brand logo

Am Fam Physician. 2019;100(7):441-442

Clinical Question

Is switching to oral antibiotics as safe and effective as at least six weeks of intravenous (IV) antibiotics for patients with bone and joint infections?

Bottom Line

Oral antibiotics started within seven days of surgery for patients with a serious bone or joint infection are as safe and effective as six weeks of IV antibiotics. (Level of Evidence = 1b)


Researchers identified adults with one of the following infections: osteomyelitis of the extra-axial skeleton, native joint infection requiring excision arthroplasty, infection of a prosthetic joint or orthopedic fixation device, or vertebral osteomyelitis. All patients would have typically been treated with IV antibiotics. They were randomized within seven days of surgery, or if no surgery, the start of antibiotic therapy, to receive IV or oral antibiotics. The antibiotics were selected on the basis of cultures, sensitivity, and other clinical factors by an infectious disease consultant. Of the 1,054 recruited patients, 39 had no end point data, so the modified intention-to-treat analysis includes 1,015 patients. The mean age of participants was 50 years, 64% were men, and all had some kind of surgical debridement or device removal. The most common identified organisms were Staphylococcus aureus (38%) and coagulase-negative staphylococci (27%). This was a noninferiority trial, which is appropriate because the goal was to evaluate the efficacy of a simpler, cheaper treatment option. Approximately 80% of patients in the IV group received six weeks of IV antibiotics; 90% of patients in the oral group received less than seven days of IV antibiotics. For the primary outcome of treatment failure, oral therapy was equivalent at one year to at least six weeks of IV therapy (14.6% in the IV group vs. 13.2% in the oral group; 95% CI for the difference, −4.9% to 2.2%). There was no difference in overall quality of life or in hip function scores, but knee function scores showed greater improvement in the oral treatment group. The length of hospital stay was three days longer in the IV treatment group. Although there were more catheter-related complications in the IV group, the overall rate of serious adverse events was similar between groups.

Study design: Randomized controlled trial (single-blinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location) with outpatient follow-up

Reference: Li HK, Rombach I, Zambellas R, et al.; OVIVA Trial Collaborators. Oral versus intravenous antibiotics for bone and joint infection. N Engl J Med. 2019;380(5):425–436.

Editor's Note: Dr. Ebell is Deputy Editor for Evidence-Based Medicine for AFP and cofounder and Editor-in-Chief of Essential Evidence Pule, published by Wiley-Blackwell.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to

This series is coordinated by Natasha J. Pyzocha, DO, contributing editor.

A collection of POEMs published in AFP is available at

Continue Reading

More in AFP

More in PubMed

Copyright © 2019 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.