Switch to oral antibiotics in the treatment of infective endocarditis is not associated with increased risk of mortality in non–severely ill patients

Abstract

Although many international guidelines exist for the management of infective endocarditis (IE), recommendations are lacking on the opportunity of switching antibiotics from the intravenous (IV) to oral route during treatment. We present a cohort study of 426 cases of IE over a period of 13 years (2000-2012), including 369 cases of definite IE according to the Duke criteria. Predictors of mortality were identified using the Cox proportional hazard analysis. The median (range) age at diagnosis was 64.5 (7-98) years. One hundred six patients (25%) had healthcare-associated IE. Oral streptococci (n = 99, 23%) and Staphylococcus aureus (n = 81, 19%) were the predominant microorganisms. Ninety-two patients (22%) died during follow-up. After an initial phase of IV antibiotherapy, 214 patients (50%) were switched to oral route a median (range) of 21 (0-70) days after diagnosis of IE. Patients in the oral group had fewer comorbidities, and criteria of severity at inclusion and were less frequently infected by S. aureus. Oral antibiotics were amoxicillin alone in 109 cases or a combination therapy of clindamycin, fluoroquinolone, rifampicin and/or amoxicillin in 46 cases, according to the susceptibility of the microorganisms. In the multivariate analysis, a switch to oral route was not associated with an increased risk of mortality. During follow-up, only two relapses and four reinfections were observed in the oral group (compared to nine and eight in the IV group, respectively). In this study, switching to oral administration was not associated with an increased risk of relapse or reinfection. These promising results need to be confirmed by prospective studies.

Partial oral antibiotic therapy is non-inferior to intravenous therapy in non-critically ill patients with infective endocarditis

“…Oral treatment strategies consisted of only amoxicillin or a combination of clindamycin, fluoroquinolones, rifampicin and amoxicillin. A switch to oral therapy was not associated with increased mortality, albeit patients in the intravenous group were more ill and more often suffered from Staphylococcus bacteremia [15]. In the POET trial, Iversen et al compared clinically stable patients suffering from left-sided IE.…”

“…Potential changes in practice due to earlier publication date; only patients with right-sided IE were included; relatively small patient collective Mzabi et al [15] Retrospective cohort study Limitation due to retrospective study design; sicker patients in the i.v. group…”

“…Due to increasing healthcare costs with pressure for containment, strategies shortening the length of hospital stay are of particular interest. Heredia-Rodriguez et al showed in their retrospective analysis that the incurred costs of IE increased from 6759.30 per patient in 1997 to 15,489.60 in 2008 and remained stable from that year onward [4]. Treatment plans with once daily parenteral or even oral antibiotic therapy enabling outpatient care could help to reduce costs.…”

Efficacy of the switch to oral antibiotics in the treatment of non- Staphylococcus aureus infective endocarditis in non-severely ill patients

“…We have read with interest the article by Mzabi et al entitled 'Switch to oral antibiotics in the treatment of infective endocarditis is not associated with increased risk of mortality in non-severely ill patients' [1]. The authors conducted a retrospective cohort study of 426 patients with infective endocarditis, including right-and leftsided infective endocarditis and prosthetic valve endocarditis.…”

“…The two groups (patients exclusively treated by the intravenous route, and patients switched to oral therapy) were not comparable because patients in the intravenous group were severely ill with many co-morbidities (see Table 2 in ref. [1]). It is hard to believe that such a difference could be accounted for in any statistical adjustment, and so it constitutes a selection bias.…”