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Content Update

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.

CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK

For the chapter in the Wells Handbook, please go to Chapter 37. Endocarditis.

KEY CONCEPTS

KEY CONCEPTS

  • Image not available. Infective endocarditis usually occurs in adult patients with specific risk factors (eg, IV drug abuse, heart failure, valvular disease, and healthcare exposure) and those with implanted cardiac material (eg, prosthetic heart valves).

  • Image not available. Three groups of organisms cause a majority of infective endocarditis cases: streptococci, staphylococci, and enterococci.

  • Image not available. The clinical presentation of infective endocarditis is highly variable and nonspecific, although a fever and murmur are usually present. Classic peripheral manifestations (eg, Osler’s nodes) may or may not occur.

  • Image not available. The diagnosis of infective endocarditis requires the integration of clinical, laboratory, and echocardiographic findings. The two major diagnostic criteria are bacteremia and echocardiographic changes (eg, valvular vegetation).

  • Image not available. Treatment of infective endocarditis involves isolation of the infecting pathogen and determination of antimicrobial susceptibilities, followed by high-dose, parenteral, bactericidal antibiotics for an extended period.

  • Image not available. Surgical replacement of the infected heart valve is an important adjunct to endocarditis treatment in certain situations (eg, patients with acute heart failure).

  • Image not available. β-Lactam antibiotics, such as penicillin G (or ceftriaxone), nafcillin, and ampicillin, remain the drugs of choice for streptococcal, staphylococcal, and enterococcal endocarditis, respectively.

  • Image not available. Aminoglycoside antibiotics are essential to obtain a synergistic bactericidal effect in the treatment of enterococcal endocarditis. Adjunctive aminoglycosides also may decrease the emergence of resistant organisms (eg, prosthetic valve endocarditis caused by coagulase-negative staphylococci) and hasten the pace of clinical and microbiologic response (eg, some streptococcal and staphylococcal infections).

  • Image not available. Vancomycin is reserved for patients with immediate β-lactam allergies and the treatment of resistant organisms.

  • Image not available. Antimicrobial prophylaxis is used to prevent infective endocarditis for patients who are at the highest risk (such as persons with prosthetic heart valves) before a bacteremia-causing procedure (eg, dental extraction).

Endocarditis is an inflammation of the endocardium, the membrane lining the chambers of the heart and covering the cusps of the heart valves.1,2 More commonly, endocarditis refers to infection of the heart valves by various microorganisms. Although it typically affects native valves, it also may involve ...

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