BALANCE+ Vanguard Phase (BALANCE+)

PLATFORM INCLUSION CRITERIA admitted to a participating hospital positive blood culture with Gram negative (GN) bacterium PLATFORM EXCLUSION CRITERIA patient's goals of care are for palliation with no active treatment moribund patient, not expected to survive > 72 hours DOMAIN SPECIFIC INCLUSION AND EXCLUSION CRITERIA (A) DE-ESCALATION VS. NO DE-ESCALATION DOMAIN Inclusion Criteria 1. included in BALANCE+ platform Exclusion Criteria receiving an empiric antibiotic regimen at the time of blood culture finalization to which the GN pathogen(s) are not sensitive carbapenem-resistance (so that patients will not need to remain on reserve-use agents) no de-escalation option due to any or all of i. resistance ii. allergies iii. medical contraindications iv. drug-interaction risk v. other relevant reason patients with a suspected or proven polymicrobial source of infection (B) BETA-LACTAM VS. NON-BETA-LACTAM ORAL/ENTERAL TREATMENT DOMAIN Inclusion Criteria included in BALANCE+ platform initially treated with intravenous antibiotics, but clinical team transitioning patient to oral/enteral antibiotic within 7 days of starting treatment Exclusion Criteria enrolled in an arm of another BALANCE+ platform domain which limits the use of oral/enteral therapy - no-de-escalation arm no non-beta-lactam options due to any or all of i. resistance ii. allergies iii. medical contraindications iv. drug-interaction risk v. other relevant reason no beta-lactam options due to any or all of i. resistance ii. allergies iii. medical contraindications iv. drug-drug interaction risk v. other relevant reason (C) CENTRAL VASCULAR CATHETER REPLACEMENT DOMAIN Inclusion Criteria included in BALANCE+ platform has an indwelling central vascular catheter that was already in place within the 48-hour period before the onset of bloodstream infection (i.e. is not a new catheter placed within 48 hours of the onset of infection) Exclusion Criteria patient has no ongoing need for a central vascular catheter patient has definite indication for central vascular catheter removal ongoing septic shock with definite/probable line source concomitant S. aureus bacteremia concomitant candidemia local suppurative signs (severe redness, warmth, pain, swelling or fluctuance/collection) necessitating catheter removal, or other clinical evidence of infected line (e.g. imaging/echocardiographic findings) definite alternative source of GN BSI (D) LOW-RISK AmpC DOMAIN Inclusion Criteria included in BALANCE+ platform positive blood culture with GN bacterium, of the following species Serratia spp. Morganella spp. Providencia spp. Proteus spp. other than P.mirabilis organism is sensitive to ceftriaxone Exclusion Criteria severe allergy to beta-lactams (eg, type 4 hypersensitivity reaction or DRESS) baseline phenotypic resistance to ceftriaxone (E) FOLLOW UP BLOOD CULTURE DOMAIN Inclusion Criteria 1. included in BALANCE+ platform Exclusion Criteria patient already discharged home prior to day 4 definite indication for repeat blood culture testing concomitant Staph. aureus bacteremia concomitant Candidemia clinical suspicion for infective endocarditis (e.g., presence of prosthetic valve, implantable cardiac device)