 5 days [Strong recommendation, high evidence] Recurrent cellulitis (>3 episodes a year): 4–52 weeks oral penicillin or erythromycin; or every 2–4 weeks intramuscular benzathine penicillin [Strong recommendation, moderate evidence] Recurrent abscess: 5–10 days [Weak recommendation, low evidence] (IDSA, 2014) | Cellulitis: 5–7 days flucloxacillin (first line), clarithromycin, erythromycin, doxycycline; 7 days amoxicillin/clavulanate (first line) or clarithromycin and metronidazole if infection near eyes or nose (avoid doxycycline in children) [Limited evidence] (NICE, 2019) | Not available | Cellulitis: 5 days amoxicillin/clavulanate, cefalexin or cloxacillin in adults and children (AWaRe antibiotic book, 2023) | |
| Intra-abdominal infections | 4–7 days with adequate source control [Moderate evidence] (IDSA, 2010) | Not available | 2–3 days in localized community-acquired intra-abdominal infections with adequate source control, adapted to the degree of contamination observed intraoperatively [Strong agreement, weak recommendation]; 5–7 days in generalized community-acquired intra-abdominal infections [Strong agreement, weak recommendation] (SRLF, 2015) | <4 days with adequate source control, <7 days in patients with secondary bacteraemia who have undergone adequate source control and are no longer bacteraemic [Weak recommendation, moderate-quality evidence] 4 days in complicated appendicitis, complicated cholecystitis, diffuse peritonitis, small bowel perforation, gastroduodenal ulcer perforation, if source control is adequate in immunocompetent patients without sepsis 3–5 days in acute cholangitis with biliary drainage, or diverticular abscesses (with percutaneous drainage in abscesses >4–5 cm) 5–7 days in uncomplicated diverticulitis in immunocompromised patients or with sepsis (no antibiotics needed for uncomplicated diverticulitis otherwise), or in established intra-abdominal infections where definitive source control procedure is not performed [Weak recommendation, weak-quality evidence] <24 h in patients with traumatic bowel perforations, acute or gangrenous appendicitis/cholecystitis in absence of perforation [Strong recommendation, high-quality evidence], gastroduodenal perforations, ischaemic and non-perforated bowel [Strong recommendation, weak-quality evidence] (SIS, 2017; WSES/GAIS/SIS-E/WSIS/AAST, 2021) | |
| Perioperative prophylaxis | Generally single dose or continuation <24 h after end of surgery, with variations across types of surgical procedures, e.g. no need for prophylaxis in clean orthopaedic procedures not involving implantation of foreign materials [Evidence from well-conducted cohort studies or randomized trials] (IDSA, 2013) | Single dose on starting anaesthesia or earlier for operations in which a tourniquet is used, repeat dose when the operation is longer than the half-life of the antibiotic given (NICE, 2020) | Single dose if surgery lasts <4 h and no significant blood loss, total duration should not exceed 24 h after the end of surgery [Low to moderate evidence] (ECDC, 2013) | Single-dose cefazolin (first line) within 120 min of surgery, add metronidazole if contamination expected (AWaRe antibiotic book, 2023) | |
Note that these recommendations are meant for when antibiotics are indicated or the decision for prescribing antibiotics has been made. Antibiotics may not be indicated in these infections. When antibiotic names are included without specific bacterial pathogens, they refer to empirical choices stated in the respective guidelines without the need for microbiological cultures. When antibiotic names are not included, they were not mentioned in the guidelines or culture directed antibiotics are required.
WHO AWaRe antibiotic book, WHO Access, Watch, Reserve antibiotic book; AAP, American Academy of Pediatrics; AAFP, American Academy of Family Physicians; ERS, European Respiratory Society; ESICM, European Society of Intensive Care Medicine, ESCMID, European Society of Clinical Microbiology and Infectious Diseases; ALAT, Latin American Thoracic Association; ATS, American Thoracic Society; EAU, European Association of Urology; RCT, randomized controlled trial; EBJIS, European Bone and Joint Infection Society; SRLF, Société de réanimation de langue française; SIS-E, Surgical Infection Society-Europe; WSES, World Society of Emergency Surgery; GAIS, Global Alliance for Infections in Surgery; WSIS, World Surgical Infection Society; AAST, American Association for the Surgery of Trauma.
aFull reference list can be found in the Supplementary material (references).
bRisk of GAS pharyngitis can be estimated by the Centor score+ local prevalence or previous history of rheumatic fever. Centor score is the sum of: presence of fever, absence of cough, tonsillar exudates or swelling, and tender anterior cervical lymphadenopathy, where each criterion is given 1 point (<2 points = low risk, 2–3 moderate risk, >3 high risk of GAS pharyngitis).
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