Abstract

Aim
To determine whether oral antibiotic therapy is non-inferior to intravenous (IV) therapy in the management of bone and joint infections, a condition with substantial implications for surgical workload and inpatient resource use.

Method
A PRISMA-compliant systematic review and meta-analysis was undertaken. MEDLINE, Embase, Scopus, and Cochrane CENTRAL were searched to November 2025 for randomised controlled trials evaluating oral versus IV antibiotics in adults. Of 2,323 records, 1,348 s were screened and 10 studies included. Random-effects modelling was performed. Study quality was assessed using Cochrane risk-of-bias tools, and certainty of evidence appraised with GRADE. Leave-one-out sensitivity analyses examined the stability of effect estimates.

Results
Across six RCTs (877 oral; 803 IV), treatment success was equivalent (RR 1.02, 95% CI 0.98–1.07; moderate certainty). Observational studies favoured oral therapy (RR 1.18, 95% CI 1.03–1.36), likely reflecting confounding by indication; pooled analysis, however, demonstrated no difference (RR 1.04, 95% CI 0.99–1.09). Relapse (RR 1.00, 95% CI 0.72–1.39), superinfection (RR 1.42, 95% CI 0.36–5.69), and adverse events (RR 1.25, 95% CI 0.71–2.19) showed no significant differences. Treatment duration and hospital stay showed no meaningful variation. Sensitivity analyses confirmed consistency across datasets.

Conclusions
Oral antibiotic therapy is non-inferior to IV therapy for treatment success in bone and joint infections. Moderate-certainty evidence supports the safe adoption of oral regimens in appropriately selected surgical patients. These findings highlight opportunities to streamline surgical infection pathways, reduce IV-associated morbidity, alleviate inpatient pressures and enhance NHS efficiency.