Antibiotic Treatment Duration for Bacterial Infections - A Systematic Review and Critical Appraisal

Reducing antibiotic treatment duration is a key stewardship intervention to mitigate antimicrobial resistance (AMR). We performed a systematic review of antibiotic duration randomised controlled trials for treatment or prevention of bacterial infections in humans, appraised their methodologies and identified gaps in evidence. All randomised trials indexed in MEDLINE and EMBASE up to October 2022 which compared different treatment durations were included. We found 296 trials, of which 85% showed equivalence or non-inferiority. The majority (73%) considered treatment for respiratory tract infections, genitourinary infections, and post-surgical prophylaxis. Few trials studied severe infections, such as bloodstream infections and ventilator-associated pneumonia. Trial designs shifted from superiority (74%, 178/242 before 2016) to non-inferiority (74%, 40/54 after 2016). 94% of the trials that defined a per-protocol population reported non-adherence, which may increase the probability of concluding non-inferiority. Only 9 trials collected data to demonstrate the effect of antibiotic duration on AMR colonisation. Registration: PROSPERO 2021 CRD42021276209 Funding: National Research Foundation Singapore Central Gap Fund; National Medical Research Council, Singapore; Medical Research Council, UK