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Evevident
Original paper
2019NEJMInfectious Disease

OVIVA

Oral versus Intravenous Antibiotics for Bone and Joint Infection

RCTInfectious disease

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Overview

For complex bone and joint infections, early oral antibiotic therapy was noninferior to prolonged IV therapy during the first 6 weeks.

Clinical takeaway

OVIVA supports switching appropriately selected bone/joint infection patients to high-bioavailability oral regimens rather than defaulting to weeks of IV therapy.

Key result

Treatment failure within 1 year was 13.2% with oral vs 14.6% with IV antibiotics (noninferior).

Practice impact

Avoid reflex PICC placement when effective oral agents and adherence are feasible.

Evidence

Study design

Randomized, open-label, noninferiority trial.

Enrollment

1,054

Follow-up

1 year.

Geography

United Kingdom

Clinical question

Are oral antibiotics noninferior to IV antibiotics for the first 6 weeks of bone/joint infection treatment?

Population

  • Adults with bone, joint, or orthopedic metalware-associated infection requiring prolonged antibiotics.

Intervention

Oral antibiotic strategy started within 7 days of definitive surgery or start of therapy.

Comparator

Intravenous antibiotic strategy for the first 6 weeks.

Primary outcome

Definite treatment failure within 1 year.

Oral antibiotics were noninferior to IV antibiotics during the first 6 weeks of therapy for complex bone and joint infection.

Absolute difference (oral minus IV) / -1.4 / CI 90% CI -5.6 to 2.9 percentage points

Key results

  • Definite treatment failure: 13.2% with oral vs 14.6% with IV therapy.
  • Difference -1.4 percentage points (90% CI -5.6 to 2.9), within the prespecified 7.5-point noninferiority margin.
  • Catheter-related complications were more frequent with IV therapy, and hospital stay was shorter with oral therapy.

Harms

  • Catheter-related complications were more common with IV therapy.
  • Overall serious adverse events were similar; early discontinuation for adverse events did not favor IV therapy.

Clinical Use

When to cite

  • When choosing oral versus IV antibiotics for bone and joint infection after an initial stabilization period.

Practice impact

  • Avoid reflex PICC placement when effective oral agents and adherence are feasible.

Applicability

  • Most applicable to adults with bone, joint, or orthopedic hardware infection who have a suitable oral regimen and can adhere to it.

Limitations

  • Not all pathogens or oral regimens are appropriate; agent choice was specialist-directed with high-bioavailability drugs.
  • Requires source control, susceptibility data, adherence, and infectious-disease oversight.
  • Open-label design, though the primary outcome was adjudicated blindly.

Common misinterpretations

  • OVIVA supports early oral switch, not oral therapy for every osteomyelitis regardless of organism or adherence.
  • It addresses the first 6 weeks of therapy, not the total duration of treatment.

Citation

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

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.