NIHR | April 2019 | Switching to oral antibiotics early for bone and joint infections gave similar results to continuing intravenous therapy
Although current practice suggests antibiotics should be given intravenously (IV) for bone and joint infections, for at least six weeks, a large NIHR-funded UK trial challenges this assumption. In the trial participants were randomised to oral antibiotics seven days after initial surgical or IV antibiotic treatment. 222 participants (average age 36 years) with hip pain and limited movement due to femoro-acetabular (hip) impingement but without a diagnosis of osteoarthritis. Fifty per cent of the people who had surgery had significant benefit compared with a third of those having physiotherapy.
The randomised controlled trial had more than 1000 participants recruited from 26 centres. Patients were enrolled within seven days of either surgery or IV antibiotics to treat infection in the bone or joint. Causes ranged from a joint replacement infection to diabetes complications. Most had Staphylococcus aureus infections, and over 90% had initial surgical treatment.
Both the IV and the oral group received antibiotics for at least six weeks. In accordance with usual practice, the IV group could also be given oral antibiotics, such as rifampicin. Similarly, the oral group could have up to five consecutive days of IV antibiotics for unrelated infections; over 80% of the oral group started with IV antibiotics. The primary outcome was treatment failure within one year (Source: NIHR).
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Full reference: Palmer, A. J. et al |2019| Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial| BMJ |364|l185.
BACKGROUND The management of complex orthopedic infections usually includes a prolonged course of intravenous antibiotic agents. We investigated whether oral antibiotic therapy is noninferior to intravenous antibiotic therapy for this indication. METHODS We enrolled adults who were being treated for bone or joint infection at 26 U.K. centers. Within 7 days after surgery (or, if the infection was being managed without surgery, within 7 days after the start of antibiotic treatment), participants were randomly assigned to receive either intravenous or oral antibiotics to complete the first 6 weeks of therapy. Follow-on oral antibiotics were permitted in both groups. The primary end point was definitive treatment failure within 1 year after randomization. In the analysis of the risk of the primary end point, the noninferiority margin was 7.5 percentage points. RESULTS Among the 1054 participants (527 in each group), end-point data were available for 1015 (96.3%). Treatment failure occurred in 74 of 506 participants (14.6%) in the intravenous group and 67 of 509 participants (13.2%) in the oral group. Missing end-point data (39 participants, 3.7%) were imputed. The intention-to-treat analysis showed a difference in the risk of definitive treatment failure (oral group vs. intravenous group) of −1.4 percentage points, indicating noninferiority. Complete-case, per-protocol, and sensitivity analyses supported this result. The between-group difference in the incidence of serious adverse events was not significant. Catheter complications, analyzed as a secondary end point, were more common in the intravenous group (9.3% vs. 1.0%). CONCLUSIONS Oral antibiotic therapy was noninferior to intravenous antibiotic therapy when used during the first 6 weeks for complex orthopedic infection, as assessed by treatment failure at 1 year. (Funded by the National Institute for Health Research; OVIVA Current Controlled Trials number, ISRCTN91566927.)
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