Oral, IV antibiotics show similar outcomes for treatment of fracture-related infections
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With associated congruent reinfection and reoperation rates, oral antibiotics are noninferior to IV antibiotics for fracture-related infections, according to results presented at the Orthopaedic Trauma Association Annual Meeting.
“Fracture-related infection (FRI) is a common and significant complication orthopedic trauma surgeons deal with,” William T. Obremskey, MD, MPH, director of OrthoTrauma Fellowship and Research at Vanderbilt University Medical Center, said in his virtual presentation.
“Treatment of FRI historically has been debridement and 6 weeks of IV antibiotics,” Obremskey added. “IV antibiotics are costly and lead to complications of [peripherally inserted central catheter] PICC line sepsis, clotting and illicit use. Oral (PO) antibiotics are clearly less expensive with fewer complications,” he said.
In their randomized clinical trial, Obremskey and colleagues analyzed 204 patients who were treated for a wound infection after internal fixation of a fracture or joint fusion.
Investigators used block randomization to separate patients in a 1:1 ratio, administering PO antibiotics to 108 patients and IV antibiotics to 96 patients. Most patients in the PO group (n = 49, 43%) received linezolid, while most patients in the IV group (n = 38, 32%) received vancomycin. All patients were treated with at least one surgical debridement, and follow-up was scheduled for 2-week, 6-week, 3-month, 6-month and 1-year intervals.
According to the study, the primary outcome was number of surgical interventions within 1 year, with PO noninferior to IV antibiotics if the difference in mean additional procedures within 1 year was less than or equal to 0.67. The secondary study outcome was the reinfection rate, defined by a recurrence of infection with a baseline, new or unknown pathogen.
Tibia or fibula fractures (61.8%) were the most common type of fracture reported. Femur fractures (9%), humerus fractures (7%) and radius or ulna fractures (6%) were also reported.
After outcome analysis, Obremskey concluded that, “in terms of reoperations, PO antibiotics are noninferior to IV. In terms of reinfection rates, PO antibiotics are noninferior to IV,” he said.
Within 1 year after initial infection, 52 patients in the PO group (45.2%) and 56 patients in the IV group (47.5%) reported one or more related surgeries. Likewise, reinfection rates also showed noninferiority, as patients in the PO group had a 32.3% estimation of reinfection at 1 year and patients in the IV group had a 32.5% estimation of reinfection at 1 year.
“Our study is similar to the Ovivia trial, published in the New England Journal of Medicine, where they had 1,000 patients randomized to PO or IV antibiotics with nearly identical recurrent infection rates of 13% and 14%,” Obremskey said.
“Additional analysis is required to look at adherence and cross-over rates,” he added. “Overall, PO antibiotics may be an equivalent treatment for FRIs.”
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Obremskey WT, et al. A prospective randomized trial to assess oral versus IV antibiotics for the treatment of postoperative wound infection after extremity fractures. Presented at: Orthopaedic Trauma Association Annual Meeting; Oct. 20-24, 2020 (virtual meeting).
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