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Evevident
Original paper
2015NEJMInfectious Disease

STOP-IT

Trial of short-course antimicrobial therapy for intraabdominal infection

RCTIntra-abdominal infection

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Overview

After adequate source control for complicated intra-abdominal infection, about 4 days of antibiotics was similar to longer therapy.

Clinical takeaway

STOP-IT supports short-course antibiotics after source control, reducing unnecessary prolonged therapy.

Key result

The composite outcome occurred in 21.8% with ~4 days of antibiotics vs 22.3% with longer therapy.

Practice impact

Once source control is achieved, do not continue antibiotics until every inflammatory marker normalizes.

Evidence

Study design

Randomized controlled trial.

Enrollment

518

Follow-up

30 days after the index source-control procedure.

Geography

United States, Canada

Clinical question

Is fixed short-course antibiotic therapy noninferior to longer therapy after source control for complicated intra-abdominal infection?

Population

  • Patients with complicated intra-abdominal infection and adequate source control.

Intervention

Fixed short-course antibiotics for about 4 days (4 +/- 1 days).

Comparator

Antibiotics continued until 2 days after resolution of fever, leukocytosis, and ileus (up to 10 days).

Primary outcome

Composite of surgical-site infection, recurrent intra-abdominal infection, or death within 30 days.

After adequate source control, roughly 4 days of antibiotics produced outcomes similar to longer, symptom-guided therapy while halving antibiotic exposure.

Absolute difference (short minus long) / -0.5 / CI 95% CI -7.0 to 8.0 percentage points / p=0.92

Key results

  • Primary composite outcome: 21.8% with short-course vs 22.3% with longer therapy (absolute difference -0.5 percentage points; 95% CI -7.0 to 8.0).
  • Median antibiotic duration was 4.0 days versus 8.0 days.
  • Individual components (surgical-site infection, recurrent infection, death) did not differ significantly.

Harms

  • Rates of extra-abdominal infection and Clostridioides difficile infection did not differ between groups.
  • The theoretical risk of undertreatment with a short course was not borne out.

Clinical Use

When to cite

  • When determining antibiotic duration after adequate source control for complicated intra-abdominal infection.

Practice impact

  • Once source control is achieved, do not continue antibiotics until every inflammatory marker normalizes.

Applicability

  • Most applicable to patients with complicated intra-abdominal infection who have had an adequate source-control procedure.

Limitations

  • Applies only when source control is adequate; inadequate source control warrants longer therapy.
  • Immunocompromised patients and those with ongoing uncontrolled sources may differ.
  • The trial was underpowered by slower-than-expected enrollment, though the point estimate favored equivalence.

Common misinterpretations

  • The 4-day course starts from the source-control procedure, not from admission.
  • Similar outcomes do not license stopping antibiotics when source control is incomplete.

Citation

Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015;372(21):1996-2005. doi:10.1056/NEJMoa1411162

In patients with intraabdominal infections who had undergone an adequate source-control procedure, the outcomes after fixed-duration antibiotic therapy (approximately 4 days) were similar to those after a longer course of antibiotics.