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Biofilm Bone infection duration Duration of Therapy guidelines idsa IDSA Guidelines Oral versus Intravenous OVIVA PJI prosthetic joint infection rifabutin rifampin Urinary Tract Infection uti
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Written: October 4th, 2024
by Ivan Fernandez, PharmD, during clinical rotation with JMC Antimicrobial Stewardship
Rifampin is commonly used to assist in the penetration of traditional antimicrobials to the site of infection required to penetrate biofilm as it also inhibits biofilm formation. Due to rifampin’s extensive drug-drug interactions some studies have been done to determine if rifabutin has similar capabilities. In response to the question if rifabutin is similar in efficacy to rifampin in being effective in the treatment of hardware-associated staph infections, I was able to determine that rifabutin has the potential to be similar in efficacy. There have been very limited in vivo studies that can fully declare rifabutin as a substitute for rifampin, and there are some in vitro studies that confirm rifabutin’s efficacy to be equal or greater than that of rifampin.
In one retrospective case study series it was observed that 5 out of 7 patients being treated with rifabutin did not experience infection recurrence. The 2 patients that did experience infection recurrence produced surgical cultures that were negative for any organism growth2. This study also noted that rifabutin has higher tissue concentrations than plasma concentrations, while rifampin is equally concentrated in the tissue and plasma and therefore should be taken into account when infections require higher plasma concentrations.
Another case study series done by the University of Maryland School of Medicine examined 10 patients that received rifabutin instead of rifampin for prosthetic material infections and concluded rifabutin had comparable activity to that of rifampin because no recurrent infections occurred in their study group1.
An in-vitro study compared the MIC, the minimum bactericidal concentrations (MBC), and the minimum biofilm eradication concentrations (MBEC) of rifabutin and rifampicin for 132 clinical strains of rifampicin-susceptible staphylococci and 33 other coagulase negative staphylococci. Results showed that the rifabutin MIC median value was significantly higher for SA, but there was no significant difference for coagulase negative staphylococci. The rifabutin MBC median value was significantly higher than that of rifampicin for SA but lower for coagulase negative staphylococci. Rifabutin MBEC median value was statistically lower than that of rifampicin for all strains3.
After review, rifabutin should be considered as a possible alternative to rifampin as an adjunctive therapy to staph infections that require an additional agent for penetration.
- Doub JB, Heil EL, Ntem-Mensah A, Neeley R, Ching PR. Rifabutin Use in Staphylococcus Biofilm Infections: A Case Series. Antibiotics. 2020; 9(6):326. https://doi.org/10.3390/antibiotics9060326
- Monk M, Elshaboury R, Tatara A, Nelson S, Bidell MR. A Case Series of Rifabutin Use in Staphylococcal Prosthetic Infections. Microbiol Spectr. 2022 Jun 29;10(3):e0038422. doi: 10.1128/spectrum.00384-22. Epub 2022 May 11. PMID: 35543561; PMCID: PMC9241794.
- Pauline Thill, Olivier Robineau, Gabrielle Roosen, Pierre Patoz, Benoit Gachet, Barthélémy Lafon-Desmurs, Macha Tetart, Safia Nadji, Eric Senneville, Nicolas Blondiaux, Rifabutin versus rifampicin bactericidal and antibiofilm activities against clinical strains of Staphylococcus spp. isolated from bone and joint infections, Journal of Antimicrobial Chemotherapy, Volume 77, Issue 4, April 2022, Pages 1036–1040, https://doi.org/10.1093/jac/dkab486
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A recent update to the IDSA Urinary Tract Infection guidelines was published (July 2025), which now recommend a shorter duration of 5-7 days for treatment of complicated UTI, including pyelonephritis (of note, this is applicable only to patients who are responding to therapy). This is a change to the dogma of treating patients with pyelonephritis for 10-14 days if a beta-lactam antibiotic is used.
Day 1 of treatment begins with the first day of EFFECTIVE antibiotic therapy.
For example: if the patient was started on Ceftriaxone on 9/1/25, and urine culture collected on 9/1/25 resulted as ESBL Escherichia coli on 9/3/25 and patient is subsequently changed to Meropenem on 9/3/25, 9/3/25 is DAY 1 of antibiotics.
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https://www.cdc.gov/std/treatment-guidelines/syphilis.htm
Neurosyphilis treatment:
https://www.cdc.gov/std/treatment-guidelines/neurosyphilis.htm
Contacting the DOH for Syphilis Treatment and Titers:
#syphilis
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Recommendation Table 9 Open in new tab… | Oxford Academic
Check out this table extracted from the Endocarditis guidelines from the European Society of Cardiology (2023).
We use (for adults):
Ampicillin 2 g IVSS q 4 hours (needs renal dose adjustment for CrCl <50 mL/min; see below)
PLUS
Ceftriaxone 2 g IVSS q 12 hours (no renal dose adjustment needed)This is the “Spanish regimen”. Please see the Spanish Study, where ampicillin+ceftriaxone was compared to ampicillin+gentamicin. https://pubmed.ncbi.nlm.nih.gov/23392394/
2013_Ampicillin plus Ceftriaxone is as effective as ampicillin plus gentamicin for treating Enterococcus faecalis Infective EndocarditisDownload
For Vancomycin-resistant Enterococcus spp, we use (for adults):
Daptomycin 10-12 mg/kg q 24 hours (needs dose adjustment for CrCl <30 mL/min; see below)
MONITORING: Check CPK once a week. If CrCl < 30, check CPK twice to three times a week
FULL GUIDELINES:
Renal Dosing:
Ampicillin:
CrCL >50 mL/min: 2 g IVSS q 4 hours
30 to <50 mL/min: 2 g IVSS q 6 hours
15 to <29 mL/min: 2 g IVSS q 8 hours
<15 mL/min, IHD: 2 g IVSS q 12 hours
CRRT: 2 g IVSS q 6 hours
Daptomycin:
CrCL >30 mL/min: 10-12 mg/kg q 24 hours
<30 mL/min: 10 mg/kg q 48 hours
IHD: 10 mg/kg q 48 hours OR 10 mg/kg three-times a week (TIW) after HD on HD days
CRRT: TBD
Extracted from:
Jacobi Antimicrobial Stewardship 
