Growing Evidence That Oral Antibiotics are the New IV

A recent systematic review in the American Journal of Medicine aims to challenge the dogma surrounding antibiotic therapy for certain types of infections, including osteomyelitis.¹ This constitutes superb work from Wald-Dickler and coworkers, adding to the growing body of evidence that (to coin a phrase from senior author Brad Spellberg, MD) shorter may be better and oral greater than IV.

Researchers set out to evaluate if current data supports long-standing tenets regarding the superiority of IV antibiotics for the full treatment course for osteomyelitis, bacteremia and infective endocarditis. Their review included 7 randomized controlled trials regarding osteomyelitis, specifically. None of the 21 total studies among all examined infections demonstrated superiority of IV-only antibiotic treatment. In fact, all of the studies either showed no clinical efficacy differences or superiority of oral antimicrobial therapy, including when evaluating for mortality. The IV-only cohorts did exhibit a higher frequency of catheter-related adverse events, however, along with increased duration of inpatient hospitalization.¹

The authors concluded that, indeed, there are multiple prospective, randomized, controlled studies that support that oral antibiotics are safer, lead to shorter hospital stays and are at least as effective at IV antibiotics for these select infections, including osteomyelitis. They did not find any data to support otherwise. They conclude and contend that modification of treatment guidelines is in order to reflect that oral antibiotic therapy is an appropriate choice for properly selected patients with osteomyelitis, bacteremia and infective endocarditis.¹

In my experience, treatment paradigms are absolutely moving, albeit slowly. If a patient has a functioning gut, then, all else being equal, oral antibiotic therapy appears to be as effective as parenteral therapy for almost anything that we, as podiatrists, collectively treat. Shifting to more oral therapy could certainly lead to more hospital-free, antibiotic-free, and complication-free days for these patients! This is definitely a trend that could make a difference for our patients and for the community. Keep communicating with other members of the team that might not have had the time or inkling to keep up with these trends.

Dr. Armstrong is Professor of Surgery at the Keck School of Medicine at the University of Southern California. He is the Director of the Southwestern Academic Limb Salvage Alliance (SALSA). 

Editor’s note: This blog originally appeared at: https://diabeticfootonline.com/2022/01/01/oral-is-the-new-iv-challenging-decades-of-blood-and-bone-infection-dogma-a-systematic-review-bradspellberg-lacuscmedcenter-usc/ . It is adapted with permission from the author.

Reference

1. Wald-Dickler N, Holtom P, Phillips MC, et al. Oral is the new IV. Challenging decades of blood and bone infection dogma: a systematic review. Am J Med. In-Press. doi: 10.1016/j.amjmed.2021.10.007.