Chances are, regardless of the area you practice in, you are probably writing prescriptions for antibiotics. You also probably grew up in healthcare hearing the same medical dogma that has been handed down for generations: the standard script we tell patients to go along with their prescription:
“Take every pill till the bottle is empty; don’t stop because you are feeling better, or the infection could come back.” Sound familiar? We are basically telling our patients that when it comes to antibiotics, more is more, and longer is better. It's this odd thought that somehow longer courses of antibiotics are an insurance policy against recurrent infections or resistant bugs, but for many common bacterial infections, the evidence is moving in the opposite direction. The irony: longer courses don't protect against antibiotic resistance. Every extra day of exposure feeds it, which is why antimicrobial resistance keeps climbing the WHO's list of global health threats.
For decades, we have been telling our patients that longer is better and that if they don’t complete the full course, their infection will come roaring back. Dose durations were rooted more in tradition and calendars, with little hard evidence to back them up. Now, a growing body of evidence indicates that short-course antibiotic therapy for many common infections is appropriate and effective, compared to traditional longer treatment durations.
Let's look at a few examples of when the evidence tells us that less is actually more:
Uncomplicated cystitis in women:
3-day courses achieved symptomatic cure rates comparable to those of 5-day or longer durations for several first-line agents.
Uncomplicated cystitis in men:
A randomized trial found 7 days of ciprofloxacin or trimethoprim-sulfamethoxazole to be clinically curative in afebrile men.
Acute pyelonephritis/complicated UTIs:
For patients presenting with complicated UTI/pyelonephritis AND who are improving clinically on effective therapy, the IDSA 2025 guidelines recommend either 5-7 days of a fluoroquinolone or 7 days of a non-fluoroquinolone.
Community-acquired pneumonia (outpatient):
A 5-day duration is reasonable for patients who are showing signs of clinical improvement.
Non-purulent cellulitis:
A 5-day duration is recommended by the IDSA, with the important caveat that duration should be extended if the infection has not significantly improved by then.
While the age-old assumption is that longer antibiotic duration provides an extra layer of “safety”, the data is pointing us in a different direction. An umbrella review looking at the risks of prolonged antibiotic durations found that each additional day of antibiotic therapy was associated with a near 4% increase in the odds of an adverse drug event. On top of increasing the risk of patients developing C. diff, antibiotics are also responsible for a large number of medication-related side effects and are responsible for 1 of every 5 ED visits for adverse drug reactions.
Old habits die hard. A 2013 retrospective analysis of antibiotic prescribing patterns in LTAC facilities in Ontario found that antibiotics were often prescribed for longer durations than clinically necessary, and that prescribing patterns were tied primarily to prescriber preference. This study is well over ten years old, but here we are today talking about the same problem.
The fight for antimicrobial stewardship is still very much an uphill battle, and one that won’t be won any time soon. The evidence is very clear that in most cases of uncomplicated common infections in healthy adults, shorter durations of treatment are often the way to go.
It's high time that we sunset our age-old dogmas surrounding antibiotics and start pushing the public narrative that “shorter is better”.
If you want to go deeper on antibiotic stewardship to the next level, check out The Right Script: An Antibiotic Stewardship Audio Course by Hippo Education to get a practical approach to prescribing guidelines, actionable advice, and essential skills to help explain the “why” to your patients.
I try to write these blog posts about topics that align with our collective experiences as clinicians and the common issues we all face, regardless of clinical location. I welcome your feedback, stories, and suggestions. Shoot me an email at NP@hippoeducation.com; I would love to hear from you!
References
Daneman N, Gruneir A, Bronskill SE, et al. Prolonged antibiotic treatment in long-term care: role of the prescriber. JAMA Intern Med. 2013;173(8):673-682. doi:10.1001/jamainternmed.2013.3029
Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016;164(6):425-434. doi:10.7326/M15-1840
Curran J, Lo J, Leung V, et al. Estimating daily antibiotic harms: an umbrella review with individual study meta-analysis. Clin Microbiol Infect. 2022;28(4):479-490. doi:10.1016/j.cmi.2021.10.022
Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu296
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia: an official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. doi:10.1164/rccm.201908-1581ST
Trautner BW, Cortés-Penfield NW, Gupta K, et al. Clinical practice guidelines by Infectious Diseases Society of America (IDSA): 2025 guidelines on management and treatment of complicated urinary tract infections—duration of antibiotics for complicated UTI. Clin Infect Dis. 2026;82(suppl 3):i79-i88. doi:10.1093/cid/ciaf462
Drekonja DM, Trautner B, Amundson C, et al. Effect of 7 vs 14 days of antibiotic therapy on resolution of symptoms among afebrile men with urinary tract infection: a randomized clinical trial. JAMA. 2021;326(4):324-331. doi:10.1001/jama.2021.9899