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Clinician Article

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Oral versus Intravenous Antibiotics for Bone and Joint Infection.

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• Li HK
• Rombach I
• Zambellas R
• Walker AS
• McNally MA
• Atkins BL, et al.

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Clinical Comments

Hospital Doctor/Hospitalists

As the authors of the editorial comment, it is probably too early to change practice, but confirmation would have a huge impact on treatment of these infections with large cost savings.

Hospital Doctor/Hospitalists

This article reveals a potential opportunity for a paradigm shift in management of orthopedic infections that will be manifest in reduced cost of care and potentially fewer direct and indirect complications of care. I will be interested to see the feedback from this data from ID and Orthopedic colleagues.

Hospital Doctor/Hospitalists

As a practicing hospitalist consultant, this article provides adequate evidence to allow for conversations between ID specialists to utilize oral antibiotics instead of IV antibiotics for patients with osteomyelitis with high likelihood of treatment completion.

Infectious Disease

This randomized comparison of IV vs PO therapy for bone and joint infection, 60.6% with prosthesis-related infection, showed non-inferiority of PO therapy vs IV therapy; 13.2% failure with oral therapy and 14.6% failure with intravenous therapy. The accompanying editorial claims victory, but this is not ready for prime time. The devil is in the details: only one-year follow-up, open label study. Kudos for inclusiveness: with and without surgery, heterogeneous population, and regimens. However, we are unable to discern what characteristics would best define patients likely to benefit from PO vs IV regimens. Most patients received therapy beyond 6 weeks, median duration 78 days in the IV group and 71 days in the PO group. Most disconcerting is the obvious selection of participants - 2077 patients were screened and only 1054 randomized. The complication rate was similar in both groups, signifying the need for close follow-up with oral regimens. Only 3-day difference in length-of-stay.

Internal Medicine

This issue is not really common but it is common enough in primary care that this is something primary care physcians should know about. If you can get away without having to place a PICC line, that's a good thing.

Internal Medicine

In this non-inferiority trial, 1054 real-world patients with bone and joint infections (including 23% with prosthetic retained implants) who normally would have received IV antibiotics for 6 weeks were randomized to oral or IV antibiotics. Most the patients (81%) had a lower limb infection, with around a quarter with hip, knee, and foot infections. They included patients on immunosuppressives (4.3%) and HIV (0.4%). S. aureus was the most commonly isolated bug (37%, including 10% MRSA), but those initially S. aureus bacteremic were excluded. Greater than 90% had 95% compliance or better with oral meds. Both groups had similar rates of treatment failure (14.6% IV, 13.2% oral) with no difference in C. difficile rates. In US practice, where extended antibiotics mean an ECF or significant out-of-pocket cost for home antibiotics, this is a significant and important study that probably bears repeating before guidelines change.

Surgery - Orthopaedics

This paper provides useful evidence that oral antibiotics is at least not inferior to IV antibiotics, following an initial period of IV antibiotics, in the management of chronic osteomyelitis. Despite the reference that 6 weeks of IV antibiotics is the standard of care for bone and joint infections, I think that most sepsis surgeons currently use targeted oral antibiotics therapy after an initial period of IV antibiotics in the management of bone and joint infections.