Dr. Chadwick
Clinical question: Does oral transitional antibiotic therapy have similar outcomes to intravenous (IV)-only antibiotic treatment for infective endocarditis (IE)?
Background: There has been a longstanding belief, not supported by strong evidence, that deep infections such as IE require prolonged IV antibiotics, although it is known that long-term IV therapy is associated with adverse events. Despite previous evidence suggesting oral transitional therapy for IE to be at least as effective as IV-only treatment, this practice has yet to be adopted into the standard of care, possibly due to an absence of real-world outcomes outside of carefully controlled randomized clinical trials.
Study design: Multi-center, retrospective, cohort study
Setting: Three acute care public hospitals in the Los Angeles County Department of Health Services, between December 2018 and June 2022
Synopsis: Chart review identified 257 adults with definite or possible IE who were treated with IV-only (n=211) versus IV then oral transitional therapy (n=46). Oral transitional therapy was initiated when patients met specific criteria. The primary efficacy endpoint was clinical success, defined as being alive, without recurrent bacteremia, and without treatment-emergent infectious complications within 90 days. Clinical success rates were similar in both the IV-only arm (84.4%) and the oral-therapy arm (87%) at 90 days. A similar rate of patients in the IV-only versus oral cohorts failed to complete their planned duration of therapy (7.1% versus 6.5%, respectively) and there was no significant difference in the median length of hospitalization. There were significantly higher rates of adverse events in the IV-only arm (27.5%) compared to the oral arm (8.7%). Limitations include the study’s retrospective nature and the possibility of missing follow-ups outside of the Los Angeles public health hospital network.
Bottom line: In patients with IE who met specific clinical criteria of stability, oral antibiotic transitional therapy has similar success rates to prolonged IV therapy but with fewer adverse events.
Citation: Freling S, et al. Real-world application of oral therapy for infective endocarditis: A multicenter retrospective, cohort study. Clin Infect Dis. 2023;ciad119. doi:10.1093/cid/ciad119.
Dr. Chadwick is an internal medicine resident, PGY-2, at Maine Medical Center, Portland, Maine, and Tufts University School of Medicine, Boston.