Efficacy and safety of earlier switching to an oral antibiotic therapy for the treatment of Gram-positive bloodstream infections: a systematic review and meta-analysis

Abstract Background Infection specialists show considerable variation in practice, with some advocating IV-to-oral switch for Gram-positive bloodstream infections (GP-BSIs). The efficacy and safety of early switching remain unclear. Methods Systematic review of the efficacy of an early switch to oral antimicrobial therapy in patients with GP-BSIs compared with IV therapy, including treatment failure, all-cause mortality, recurrence, hospital readmission rates, length of hospital stay and adverse events (AEs). PubMed, Embase and the Cochrane Library Database were independently searched up to May 2025. ROBINS-I and ROB-2 tools were used. Results A total of 27 studies with 6015 patients were included. Although treatment failure in the IV-to-oral group is comparable to that of IV treatment, the 30-day (OR 0.33, 95% CI 0.13, 0.83) and 90-day all-cause mortality (OR 0.59, 95% CI 0.36, 0.97) in patients with GP-BSIs were significantly lower in association with oral switch. Notably, the decline in all-cause mortality rate was more pronounced in the subgroups of S. aureus (OR 0.37, 95% CI 0.26, 0.53), oral conversion time ≥7 days (OR 0.25, 95% CI 0.16, 0.38) and switched to oral non-β-lactam antibiotics (OR 0.58, 95% CI 0.39, 0.86). Moreover, oral switch therapy significantly reduced hospital stay (MD −6.21 days, 95% CI −7.99, −4.43). Recurrence rate, hospital readmission rates and AEs were similar between IV and oral switch groups. Conclusions This meta-analysis, although primarily based on observational studies, supports that transitioning from IV to oral therapy constitutes a suitable alternative for patients with GP-BSIs exclusively managed via parenteral administration.