Fixed versus individualized treatment for five common bacterial infectious syndromes: a survey of the perspectives and practices of clinicians

BACKGROUND: Traditionally, bacterial infections have been treated with fixed-duration antibiotic courses; however, some have advocated for individualized durations. It is not known which approach currently predominates. METHODS: We conducted a multinational clinical practice survey asking prescribers their approach to treating skin and soft tissue infection (SSTI), community-acquired pneumonia (CAP), pyelonephritis, cholangitis and bloodstream infection (BSI) of an unknown source. The primary outcome was self-reported treatment approach as being fully fixed duration, fixed minimum, fixed maximum, fixed minimum and maximum, or fully individualized durations. Secondary questions explored factors influencing duration of therapy. Multivariable logistic regression with generalized estimating equations was used to examine predictors of use of fully fixed durations. RESULTS: Among 221 respondents, 170 (76.9%) completed the full survey; infectious diseases physicians accounted for 60.6%. Use of a fully fixed duration was least common for SSTI (8.5%) and more common for CAP (28.3%), BSI (29.9%), cholangitis (35.7%) and pyelonephritis (36.3%). Fully individualized therapy, with no fixed minimum or maximum, was used by only a minority: CAP (4.9%), pyelonephritis (5.0%), cholangitis (9.9%), BSI (13.6%) and SSTI (19.5%). In multivariable analyses, a fully fixed duration approach was more common among Canadian respondents [adjusted OR (aOR) 1.76 (95% CI 1.12–2.76)] and for CAP (aOR 4.25, 95% CI 2.53–7.13), cholangitis (aOR 6.01, 95% CI 3.49–10.36), pyelonephritis (aOR 6.08, 95% CI 3.56–10.39) and BSI (aOR 4.49, 95% CI 2.50–8.09) compared with SSTI. CONCLUSIONS: There is extensive practice heterogeneity in fixed versus individualized treatment; clinical trials would be helpful to compare these approaches.