Early switch from intravenous to oral antibiotic treatment in bone and joint infections

Oral versus intravenous antibiotics for bone and joint infections: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Recent trials suggest oral (PO) antibiotics may be as effective as prolonged intravenous (IV) regimens in specific clinical scenarios. This meta-analysis compared PO and IV antibiotic therapy in bone and joint infections.

MATERIALS AND METHODS

PubMed, Embase and CENTRAL databases were searched for published trials from inception until February 2025 for randomized clinical trials (RCTs) that enrolled patients of any age with confirmed bone and/or joint infections compared oral versus intravenous antibiotic therapy and reported at least one of the prespecified outcomes.

RESULTS

Nine RCTs (1723 patients) published from 1987 to 2025 were included. PO and IV therapies showed comparable efficacy in treatment failure (RR 0.96; 95 % CI 0.78-1.17; p = 0.68; I2 = 0 %) and adverse events (RR 1.00; 95 % CI 0.90-1.12; I2 = 10 %; p = 0.94). Overall, recurrence rates were similar. However, a subgroup analysis excluding fracture-related infections favored IV therapy (RR 1.47; 95 % CI 1.08-2.02; I2 = 0 %; p = 0.02). Superinfection rates showed no difference (RR 1.12; 95 % CI 0.32-3.98; I2 = 0 %; p = 0.86). Although not statistically significant, hospitalization duration may be shorter with PO therapy (MD -5.03 days; 95 % CI -15.84-5.77; I2 = 4 %; p = 0.36).

CONCLUSION

Appropriately selected PO antibiotic regimens demonstrate comparable efficacy and safety to IV therapy in bone and joint infections, although there is a slight tendency to increase the recurrence of infections. These findings support a shift toward oral therapy in carefully chosen patients.

Optimizing Antibiotic Therapy in Musculoskeletal Infections

Research into the optimal antibiotic management of musculoskeletal infections has advanced tremendously over the past quarter century, including over a dozen randomized controlled trials and numerous observational studies. This review examines the rationale for and evidence base supporting modern approaches to antibiotic decision making and stewardship in orthopedic infections. Specific practice advances discussed include the increased and earlier use of oral antibiotics, other principles of antibiotic selection (eg, the notion of "bone penetration" and novel local antimicrobial strategies), individualizing durations of therapy, and increasingly selective approaches to empiric antipseudomonal therapy, suppressive antibiotic therapy, and periprocedural antimicrobial prophylaxis following arthroplasty.

Osteomyelitis: Considerations for nursing practice

ABSTRACT

Osteomyelitis is characterized by inflammation of the bone tissue, typically caused by microorganisms such as bacteria. It can be challenging to treat and may lead to unnecessary antibiotic therapies. Prompt identification of osteomyelitis and implementation of effective treatments are necessary to eradicate this infection. This article discusses the pathophysiology, clinical presentation, diagnosis, and nursing management of osteomyelitis, focusing on native bone infection.

Comparative study of the inhibitory effects of different antibiotic administration routes on bone healing in a rat tibial infection model

Objective

This study aimed to evaluate the effectiveness of intravenous versus oral antibiotic treatments in managing bone infections, particularly osteomyelitis, using a rat tibial infection model.

Methods

A tibial bone infection model was established in twelve-week-old Wistar rats via injection of Staphylococcus aureus at a cortical defect site. After six weeks, rats were treated with vancomycin (intravenous), cefazolin (intravenous), ciprofloxacin (oral), or ciprofloxacin combined with rifampin (oral). Microbial analysis, blood analysis for pro-inflammatory cytokines, micro-computed tomography (μCT), histological analysis, and osteoclast activity were used to assess the efficacy of each treatment.

Results

Blood analysis showed significant reductions in white blood cell count and pro-inflammatory cytokines in the intravenous treatment groups, especially with vancomycin. μCT imaging revealed better preservation of bone structure in intravenous treatment groups, while oral treatments resulted in more pronounced structural deterioration. Microbial analysis confirmed a lower bacterial load in the intravenous groups, particularly vancomycin, compared to oral treatments. Histological analysis revealed reduced inflammation, lower fibrosis, and minimal bacterial presence in intravenous groups. Osteoclast activity was notably reduced in the vancomycin and cefazolin groups, indicating better control of bone resorption.

Conclusion

Intravenous administration of vancomycin demonstrated superior efficacy in controlling bone infection, reducing inflammation, and preserving bone structure compared to oral treatments. While ciprofloxacin and the ciprofloxacin-rifampin combination showed some efficacy, they were less effective than intravenous vancomycin, likely due to lower bioavailability and insufficient drug penetration in bone tissue.

Factors influencing the use of highly bioavailable oral antibiotic therapy for the treatment of prosthetic joint infections

We conducted a retrospective cohort study to identify factors influencing intravenous (IV) versus oral antibiotic therapy in first-episode prosthetic joint infections. Of the 34/78 (44%) cases treated intravenously, negative cultures (26%), concomitant infections necessitating IV antibiotics (21%), and delays in susceptibility testing (15%) were the most common reasons for IV therapy.

''Myth Busting in Infectious Diseases'': A Comprehensive Review

Antibiotics have played a pivotal role in modern medicine, drastically reducing mortality rates associated with bacterial infections. Despite their significant contributions, the emergence of antibiotic resistance has become a formidable challenge, necessitating a re-evaluation of antibiotic use practices. The widespread belief in clinical practice that bactericidal antibiotics are inherently superior to bacteriostatic ones lacks consistent support from evidence in randomized controlled trials (RCTs). With the latest evidence, certain infections have demonstrated equal or even superior efficacy with bacteriostatic agents. Furthermore, within clinical practice, there is a tendency to indiscriminately order urine cultures for febrile patients, even in cases where alternative etiologies might be present. Consequently, upon obtaining a positive urine culture result, patients often receive antimicrobial prescriptions despite the absence of clinical indications warranting such treatment. Furthermore, it is a prevailing notion among physicians that extended durations of antibiotic therapy confer potential benefits and mitigate the emergence of antimicrobial resistance. Contrary to this belief, empirical evidence refutes such assertions. This article aims to address common myths and misconceptions within the field of infectious diseases.

Clinical, organizational, and pharmacoeconomic perspectives of dalbavancin vs standard of care in the infectious disease network

Introduction

The therapeutic approach to the patient with acute bacterial skin and skin structure infection (ABSSSI) and complicated infections often involves the early transition from intravenous to oral therapy (early switch) or early discharge. Our study aimed to evaluate sustainable and innovative care models that can be transferred to community healthcare and the economic impact of dalbavancin therapy vs Standard of Care (SoC) therapy for the treatment of ABSSSI and other Gram-positive infections including those by multidrug-resistant organisms. We also described the organization of an infectious disease network that allows optimizing the treatment of ABSSSI and other complex infections with dalbavancin.

Materials and Methods

We retrospectively studied all patients treated with dalbavancin in the University Hospital "S. Anna" of Ferrara, Italy, between November 2016 and December 2022. The clinical information of each patient was collected from the hospital's SAP database and used to evaluate the impact of dalbavancin in early discharge with reduction of length of stay promoting dehospitalization and in improving adherence to antibiotic therapy.

Results

A total of 287 patients (165 males and 122 females) were included in the study of which 62 were treated with dalbavancin. In 13/62 patients dalbavancin was administered in a single dose at the completion of therapy to facilitate early discharge. Assuming a 12-day hospitalization required for the treatment of ABSSSI or to complete the treatment of osteomyelitis or spondilodiscitis, the treatment with dalbavancin results in a cost reduction of more than €3,200 per single patient compared to SoC (dancomycin, linezolid or vancomycin).

Conclusions

Dalbavancin has proven to be a valid therapeutic aid in the organization of a territorial infectious disease network given its prolonged action, which allows the dehospitalization with management of even patients with complex infections in outpatient parenteral antimicrobial therapy.

Using antibiotics wisely

PURPOSE OF REVIEW

This review will describe role of shorter antibiotic therapies, early switch from intravenous to oral therapy, and artificial intelligence in infectious diseases.

RECENT FINDINGS

There is evidence that shorter courses of antibiotics are noninferior to standard durations of therapy. This has been demonstrated with Enterobacterales bacteremia that can be treated with 7 days of therapy, community acquired pneumonia with 3 days and ventilator associated pneumonia with just 7 days of antibiotic therapy. The conversion from intravenous to oral therapy in treating bacteremia, endocarditis and bone and joint infections is safe and effective and reduces line complications and costs. Also, for clean surgical procedures only one dose of antibiotic is needed, but it should be the most effective antibiotic which is cefazolin. This means avoiding clindamycin, removing penicillin allergies where possible for improved outcomes. Finally, the role of artificial intelligence to incorporate into using antibiotics wisely is rapidly emerging but is still in early stages.

SUMMARY

In using antibiotics wisely, targeting such as durations of therapy and conversion from intravenous antibiotic therapy to oral are low hanging fruit. The future of artificial intelligence could automate a lot of this work and is exciting but needs to be proven.

VIDEO ABSTRACT

http://links.lww.com/COID/A50.

Methicillin Resistance Increased the Risk of Treatment Failure in Native Joint Septic Arthritis Caused by Staphylococcus aureus

This study aimed to compare clinical characteristics and outcomes in patients with native joint septic arthritis (NJSA) due to methicillin-resistant Staphylococcus aureus (MRSA) in comparison to methicillin-sensitive S. aureus (MSSA) and identify treatment failure risk factors. We conducted a multi-center retrospective study on adult NJSA patients at three teaching hospitals in South Korea from 2005 to 2017. Among 101 patients diagnosed with S. aureus NJSA, 39 (38.6%) had MRSA strains. Compared to MSSA, patients with MRSA had a higher prevalence of nosocomial infections (17.9% vs. 1.6%; p = 0.005) and received inappropriate antibiotics within 48 h more frequently (74.4% vs. 0%; p < 0.001). In total, twenty patients (19.8%) experienced treatment failure, which encompassed five patients (5.0%) who passed away, nine (8.9%) requiring repeated surgical drainage after 30 days of antibiotic therapy, and seven (6.9%) with relapse. The MRSA group showed a higher rate of overall treatment failure (33.3% vs. 11.3%; p = 0.007) with a notably increased frequency of requiring repeated surgical interventions after 30 days of antibiotic therapy (17.9% vs. 3.2%, p = 0.026), in contrast to the MSSA group. Independent risk factors for treatment failure included Charlson comorbidity score, elevated CRP levels, and methicillin resistance. Methicillin resistance is an independent risk factor for treatment failure, emphasizing the need for vigilant monitoring and targeted interventions in MRSA-related NJSA cases.

Administering Antibiotics for Less Than Four Weeks Increases the Risk of Relapse in Culture-Positive Septic Arthritis of Native Joints

(1) Objectives: This study investigated the optimal duration of antibiotic therapy and determined the risk factors associated with relapse in patients with culture-proven septic arthritis of native joints. (2) Methods: A retrospective review was conducted on patients aged ≥18 years diagnosed with native joint septic arthritis, with bacteria isolated from joints and/or blood. The exclusion criteria were prosthetic joint infections and cases with no identified microorganisms. The outcomes were assessed in the remission and relapse groups. (3) Results: Among 479 patients with native joint septic arthritis, 137 met the inclusion criteria, with a median follow-up duration of 2.7 years. The relapse rate was 9.5%, which mainly occurred within 30 days after antibiotic treatment completion. Compared with the remission group, the relapse group showed a significantly higher proportion of cases that received antibiotic therapy for ≤ 4 weeks (4.8% vs. 46.2%, p < 0.001), synovial fluid white blood cell (WBC) counts ≥150 × 103/mm3 (25.3% vs. 60.0%, p = 0.030), acute kidney injury (19.2% vs. 50%, p = 0.024), and extended-spectrum beta-lactamases-producing Enterobacteriaceae (0.8 vs. 15.4%, p = 0.024). Independent risk factors for relapse were determined as antibiotic therapy duration of ≤ 4 weeks (odds ratio (OR), 25.47; 95% confidence interval (CI), 1.57-412.33; p = 0.023) and synovial fluid WBC counts ≥150 × 103/mm3 (OR, 17.46; 95% CI, 1.74-175.62; p = 0.015). (4) Conclusions: Patients with native joint septic arthritis require vigilant monitoring for relapse, particularly when treated with antibiotic regimens administered for less than four weeks or when synovial aspirates exhibit elevated WBC counts at diagnosis.