IV antibiotics safely substituted by oral antibiotics in patients with infectious endocarditis

ESC 2018 The POET study found that in-hospital IV antibiotics could be safely substituted by early discharge with oral antibiotics, with equal efficacy and shorter hospital stays.

POET study: Partial oral treatment of left-sided infectious endocarditis

Presented at the ESC congress 2018 by: Henning Bundgaard (Copenhagen, Denmark)

Introduction and Methods

The standard treatment of infectious endocarditis involves in-hospital and intravenous (i.v.) antibiotics for up to 6 weeks. The endocarditis complications occur mainly at the early phase, and after stabilization of the patient. The reason for keeping patients in the hospital is the i.v. treatment, although the prolonged hospital stay per se can cause complications.

The POET study evaluated whether the efficacy and safety of orally administered antibiotics was non-inferior to i.v. antibiotics in 400 stabilized patients with left-sided endocarditis, caused by streptococcus spp, enterococcus faecalis, staphylococcus aureus, or coagulase-negative staphylococci.

All patients received i.v. antibiotics for 10 days, and were then randomized to continuous i.v. treatment or to switch to oral antibiotic therapy. The primary endpoint was a composite of all-cause mortality, unplanned cardiac surgery, embolic events or relapse of bacteremia.

Main results

The primary endpoint occurred in 12.1% of patients in the i.v. group and in 9.0% of patients in the orally treated group (between-group difference: 3.1 %; 95%CI: -3.4 to 9.6; P=0.40), and thereby non-inferiority between the 2 treatment options was met.

Conclusion

Switching from i.v. to oral antibiotic treatment is a safe option with equivalent efficacy for patients with infectious endocarditis, and may halve the hospital stays for these patients.

Discussion

After the presentation of the study results at the ESC Press Room, the speaker was asked how stabilization of patients was defined and whether the results can be extrapolated to all antibiotics, given high rates of resistances. Patients were considered to be stable after 10 days of i.v. treatment with antibiotics if they had no fever, their CRP levels were normalized, and the echocardiographic examination revealed no abscess or other reason for surgery. Moreover, patients were eligible for the study if their pathogen was sensitive to at least 2 antibiotics, which is the case in at least 50% of patients with infectious endocarditis. Considering antibiotics resistance, he noted that levels are low in Denmark. In other countries, options may be scarcer.

The practical approach of patient follow-up after discharge was discussed in more detail. The patients randomized to oral antibiotics were discharged after a median of three days, as compared with after 19 days in the i.v. group. Patients on oral antibiotics visited the ward to see a doctor or a nurse every 3 to 4 days, for safety reasons (check temperature, complications). This may be organized differently in other countries.