Intravenous vs oral antibiotics: is intravenous therapy ‘stronger’?
This is an interesting topic that came up on SAMSoc forum recently. I guess the conventional view has always been that, yes, they somehow are more potent when given intravenously. We probably all tend to go intravenous for life-threatening infections such as endocarditis or septic peritonitis.
But is this really borne out by the evidence? And, further, if we start with intravenous, how long should we persevere with this before we swap to oral?
Clearly, if the patient isn’t eating and/or can’t reliably be dosed orally then we are going to have to treat parenterally. For situations where we have the choice then, as ever, we have to go to the human evidence.
This is a useful systematic review for the Norweigan Institute of Public Health from 2010:
Antibiotic therapy in hospital, oral versus intravenous treatment
‘Conclusion: The documentation provides no basis for determining whether there is difference in efficacy and side effects of oral versus intravenous administration of antibiotics. This does not mean that there are no differences in the administration route, but the results are too uncertain for us to draw conclusions about this.’
And a more recent review concurs:
PLoS Med. 2015 May; 12(5): e1001825.
An Unsupported Preference for Intravenous Antibiotics
Li Ho Kwong, 1 Ambrose Agweyu, 2 Mike English, 2 , 3 and Philip Bejon
Stating that….’No large single randomized controlled trial (RCT) has demonstrated superiority in intravenous treatment, but a number of trials (many adopting the strategy of early oral switch) have demonstrated equivalence of oral versus intravenous antibiotic therapy, as illustrated by the following references.’
These authors argue that the potentially-deleterious effects of intravenous treatment (e.g. higher incidence of acute adverse reactions, catheter complications) are significant and should be taken into consideration.
More specifically and more recently we have:
Open Forum Infect Dis. 2018 Nov; 5(Suppl 1): S127.
Oral Vs. Intravenous Antibiotic Treatment for Gram-Positive Prosthetic Joint Infections: A Retrospective Study
Alexandre Coehlo, Student,1 Olivier Robineau, MD,2 Marie Titecat, MD PhD,3 Sophie Putman, MD,3 Nicolas Blondiaux, PharmD PhD,1 Michel Valette, MD,2 Eric Beltrand, MD,4 Henri Migaud, PH MD,5 and Eric Senneville, MD, PhD2
‘Conclusion: Oral antibiotic treatment seems to be as efficient as an intravenous regimen to treat prosthetic Gram-positive prosthetic joint infections.’
So that’s interesting and, to be honest, a bit unexpected….new protocols required!