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N Engl J Med. 2019 Jan 31;380(5):425-436. doi: 10.1056/NEJMoa1710926.

Oral versus Intravenous Antibiotics for Bone and Joint Infection.

Author information

1
From Oxford University Hospitals NHS Foundation Trust (H.-K.L., M.A.M., B.L.A., P.C.M., A.J.B., J.L., R.G., M.R., A.T., B.A., I.B., A.R.B., E.K., T.W., T.H.N.W., L.K.B., A.A., P.B., M.S.) and the Nuffield Departments of Orthopaedics, Rheumatology and Musculoskeletal Science (I.R., R.Z., C.C., A.A.) and Medicine (M.K., C.S., P.C.M., A.J.B., B.A., G.E.T., P.B., M.S.) and the Division of Medical Sciences (B.A.L.), University of Oxford, Oxford, the Division of Infectious Diseases, Imperial College London (H.-K.L., G.C.), Medical Research Council Clinical Trials Unit, University College London (A.S.W.), Royal Free London NHS Foundation Trust (S.W., D.J.F.M., S.H.), Guy's and St. Thomas' NHS Foundation Trust (C.J.H., K.B.), and Public Health England (J.P.), London, University Hospital of Wales, Cardiff (H.C.H.), University Hospital Birmingham NHS Foundation Trust (D.B.) and Heart of England NHS Foundation Trust (N.J., C.E.M., A.F.W., S.S.), Birmingham, Royal National Orthopaedic Hospital NHS Trust, Stanmore (S.W., F.E.F., D.J.F.M.), Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool (J.F., H.E.R.), Cambridge University Hospitals NHS Foundation Trust, Cambridge (E.M., J.M.), Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde (R.A.S., C.V.), and Health Economics and Health Technology Assessment, University of Glasgow (C.G., N.M., A.H.B.), Glasgow, Leeds Teaching Hospital NHS Trust, University of Leeds, Leeds (J.A.T.S.), Ninewells Hospital, NHS Tayside, Dundee (I.A.), Northumbria Healthcare NHS Foundation Trust, Northumberland (S.C.E., D.J.B.), Western General Hospital, NHS Lothian, Edinburgh (R.K.S.), and Hull and East Yorkshire Hospitals NHS Trust, Hull (G.B.) - all in the United Kingdom; University of Bern, Bern, Switzerland (P.S.); Oxford University Clinical Research Unit, Wellcome Trust, Ho Chi Minh City, Vietnam (G.E.T.); and Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya (P.B.). C.F.O. and J.B. are patient representatives and do not have an institutional affiliation.

Abstract

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 (90% confidence interval [CI], -4.9 to 2.2; 95% CI, -5.6 to 2.9), 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 (146 of 527 participants [27.7%] in the intravenous group and 138 of 527 [26.2%] in the oral group; P=0.58). Catheter complications, analyzed as a secondary end point, were more common in the intravenous group (9.4% 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 .).

PMID:
30699315
DOI:
10.1056/NEJMoa1710926
[Indexed for MEDLINE]

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