Oral step-down therapy for infective endocarditis


Background: The standard of care for IE has been a prolonged course of IV antibiotics. Recent literature has suggested that oral antibiotics might be a safe and effective step-down therapy for IE.

Dr. Elizabeth Yoo, division of hospital medicine, Mount Sinai Health System, New York

Dr. Elizabeth Yoo

Study design: Systematic review.

Setting: Literature review in October 2019, with update in February 2020, consisting of 21 observational studies and 3 randomized controlled trials.

Synopsis: Three RCTs and 21 observational studies were reviewed, with a focus on the effectiveness of antibiotics administered orally for part of the therapeutic course for IE patients. Patients included in the study had left- or right-sided IE. Pathogens included viridians streptococci, staphylococci, and enterococci, with a minority of patients infected with methicillin-resistant Staphylococcus aureus. Treatment regimens included beta-lactams, linezolid, fluoroquinolones, trimethoprim-sulfamethoxazole, or clindamycin, with or without rifampin.

In studies wherein IV antibiotics alone were compared with IV antibiotics with oral step-down therapy, there was no difference in clinical cure rate. Those given oral step-down therapy had a statistically significant lower mortality rate than patients who received only IV therapy.

Limitations include inconclusive data regarding duration of IV lead-in therapy, with the variance before conversion to oral antibiotics amongst the studies ranging from 0 to 24 days. The limited number of patients with MRSA infections makes it difficult to draw conclusions regarding this particular pathogen.

Bottom line: Highly orally bioavailable antibiotics should be considered for patients with IE who have cleared bacteremia and achieved clinical stability with IV regimens.

Citation: Spellberg B et al. Evaluation of a paradigm shift from intravenous antibiotics to oral step-down therapy for the treatment of infective endocarditis: a narrative review. JAMA Intern Med. 2020;180(5):769-77. doi: 10.1001/jamainternmed.2020.0555.

Dr. Yoo is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

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