Jan. 30, 2019
Partial Oral Treatment of Bacterial Infective Endocarditis: Effectiveness of oral treatment for infective endocarditis (IE) has been investigated since the 1940s. Retrospective observational studies and few small randomized trials have suggested promising results with certain highly bioavailable oral regimens. “The Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis” or “POET” trial randomized 400 adult patients with left-sided IE to either continued IV treatment or conversion to oral therapy. Difference in the composite efficacy end point between groups met the study’s non-inferiority criteria (3.1%; 95% confidence interval, -3.4 to 9.6; P = 0.40). The average patient in the POET trial may look quite different from the typical IE patient in many US hospitals. Pathogen, oral antibiotic choice, and individual patient characteristics should be considered when assessing potential candidates for partial oral therapy.
Upon completion of the chapter, the reader will be able to:
Differentiate the causes and development of infective endocarditis (IE).
Identify the clinical presentation and laboratory evaluation for IE.
Assess diagnostic criteria used to evaluate a patient suspected of having IE.
Describe the most likely causative pathogens of IE, particularly in specific patient populations.
Develop appropriate pharmacologic treatment recommendations for patients with IE.
Define appropriate patient populations requiring prophylactic treatment, and differentiate appropriate drug regimens.
Devise a monitoring plan for patients with IE to determine treatment efficacy and discern any adverse effects.
Infective endocarditis (IE) is a serious infection affecting the lining and valves of the heart. Although this disease is mostly associated with infection of the heart valves, septal defects may become involved in some cases. Infections also occur in patients with prosthetic or mechanical devices or who are intravenous drug users (IVDUs). Bacteria are the primary cause of IE; however, fungi and atypical organisms may also be responsible pathogens.
Typically, IE is classified into two categories: acute or subacute. Differences between the two categories are based on the progression and severity of the disease. Acute disease is more aggressive, characterized by high fevers, leukocytosis, and systemic toxicity, with death occurring within a few days to weeks. This type of IE is often caused by more virulent organisms, particularly Staphylococcus aureus. Subacute disease is often caused by less virulent organisms, such as viridans group streptococci, producing a slower and more subtle presentation. It is characterized by nonspecific symptoms including fatigue, low-grade fever, and weight loss, with death occurring in several months.
Successful management of patients with IE is based on proper diagnosis, treatment with appropriate therapy, and monitoring for complications, adverse events, or development of resistance. The treatment and management of IE are best determined through identification of the causative organism. IE has varied clinical presentations; therefore, patients with this infection may be found in any medical subspecialty (ie, medicine, surgery, critical care, etc).
EPIDEMIOLOGY AND ETIOLOGY