Clinical Question

Is switching to oral antibiotics as safe and effective as at least six weeks of intravenous (IV) antibiotics for patients with bone and joint infections?

Bottom Line

Oral antibiotics started within seven days of surgery for patients with a serious bone or joint infection are as safe and effective as six weeks of IV antibiotics. (Level of Evidence = 1b)

Synopsis

Researchers identified adults with one of the following infections: osteomyelitis of the extra-axial skeleton, native joint infection requiring excision arthroplasty, infection of a prosthetic joint or orthopedic fixation device, or vertebral osteomyelitis. All patients would have typically been treated with IV antibiotics. They were randomized within seven days of surgery, or if no surgery, the start of antibiotic therapy, to receive IV or oral antibiotics. The antibiotics were selected on the basis of cultures, sensitivity, and other clinical factors by an infectious disease consultant. Of the 1,054 recruited patients, 39 had no end point data, so the modified intention-to-treat analysis includes 1,015 patients. The mean age of participants was 50 years, 64% were men, and all had some kind of surgical debridement or device removal. The most common identified organisms were Staphylococcus aureus (38%) and coagulase-negative staphylococci (27%). This was a noninferiority trial, which is appropriate because the goal was to evaluate the efficacy of a simpler, cheaper treatment option. Approximately 80% of patients in the IV group received six weeks of IV antibiotics; 90% of patients in the oral group received less than seven days of IV antibiotics. For the primary outcome of treatment failure, oral therapy was equivalent at one year to at least six weeks of IV therapy (14.6% in the IV group vs. 13.2% in the oral group; 95% CI for the difference, −4.9% to 2.2%). There was no difference in overall quality of life or in hip function scores, but knee function scores showed greater improvement in the oral treatment group. The length of hospital stay was three days longer in the IV treatment group. Although there were more catheter-related complications in the IV group, the overall rate of serious adverse events was similar between groups.

Study design: Randomized controlled trial (single-blinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location) with outpatient follow-up

Reference: Li HK, Rombach I, Zambellas R, et al.; OVIVA Trial Collaborators. Oral versus intravenous antibiotics for bone and joint infection. N Engl J Med. 2019;380(5):425–436.

Editor's Note: Dr. Ebell is Deputy Editor for Evidence-Based Medicine for AFP and cofounder and Editor-in-Chief of Essential Evidence Pule, published by Wiley-Blackwell.