IMPLEMENTATION OF INSTITUTIONAL GUIDELINES FOR ORAL THERAPY FOR OSTEOMYELITIS

Introduction/Aim Uptake of oral therapy for osteomyelitis amongst infectious diseases specialists has been mixed, despite randomized controlled trial data (1). A recent survey of infectious diseases clinicians in the United States reported 67% of practitioners prescribing at least 2 weeks of intravenous (IV) therapy (2). The impact of institutional guidelines on uptake of oral (PO) therapy remains unclear. Methods In July of 2025, a large US academic medical center implemented a new internal osteomyelitis/prosthetic joint infection guideline recommending oral therapy for patients without contraindications. We retrospectively reviewed all discharge referrals for osteomyelitis and prosthetic joint infection during a period ten months before and eight months after implementation. Proportions discharged with and without a referral to our outpatient parenteral antibiotic therapy (OPAT) service (as a proxy for discharge on IV therapy) were compared (chi-squared test). A subset (all patients in January 2026) was manually reviewed by two infectious diseases attendings. Results 799 patients (373 pre-implementation and 426 post implementation) were discharged with bone and joint infection. After guideline implementation, patients were modestly more likely to be discharged on oral therapy (30% vs. 18%, p<0.01). Review of a subset of cases found that in addition to the 24% discharged on oral therapy that month, a further 21% of patients met criteria for PO therapy but were discharged on IV. Common reasons for appropriate IV therapy included: no oral options, difficult to treat pathogens (Pseudomonas, Corynebacterium striatum), Staphylococcus aureus bacteremia, and culture-negative infection. Discussion Our data demonstrates that internal consensus guidelines modestly increased uptake of oral therapy. Data from the US suggests that as many as 60% of patients may meet criteria for oral therapy at discharge, and our data contrasts with other reports of discharge on oral therapy as high as 70% after guideline implementation (3). Although a larger proportion of patients at our tertiary care center have appropriate indications for intravenous therapy, a substantial proportion still met criteria for oral therapy, suggesting opportunities to increase appropriate use of oral regimens. Significant monthly variability may suggest practice variation between individual providers and an opportunity for targeted education. Investigation of local factors contributing to continued use of IV therapy are needed to ensure uptake of even consensus internal guidelines.