Oral Versus Intravenous Antibiotic Therapy for Staphylococcus aureus Bacteremia or Endocarditis: A Systematic Review and Meta-Analysis of Randomized, Controlled Trials

Abstract

Background: We conducted a systematic review of randomized, controlled trials (RCTs) to generate more precise estimates of the efficacy and safety of oral versus intravenous antibiotic therapy for Staphylococcus aureus bacteremia or endocarditis.

Methods: MEDLINE, Embase, the Cochrane Library, and Web of Science databases were searched through February 2024. RCTs were included if they compared oral versus intravenous antibiotic therapy for S. aureus bacteremia or endocarditis and appropriately reported outcomes for each group. Risk of bias was assessed using the revised Cochrane tool for assessing risk of bias in randomized trials. Heterogeneity between studies was evaluated with Cochran's Q-statistic and I2 test. Treatment effects were summarized with pooled risk ratios using a random effects model meta-analysis (PROSPERO CRD42024481512).

Results: Only four RCTs met criteria for inclusion in meta-analysis. Among participants assessed for treatment failure, there was no difference between oral and intravenous therapy groups (risk ratio [RR], 0.99; 95% confidence interval [CI], .63-1.57; I2 = 0%). There was also no significant difference in adverse events between oral and intravenous therapy groups (RR, 0.65; 95% CI, .07-5.94; I2 = 74%); however, the confidence interval was wide, and heterogeneity was high.

Conclusions: In this systematic review of RCTs comparing oral with intravenous antibiotic therapy for S. aureus bacteremia or endocarditis, few studies met the eligibility criteria for inclusion. Meta-analysis of these studies suggests that transitioning from intravenous to oral therapy is likely effective in a subgroup of carefully selected patients. Additional randomized trials are necessary before transition to oral therapy can be routinely recommended.

Keywords: Staphylococcus aureus bacteremia; endocarditis; oral antibiotic therapy.