Another Point Goes to Team Short Course: Implications of the BALANCE Trial Post Hoc Analysis for Pseudomonas aeruginosa Bloodstream Infections

Pseudomonas aeruginosa (PA) is one of the most important contributors to the morbidity and mortality attributable to multidrug-resistant infections globally. Tension often arises between concern for undertreatment of PA and overtreatment leading to adverse events and increasing resistance. In the absence of data supporting the alternative, extended treatment duration for PA is often given precedence. The presupposition that PA requires prolonged treatment is pervasive throughout infectious diseases guidelines. In 2019, it was established that most cases of community-acquired pneumonia need only be treated for 5 days, though a 7-day course was recommended for PA in alignment with the then recently published ventilator-associated pneumonia guidelines [1]. The iDIAPASON study raised further questions of whether a shorter 8-day course for ventilator-associated pneumonia secondary to PA could truly be considered noninferior to a 15-day course [2]. Regarding management of bloodstream infections (BSIs), similar concerns were discussed in the first consensus guidance developed for uncomplicated gram-negative bacteremia, in which 7 days of treatment was recommended for all gram-negative organisms, but the lack of data for non-lactose-fermenting bacteria such as PA was acknowledged, and furthermore it was suggested that these pathogens may be less likely to meet the criteria for uncomplicated BSI [3]. Up to that point, just 1 randomized controlled trial comparing 7 to 14 days of therapy for gram-negative BSI had included PA infections, and only 48 patients with PA were ultimately enrolled [4].