Real-World Application of Oral Therapy for Infective Endocarditis: A Multicenter, Retrospective, Cohort Study

Abstract

Background We sought to compare the outcomes of patients treated with intravenous (IV)-only vs. oral transitional antimicrobial therapy for infective endocarditis (IE) after implementing a new Expected Practice within The Los Angeles County Department of Health Services (LAC DHS). Methods We conducted a multi-centered, retrospective cohort study of adults with definite or possible IE treated with IV-only vs. oral therapy at the three acute care, public hospitals in the LAC DHS system between December 2018 to June 2022. The primary outcome was clinical success at 90 days, defined as being alive, and without recurrence of bacteremia or treatment-emergent infectious complications. Results We identified 257 patients with IE treated with IV-only (n=211) or oral transitional (n=46) therapy who met study inclusion criteria. Study arms were similar for many demographics; however, the IV cohort was older, and had more aortic valve involvement, hemodialysis patients, and central venous catheters present. In contrast, the oral cohort had a higher percentage of IE caused by methicillin-resistant S. aureus. There was no significant difference between the groups in clinical success at 90 days or last follow-up. There was no difference in recurrence of bacteremia or readmission rates. However, patients treated with oral therapy had significantly fewer adverse events. Multivariable regression adjustments did not find significant associations between any selected variables and clinical success across treatment groups. Conclusions These results demonstrate similar outcomes of real-world use of oral vs. IV-only therapy for IE, in accord with prior randomized controlled trials and meta-analyses.

Using antibiotics wisely

“…They evaluated 257 patients with proven and possible IE treated with IV only versus 45 treated with PO-stepdown at any time point. Outcomes at 90 days between the IV and PO groups were similar with clinical success (84.4% vs 87%), survival (91.5% vs 89%), recurrence (3.3% vs 2.8%) and with less treatment complication in the PO group [25 ▪▪ ]. This example shows that early conversion from IV to PO can be safely implemented in a hospital system.…”

“…This suggests that once the IV component has cleared the blood, the role of PO therapy is to reduce relapse of infection [42 ▪ ]. A real world example of the impact of IV-PO step-down therapy for IE was performed at three acute care hospitals [25 ▪▪ ]. They evaluated 257 patients with proven and possible IE treated with IV only versus 45 treated with PO-stepdown at any time point.…”

Guidelines for Diagnosis and Management of Infective Endocarditis in Adults

“…For MSSA, there is observational evidence that beta-lactam therapy is superior to vancomycin therapy, and for this reason many authors prefer to include a beta-lactam with good S. aureus activity. Most WikiGuidelines authors prefer cefazolin over anti-staphylococcal penicillins in this context due to decreased toxicity, with similar clinical efficacy described in recent observational studies …”

“…45,67 If oral therapy is used, it is rational to select antibiotics demonstrated to have efficacy in published studies (Table 3 and Box 2). 46,47,55,61,62,[68][69][70][71][73][74][75][76][77] It is unclear whether dual regimens, such as those used in the POET study, 55 are required, as other data have demonstrated favorable outcomes with certain monotherapy regimens (Table 2; eAppendix 3 in Supplement 1). It is also unclear to what extent intravenous lead-in therapy is needed prior to transitioning to oral therapy, as studies have used a wide range of intravenous lead-in prior to oral therapy, including 1 RCT with no intravenous lead-in.…”

Nach der Pandemie ist vor der Pandemie...

“…80 Patienten in beiden Armen [6]. ▪ Selbst bei Patienten mit Endokarditisund nicht nur mit Streptokokkenwar die orale Sequenztherapie einer ausschließlichen intravenösen Therapie gleichwertig [7]. ▪ Patienten mit ambulant erworbener Pneumonie, bei welchen bereits nach 3 Tagen bei klinischer Besserung die AB-Therapie oralisiert wurde, hatten bei vergleichbarem klinischen Outcome eine entsprechend kürzere i. v. Gabe und einen kürzeren stationären Aufenthalt [8].…”