Research Summary

Institutional Guidelines Increase Use of Oral Antibiotics in Bone and Joint Infections

Anthony Calabro, MA

Key Highlights

  • Implementation of a guideline promoting oral antibiotics increased oral-only discharges from 25% to 70%.
  • No significant difference was observed in patients who did not respond to treatment at 90 days between oral and intravenous groups.
  • Length of hospital stay and peripherally inserted central catheter-related complications were reduced after guideline implementation.

Implementation of an institutional guideline prioritizing oral (PO) antibiotics for bone and joint infections significantly increased PO antibiotic use without compromising patient outcomes, according to the results of a recent study published in Open Forum Infectious Diseases.1 Following this guideline change, the proportion of patients discharged exclusively on PO antibiotics nearly tripled, with reduced reliance on intravenous (IV) therapy, shorter hospital stays, and fewer complications related to central catheter use.

Historically, bone and joint infections have been managed with prolonged IV antibiotic therapy due to concerns about oral absorption, bioavailability, and effectiveness. However, studies such as the OVIVA trial2 have demonstrated noninferiority of oral regimens, even for complex infections. Despite these findings and guideline support, real-world adoption remains limited due to provider hesitation and lack of institutional protocols. This study aimed to fill this knowledge gap by examining the effectiveness of a guideline introduced to increase the use of PO antibiotics and improve patient-centered outcomes at a tertiary academic hospital.

Researchers conducted a retrospective cohort study comparing patients with bone and joint infections discharged before and after implementation of the PO antibiotic guideline in April 2023. Inclusion criteria required inpatient infectious diseases consultation and treatment for a minimum of 2 weeks. The primary outcome was the rate of discharge on PO antibiotics alone. Secondary outcomes included 90-day clinical failure, repeat surgery, hospital readmission, adverse events, and discharge disposition.

A total of 186 patients were included (53 pre- and 133 post-guideline). After the intervention, 70% of patients were discharged on PO antibiotics compared with 25% prior (P < .01). Among those meeting criteria for oral therapy, 79% in the post-guideline cohort received PO antibiotics, versus only 27% pre-guideline. The post-guideline group also had shorter IV therapy duration (median, 7 vs 45 days; P < .01), shorter total antibiotic duration (49 vs 66 days; P = .04), and a lower median length of stay (7 vs 8 days; P = .04).

No statistically significant differences were seen in patients who did not respond to treatment at 90-days (9% post-guideline vs 8% pre-guideline; P = .75), repeat surgeries, or readmissions. Within the post-guideline cohort, those discharged on PO antibiotics had similar outcomes to those on IV therapy, though there was a non-significant trend toward higher failure in the PO group (12% vs 3%; P = .08), primarily among patients with diabetic foot infections and comorbidities like peripheral arterial disease.

This study had limitations, including its single-center design, modest sample size, retrospective methodology, and limited 90-day follow-up. The authors also noted that future studies are needed to better identify circumstances in which patients may be poor candidates for PO therapy. This would be particularly important, the authors noted, should institutions implement their own criteria for PO therapy for treatment of bone and joint infections.

“We were able to show that an institutional guideline promoting PO antibiotics for bone and joint infections can be effectively implemented to increase PO antibiotic utilization,” the study authors concluded. “Our intervention led to similar clinical outcomes while reducing length of stay and trending toward other improved patient-centered metrics.”

Reference

  1. Hawkins MR, Thottacherry E, Juthani P, et al. Implementing oral antibiotics for bone and joint infections: lessons learned and opportunities for improvement. Open Forum Infect Dis. 2024;11(12):ofae683. Published 2024 Nov 16. doi:10.1093/ofid/ofae683
  2. Li HK, Rombach I, Zambellas R, et al. Oral versus intravenous antibiotics for bone and joint infection. N Engl J Med. 2019;380(5):425-436. doi:10.1056/NEJMoa1710926