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Review article: Biomedical intelligence

Vol. 150 No. 2324 (2020)

Oral antibiotic therapy in people who inject drugs (PWID) with bacteraemia

Cite this as:
Swiss Med Wkly. 2020;150:w20259


Bacterial infections are a major cause of morbidity and mortality in people who inject drugs (PWID). Patients with bacteraemia have a particularly high risk of complications and are usually treated with intravenous antibiotics. Intravenous treatment is challenging in certain PWID because of difficult venous access and a high rate of catheter-associated complications. Therefore, oral treatment alternatives must be considered.

This review discusses the potential options for oral antimicrobial treatment of gram-positive and gram-negative bacteraemia in PWID and the evidence for them.

Data on oral antibiotic treatment of bacteraemia in PWID is scarce. Whenever possible, a course of intravenous antibiotic treatment should precede the switch to an oral regimen. For Staphylococcus aureus bacteraemia, there is growing evidence that initial intravenous antibiotics can be switched to oral treatment (e.g., a fluoroquinolone and rifampin or linezolid) when the patient is clinically stable and source control has been achieved. However, regimen selection remains challenging due to pharmacokinetic/pharmacodynamic issues, potential toxicity and drug-drug interactions of oral antibiotics. For some streptococcal bacteraemia, oral amoxicillin is probably a reasonable option. The best existing evidence for oral antibiotic treatment is for gram-negative bacteraemia, which, if susceptible, can be treated successfully with oral fluoroquinolones. Oral antibiotic options for fluoroquinolone-resistant gram-negative bacteraemia are very limited, although in selected patients oral trimethoprim-sulfamethoxazole can be considered.

In conclusion, treatment of bacteraemia in PWID remains very complex, and an interdisciplinary approach is essential in order to select the best therapy for this vulnerable group of patients.


  1. Scheidegger C, Zimmerli W. Infectious complications in drug addicts: seven-year review of 269 hospitalized narcotics abusers in Switzerland. Rev Infect Dis. 1989;11(3):486–93. doi:.
  2. Bassetti S, Hoffmann M, Bucher HC, Fluckiger U, Battegay M. Infections requiring hospitalization of injection drug users who participated in an injection opiate maintenance program. Clin Infect Dis. 2002;34(5):711–3. doi:.
  3. Louria DB, Hensle T, Rose J. The major medical complications of heroin addiction. Ann Intern Med. 1967;67(1):1–22. doi:.
  4. World Health Organization. Management of common health problems of drug users. Geneva: World Health Organization; 2009. 131 p.
  5. Hope VD, Ncube F, Parry JV, Hickman M. Healthcare seeking and hospital admissions by people who inject drugs in response to symptoms of injection site infections or injuries in three urban areas of England. Epidemiol Infect. 2015;143(1):120–31. doi:.
  6. Scheidegger C, Zimmerli W. Incidence and spectrum of severe medical complications among hospitalized HIV-seronegative and HIV-seropositive narcotic drug users. AIDS. 1996;10(12):1407–14. doi:.
  7. Zou H, Li G. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Chinese J Infect Chemother. 2010;10(2):81–4. Available from:
  8. Scarborough M, Li HK, Rombach I, Zambellas R, Walker AS, McNally M, et al. Oral versus intravenous antibiotics for bone and joint infections: the OVIVA non-inferiority RCT. Health Technol Assess. 2019;23(38):1–92. doi:.
  9. Cunha BA. Oral antibiotic therapy of serious systemic infections. Med Clin North Am. 2006;90(6):1197–222. doi:.
  10. Gardner EM, Kestler M, Beieler A, Belknap RW. Clostridium butyricum sepsis in an injection drug user with an indwelling central venous catheter. J Med Microbiol. 2008;57(Pt 2):236–9. doi:.
  11. Rodger L, Shah M, Shojaei E, Hosseini S, Koivu S, Silverman M. Recurrent Endocarditis in Persons Who Inject Drugs. Open Forum Infect Dis. 2019;6(10):ofz396. doi:.
  12. Mertz D, Viktorin N, Wolbers M, Laifer G, Leimenstoll B, Fluckiger U, et al. Appropriateness of antibiotic treatment in intravenous drug users, a retrospective analysis. BMC Infect Dis. 2008;8(1):42. doi:.
  13. Hill A, Wai A, Marsh D, Stiver H, Sakakibara T. Pilot assessment of Intravenous Antibiotic Therapy in Live-in Street-based Clinic, for Infections in Intravenous Dur Users [Internet]. IDWeek. Idsa; 2006 [cited 2019 Dec 10]. Available from:
  14. Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrob Chemother. 2010;65(12):2641–4. doi:.
  15. Summanen PH, Talan DA, Strong C, McTeague M, Bennion R, Thompson JE, Jr, et al. Bacteriology of skin and soft-tissue infections: comparison of infections in intravenous drug users and individuals with no history of intravenous drug use. Clin Infect Dis. 1995;20(Suppl 2):S279–82. doi:.
  16. Heldman AW, Hartert TV, Ray SC, Daoud EG, Kowalski TE, Pompili VJ, et al. Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy. Am J Med. 1996;101(1):68–76. doi:.
  17. Fäh F, Zimmerli W, Jordi M, Schoenenberger RA. Septic deep venous thrombosis in intravenous drug users. Swiss Med Wkly. 2002;132(27-28):386–92.
  18. Peterson TC, Pearson C, Zekaj M, Hudson I, Fakhouri G, Vaidya R. Septic arthritis in intravenous drug abusers: a historical comparison of habits and pathogens. J Emerg Med. 2014;47(6):723–8. doi:.
  19. Nathan AJ, Scobell A. How China sees America. Foreign Aff. 2012;91:1689–99. Available from:
  20. Spyker DA, Rugloski RJ, Vann RL, O’Brien WM. Pharmacokinetics of amoxicillin: dose dependence after intravenous, oral, and intramuscular administration. Antimicrob Agents Chemother. 1977;11(1):132–41. doi:.
  21. Catchpole C, Andrews JM, Woodcock J, Wise R. The comparative pharmacokinetics and tissue penetration of single-dose ciprofloxacin 400 mg i.v. and 750 mg po. J Antimicrob Chemother. 1994;33(1):103–10. doi:.
  22. Fish DN, Chow AT. The clinical pharmacokinetics of levofloxacin. Clin Pharmacokinet. 1997;32(2):101–19. doi:.
  23. Chin TWF, Vandenbroucke A, Fong IW. Pharmacokinetics of trimethoprim-sulfamethoxazole in critically ill and non-critically ill AIDS patients. Antimicrob Agents Chemother. 1995;39(1):28–33. doi:.
  24. Dan M, Yampolsky E, Poch F. Serum concentrations and ex vivo inhibitory/bactericidal activity of clindamycin after administration of two oral dosages. Chemotherapy. 1997;43(4):227–31. doi:.
  25. Shorr AF, Kunkel MJ, Kollef M. Linezolid versus vancomycin for Staphylococcus aureus bacteraemia: pooled analysis of randomized studies. J Antimicrob Chemother. 2005;56(5):923–9. doi:.
  26. Beibei L, Yun C, Mengli C, Nan B, Xuhong Y, Rui W. Linezolid versus vancomycin for the treatment of gram-positive bacterial infections: meta-analysis of randomised controlled trials. Int J Antimicrob Agents. 2010;35(1):3–12. doi:.
  27. Willekens R, Puig-Asensio M, Ruiz-Camps I, Larrosa MN, González-López JJ, Rodríguez-Pardo D, et al. Early Oral Switch to Linezolid for Low-risk Patients With Staphylococcus aureus Bloodstream Infections: A Propensity-matched Cohort Study. Clin Infect Dis. 2019;69(3):381–7. doi:.
  28. Mzabi A, Kernéis S, Richaud C, Podglajen I, Fernandez-Gerlinger M-P, Mainardi J-L. Switch to oral antibiotics in the treatment of infective endocarditis is not associated with increased risk of mortality in non-severely ill patients. Clin Microbiol Infect. 2016;22(7):607–12. doi:.
  29. Iversen K, Ihlemann N, Gill SU, Madsen T, Elming H, Jensen KT, et al. Partial oral versus intravenous antibiotic treatment of endocarditis. N Engl J Med. 2019;380(5):415–24. doi:.
  30. Amodio-Groton M, Madu A, Madu CN, Briceland LL, Seligman M, McMaster P, et al. Sequential parenteral and oral ciprofloxacin regimen versus parenteral therapy for bacteremia: a pharmacoeconomic analysis. Ann Pharmacother. 1996;30(6):596–602. doi:.
  31. Dinh A, Davido B, Etienne M, Bouchand F, Raynaud-Lambinet A, Aslangul-Castier E, et al. Is 5 days of oral fluoroquinolone enough for acute uncomplicated pyelonephritis? The DTP randomized trial. Eur J Clin Microbiol Infect Dis. 2017;36(8):1443–8. doi:.
  32. Kutob LF, Justo JA, Bookstaver PB, Kohn J, Albrecht H, Al-Hasan MN. Effectiveness of oral antibiotics for definitive therapy of Gram-negative bloodstream infections. Int J Antimicrob Agents. 2016;48(5):498–503. doi:.
  33. Rieger KL, Bosso JA, MacVane SH, Temple Z, Wahlquist A, Bohm N. Intravenous-only or Intravenous Transitioned to Oral Antimicrobials for Enterobacteriaceae-Associated Bacteremic Urinary Tract Infection. Pharmacotherapy. 2017;37(11):1479–83. doi:.
  34. Tamma PD, Conley AT, Cosgrove SE, Harris AD, Lautenbach E, Amoah J, et al.; Antibacterial Resistance Leadership Group. Association of 30-Day Mortality With Oral Step-Down vs Continued Intravenous Therapy in Patients Hospitalized With Enterobacteriaceae Bacteremia. JAMA Intern Med. 2019;179(3):316–23. doi:.
  35. Rapoport AB, Beekmann SE, Polgreen PM, Rowley CF. Injection Drug Use and Infectious Disease Practice: A National Provider Survey. Open Forum Infect Dis. 2017;4(suppl1):S340. doi:.
  36. De Paepe P, Belpaire FM, Buylaert WA. Pharmacokinetic and pharmacodynamic considerations when treating patients with sepsis and septic shock. Clin Pharmacokinet. 2002;41(14):1135–51. doi:.
  37. Dajani AS, Bawdon RE, Berry MC. Oral amoxicillin as prophylaxis for endocarditis: what is the optimal dose? Clin Infect Dis. 1994;18(2):157–60. doi:.
  38. de Velde F, de Winter BCM, Koch BCP, van Gelder T, Mouton JW ; COMBACTE-NET consortium. Non-linear absorption pharmacokinetics of amoxicillin: consequences for dosing regimens and clinical breakpoints. J Antimicrob Chemother. 2016;71(10):2909–17. doi:.
  39. Hale AJ, Snyder GM, Ahern JW, Eliopoulos G, Ricotta D, Alston WK. When are oral antibiotics a safe and effective choice for bacterial bloodstream infections? An evidence-based narrative review. J Hosp Med. 2018;13(5):328–35. doi:.
  40. LeBel M. Ciprofloxacin: chemistry, mechanism of action, resistance, antimicrobial spectrum, pharmacokinetics, clinical trials, and adverse reactions. Pharmacotherapy. 1988;8(1):3–33. doi:.
  41. Hartnett KP, Jackson KA, Felsen C, McDonald R, Bardossy AC, Gokhale RH, et al. Bacterial and fungal infections in persons who inject drugs - Western new york, 2017. MMWR Morb Mortal Wkly Rep. 2019;68(26):583–6. doi:.
  42. Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, et al.; Infectious Diseases Society of America. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18–55. doi:.
  43. Holland TL, Arnold C, Fowler VG, Jr. Clinical management of Staphylococcus aureus bacteremia: a review. JAMA. 2014;312(13):1330–41. doi:.
  44. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJC, Gorbach SL, et al.; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10–52. doi:. Correction in: Clin Infect Dis. 2015;60(9):1448
  45. Baddour LM, Wilson WR, Bayer AS, Fowler VG, Jr, Tleyjeh IM, Rybak MJ, et al.; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective endocarditis in adults: Diagnosis, antimicrobial therapy, and management of complications: A scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132(15):1435–86. doi:.
  46. Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al. Ghid de management al endocarditei infecţioase 2015. Rev Rom Cardiol. 2016;26(3):343–405. Available from:
  47. Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK, et al.; Infectious Diseases Society of America. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis. 2015;61(6):e26–46. doi:.
  48. Mertz D, Khanlari B, Viktorin N, Battegay M, Fluckiger U. Less than 28 days of intravenous antibiotic treatment is sufficient for suppurative thrombophlebitis in injection drug users. Clin Infect Dis. 2008;46(5):741–4. doi:.
  49. Casalta JP, Zaratzian C, Hubert S, Thuny F, Gouriet F, Habib G, et al. Treatment of Staphylococcus aureus endocarditis with high doses of trimethoprim/sulfamethoxazole and clindamycin-Preliminary report. Int J Antimicrob Agents. 2013;42(2):190–1. doi:.
  50. Tissot-Dupont H, Gouriet F, Oliver L, Jamme M, Casalta JP, Jimeno MT, et al. High-dose trimethoprim-sulfamethoxazole and clindamycin for Staphylococcus aureus endocarditis. Int J Antimicrob Agents. 2019;54(2):143–8. doi:.
  51. Markowitz N, Quinn EL, Saravolatz LD. Trimethoprim-sulfamethoxazole compared with vancomycin for the treatment of Staphylococcus aureus infection. Ann Intern Med. 1992;117(5):390–8. doi:.
  52. Paul M, Bishara J, Yahav D, Goldberg E, Neuberger A, Ghanem-Zoubi N, et al. Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by meticillin resistant Staphylococcus aureus: randomised controlled trial. BMJ. 2015;350(may14 24):h2219. doi:.
  53. Gillman PK. Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. Br J Anaesth. 2005;95(4):434–41. doi:.
  54. Gupta V, Karnik ND, Deshpande R, Patil MA. Linezolid-induced serotonin syndrome. BMJ Case Rep. 2013;2013:bcr2012008199.
  55. Van Hise NW, Anderson M, McKinsey D, McKinsey J, Harting B, Belmares J, et al. The Use of Dalbavancin for Staphylococcus aureus Bacteremia in Persons Who Inject Drugs (PWID). Open Forum Infect Dis. 2019;6(Suppl2):S772. doi:.
  56. Bork JT, Heil EL, Berry S, Lopes E, Davé R, Gilliam BL, et al. Dalbavancin Use in Vulnerable Patients Receiving Outpatient Parenteral Antibiotic Therapy for Invasive Gram-Positive Infections. Infect Dis Ther. 2019;8(2):171–84. doi:.
  57. Bryson-Cahn C, Beieler AM, Chan JD, Harrington RD, Dhanireddy S. Dalbavancin as Secondary Therapy for Serious Staphylococcus aureus Infections in a Vulnerable Patient Population. Open Forum Infect Dis. 2019;6(2):ofz028. doi:.
  58. Curtis SJ, Tanna A, Russell HH, Efstratiou A, Paul J, Cubbon M, et al. Invasive group A streptococcal infection in injecting drug users and non-drug users in a single UK city. J Infect. 2007;54(5):422–6. doi:.
  59. Alwan M, Davis JS, Daneman N, Fowler R, Shehabi Y, Rogers B. Duration of therapy recommended for bacteraemic illness varies widely amongst clinicians. Int J Antimicrob Agents. 2019;54(2):184–8. doi:.
  60. Jorup-Rönström C, Britton S, Gavlevik A, Gunnarsson K, Redman AC. The course, costs and complications of oral versus intravenous penicillin therapy of erysipelas. Infection. 1984;12(6):390–4. doi:.
  61. Sutton JD, Sayood S, Spivak ES. Top Questions in Uncomplicated, Non-Staphylococcus aureus Bacteremia. Open Forum Infect Dis. 2018;5(5):ofy087. doi:.
  62. Oosterheert JJ, Bonten MJM, Schneider MME, Buskens E, Lammers JWJ, Hustinx WMN, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomised trial. BMJ. 2006;333(7580):1193–5. doi:.
  63. Ramirez JA, Bordon J. Early switch from intravenous to oral antibiotics in hospitalized patients with bacteremic community-acquired Streptococcus pneumoniae pneumonia. Arch Intern Med. 2001;161(6):848–50. doi:.
  64. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al.; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(Suppl 2):S27–72. doi:.
  65. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and treatment of adults with community-acquired pneumonia. Am J Respir Crit Care Med. 2019;200(7):e45–67. doi:.
  66. Nair MK, Patel K, Starer PJ. Ciprofloxacin-induced torsades de pointes in a methadone-dependent patient. Addiction. 2008;103(12):2062–4. doi:.
  67. Sandberg T, Englund G, Lincoln K, Nilsson LG. Randomised double-blind study of norfloxacin and cefadroxil in the treatment of acute pyelonephritis. Eur J Clin Microbiol Infect Dis. 1990;9(5):317–23. doi:.
  68. Musson DG, Majumdar A, Birk K, Holland S, Wickersham P, Li SX, et al. Pharmacokinetics of intramuscularly administered ertapenem. Antimicrob Agents Chemother. 2003;47(5):1732–5. doi:.
  69. Roubaud-Baudron C, Forestier E, Fraisse T, Gaillat J, de Wazières B, Pagani L, et al. Tolerance of subcutaneously administered antibiotics: a French national prospective study. Age Ageing. 2017;46(1):151–5.
  70. Walker P, Neuhauser MN, Tam VH, Willey JS, Palmer JL, Bruera E, et al. Subcutaneous administration of cefepime. J Pain Symptom Manage. 2005;30(2):170–4. doi:.

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