October 25, 2023European Heart Journal
Clinical implementation of partial oral treatment in infective endocarditis: the Danish POETry study
Why the study?
Following the POET trial demonstrating non-inferiority of oral step-down therapy in stabilized left-sided IE, this study examined the first guideline-driven clinical implementation of the oral step-down regimen.
Does oral step-down antibiotic therapy reduce the composite of embolic events, unplanned cardiac surgery, relapse of bacteraemia and all-cause mortality in patients with infective endocarditis?
Key Points
- To evaluate the real-world clinical implementation, feasibility, and 6-month outcomes of an oral step-down antibiotic regimen compared with continued intravenous therapy in patients with infective endocarditis.
- Observational implementation study of 562 patients diagnosed with infective endocarditis between May 2019 and December 2020 caused by Staphylococcus aureus, Enterococcus faecalis, Streptococcus spp., or coagulase-negative staphylococci.
- Eligible patients were assigned at the discretion of the treating physician to oral step-down antibiotic therapy (n=240, 43%) or continued intravenous antibiotic therapy (n=322, 57%).
- Assessed a composite primary outcome at 6 months consisting of embolic events, unplanned cardiac surgery, relapse of bacteremia, and all-cause mortality.
- The primary composite outcome occurred in 13% (30/240) of patients in the oral group compared with 18% (59/322) in the intravenous group (P = .051).
- All-cause mortality at 6 months was 8% (20/240) in the oral group versus 14% (46/322) in the intravenous group (P = .024).
- Patients treated orally had a significantly shorter median hospital length of stay of 24 days (IQR 17-36) versus 43 days (IQR 32-51) for intravenously treated patients (P < .001).
Structured PICO
Does oral step-down antibiotic therapy reduce the composite of embolic events, unplanned cardiac surgery, relapse of bacteraemia and all-cause mortality in patients with infective endocarditis?
P
Population
562 patients with infective endocarditis (IE) caused by Staphylococcus aureus, Enterococcus faecalis, Streptococcus spp. or coagulase-negative staphylococci, median age 74 years, 70% males, in Denmark.
I
Intervention
Oral step-down antibiotic therapy (PO)
C
Comparator
Conventional continued intravenous antibiotic treatment (IV)
O
Outcome
Composite of embolic events, unplanned cardiac surgery, relapse of bacteraemia and all-cause mortality within 6 monthscomposite
Limitations
- observational design
- selection bias
- unmeasured confounding
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“It is a huge challenge for patients to stay in hospital for up to six weeks receiving intravenous treatment, which is associated with an increased risk of complications. Reducing the length of hospital stay has improved outcomes in other diseases and oral antibiotics could be a safe way to achieve this.”
“Oral antibiotics may safely be administered during approximately half the recommended antibiotic treatment period, and that could potentially be as outpatient treatment.”
“This important study does not imply that oral [antibiotics] are applicable to all patients with infective endocarditis.”
Implication
Real-world clinical implementation of oral step-down antibiotic therapy for infective endocarditis appears feasible and safe, significantly reducing hospital length of stay compared to continued intravenous therapy.
Abstract
BACKGROUND AND AIMS: In the Partial Oral Treatment of Endocarditis (POET) trial, stabilized patients with left-sided infective endocarditis (IE) were randomized to oral step-down antibiotic therapy (PO) or conventional continued intravenous antibiotic treatment (IV), showing non-inferiority after 6 months. In this study, the first guideline-driven clinical implementation of the oral step-down POET regimen was examined. METHODS: Patients with IE, caused by Staphylococcus aureus, Enterococcus faecalis, Streptococcus spp. or coagulase-negative staphylococci diagnosed between May 2019 and December 2020 were possible candidates for initiation of oral step-down antibiotic therapy, at the discretion of the treating physician. The composite primary outcome in patients finalizing antibiotic treatment consisted of embolic events, unplanned cardiac surgery, relapse of bacteraemia and all-cause mortality within 6 months. RESULTS: A total of 562 patients [median age 74 years (IQR, interquartile range, 65-80), 70% males] with IE were possible candidates; PO was given to 240 (43%) patients and IV to 322 (57%) patients. More patients in the IV group had IE caused by S. aureus, or had an intra-cardiac abscess, or a pacemaker and more were surgically treated. The primary outcome occurred in 30 (13%) patients in the PO group and in 59 (18%) patients in the IV group (P = .051); in the PO group, 20 (8%) patients died vs. 46 (14%) patients in the IV group (P = .024). PO-treated patients had a shorter median length of stay [PO 24 days (IQR 17-36) vs. IV 43 days (IQR 32-51), P < .001]. CONCLUSIONS: After clinical implementation of the POET regimen almost half of the possible candidates with IE received oral step-down antibiotic therapy. Patients in the IV group had more serious risk factors for negative outcomes. At 6-month follow-up, there was a numerically but not statistically significant difference towards a lower incidence of the primary outcome, a lower incidence of all-cause mortality and a reduced length of stay in the PO group. Due to the observational design of the study, the lower mortality may to some extent reflect selection bias and unmeasured confounding. Clinical implementation of PO regimens seemed feasible and safe.
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Cite This Study
Pries‐Heje et al. (2023) studied this question.