Journal Article w/ Summary
Article: Oral Is the New IV – Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review
Citation: Wald-Dickler N, Holtom PD, Phillips MC, et al. Oral Is the New IV. Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review. Am J Med. 2022;135(3):369-379.e1. doi:10.1016/j.amjmed.2021.10.007
Abstract:
Background: We sought to determine if controlled, prospective clinical data validate the long- standing belief that intravenous (IV) antibiotic therapy is required for the full duration of treatment for three invasive bacterial infections: osteomyelitis, bacteremia, and infective endocarditis.
Methods: We performed a systematic review of published, prospective, controlled trials that compared IV-only to oral stepdown regimens in the treatment of these diseases. Using the PubMed database, we identified 7 relevant randomized controlled trials (RCTs) of osteomyelitis, 9 of bacteremia, 1 including both osteomyelitis and bacteremia, and 3 of endocarditis, as well as one quasi-experimental endocarditis study. Study results were synthesized via forest plots and funnel charts (for risk of study bias), using RevMan 5.4.1 and Meta-Essentials freeware, respectively.
Results: The 21 studies demonstrated either no difference in clinical efficacy, or superiority of oral vs. IV-only antimicrobial therapy, including for mortality; in no study was IV-only treatment superior in efficacy. The frequency of catheter-related adverse events and duration of inpatient hospitalization were both greater in IV-only groups.
Discussion: Numerous prospective, controlled investigations demonstrate that oral antibiotics are at least as effective, safer, and lead to shorter hospitalizations than IV-only therapy; no contrary
Type of Study: Systematic Review
Reason:
I selected this article because my patient, M.C., has osteomyelitis of the RT ischium. While discussing management strategies, the attending stated that IV and PO medications are not equal in their ability to manage bone infections, specifically, PO medications are not able to penetrate the bone. I was curious about the efficacy of PO vs IV antibiotics for the treatment of osteomyelitis.
Summary:
There is insufficient information dictating whether IV antibiotics are superior PO antibiotics in managing blood or bone infections. Authors of this study developed a systematic review which included prospective, interventional, quasi-experimental, and randomized control trials. All other studies, including studies where the infectious agent was a non-bacterial pathogen, were excluded. Twenty randomized control trials and one quasi-experimental study met the inclusion criteria. Eight randomized control trials comprised of 1,321 patients compared IV-only vs oral therapy for osteomyelitis. Six trials compared an oral fluoroquinolone with or without oral rifamycin to IV cloxacillin. One study compared oral bactrim w/ adjunct rifampin to IV cloxacillin. One study compared the efficacy of “standard IV regimens” to “varied oral regimens” such as fluoroquinolones, penicillins, and macrolides. The first six trials demonstrated similar success rates between the IV and oral groups. One study demonstrated “superior cure rates” for oral ofloxacin when compared to IV imipenem/cilastin. Complications associated with IVs such as local cellulitis, phlebitis, and UE DVT were also eliminated in the oral group. Based on the evidence provided in this systematic review, I believe that the patient can be managed with an oral fluoroquinolone dependent on her kidney function. She should be monitored for fluoroquinolone toxicity which can precipitate QT prolongation and potentially Torsades De Pointes as well as tendon rupture.