Choosing patients over placebos: oral transitional therapy vs. IV-only therapy for bacteraemia and infective endocarditis

Not All in Vein: Oral Antibiotics for Diabetic Foot Osteomyelitis: A Narrative Review

INTRODUCTION

Osteomyelitis is a severe complication of diabetes-related foot ulcers (DFUs) often managed with antibiotic therapy and surgical resection of the infected bone. Areas of research: While intravenous (IV) antibiotics have been the traditional approach for bone and joint infections in general, randomized clinical trials have shown that, overall, oral antibiotics are non-inferior to IV antibiotics. While comparisons between oral antibiotics are generally lacking, the data suggest that oral antibiotics with high bioavailability and bone penetration ratios should be prioritized for osteomyelitis treatment, including diabetic foot osteomyelitis (DFO). Oral regimens reduce hospital stays, avert catheter-related complications, and decrease treatment costs while improving patient satisfaction and quality of life. Despite these advantages, IV antibiotics remain widely used, partly due to clinical tradition and concerns about oral absorption in individuals with diabetes. Current guidelines recommend transitioning to oral therapy once systemic signs improve, but robust data supporting oral-only regimens for DFO treated non-surgically remain limited.

CONCLUSIONS

Oral antibiotics represent a safe and effective alternative to IV therapy for many patients with DFO, particularly when high-bioavailability agents are used. Further well-designed studies are needed to validate their efficacy in non-surgical DFO management and inform clinical guidelines.

Treatment of Complicated Gram-Positive Bacteremia and Infective Endocarditis

The Gram-positive cocci Staphylococcus aureus, Streptococcus spp., and Enterococcus spp. are the most frequent causative organisms of bloodstream infections and infective endocarditis. "Complicated bacteremia" is a term used in S. aureus bloodstream infections and originally implied the presence of metastatic infectious foci (i.e. complications of S. aureus bacteremia). These complications demand longer antimicrobial treatment durations and, frequently, interventional source control. Several risk factors for the incidence of bacteremia complications have been identified and are often used for the definition of complicated bacteremia. Here, we discuss management and diagnostic approaches and treatment options for patients with complicated bacteremia, with particular focus on infective endocarditis. We also summarize the available evidence regarding imaging modalities and the choice of antimicrobial mono- or combination therapy according to resistance patterns for these pathogens as well as treatment durations and optimized application routes. Finally, we synopsize current and future areas of research in complicated bacteremia and infective endocarditis.

A Longer Duration of Intravenous Antibiotic Treatment for Patients with Early Periprosthetic Joint Infections Is Not Associated with a Lower Failure Rate

BACKGROUND

In recent years, many studies have demonstrated the efficacy of an early switch to oral antibiotics after surgical treatment in orthopedic-related infections. However, large analyses on periprosthetic joint infections (PJIs) are lacking.

MATERIAL AND METHODS

We conducted a retrospective observational multicenter study in patients diagnosed with an early post-operative PJI, defined as one occurring <3 months after the index arthroplasty and treated with debridement, antibiotics, and implant retention (DAIR). Patients from Europe and the USA were included. We took advantage of the fact that an early oral antibiotic switch is routine practice in Europe as opposed to a long duration of intravenous (IV) antibiotic treatment in the USA. Failure was defined as the clinical need for (i) a second unintended DAIR procedure, (ii) implant removal, (iii) suppressive antibiotic treatment, or (iii) PJI-related death, all within one year after DAIR.

RESULTS

A total of 668 patients were included. A total of 277 received IV antibiotics for <14 days, 232 between 14 and 27 days, and 159 for >27 days. The overall 1-year failure rate within the 3 groups was 41.5%, 44.4%, and 42.1%, respectively (p = 0.80). This observation remained when excluding patients who failed during IV therapy. A longer duration of IV therapy seemed beneficial for those patients with a high pre-operative C-reactive protein level and lack of modular component exchange.

CONCLUSIONS

In early post-operative PJIs, a longer duration of IV therapy is not associated with a lower failure rate but may be continued until a sufficient bacterial load reduction has been achieved.

Virtual Home Care for Patients With Acute Illness

Importance

Recent evolutions in clinical care and remote monitoring suggest that some acute illnesses no longer require intravenous therapy and inpatient hospitalization.

Objective

To describe outcomes of patients receiving care in a new, outpatient, virtual, home-based acute care model called Safer@Home.

Design, Setting, and Participants

This retrospective cohort analysis, conducted from September 1, 2022, through August 31, 2023, included 2466 patients treated at a safety net hospital in Los Angeles County for 10 core illnesses and 24 other acute illnesses for which patients are commonly hospitalized.

Exposure

Outpatient, home-based, acute care with virtual monitoring and clinic visits in lieu of inpatient or in-home care.

Main Outcomes and Measures

The primary measure was hospital length of stay. Secondary measures included all-cause mortality, 30-day readmission, return urgent care visit rates, and return emergency department (ED) visit rates.

Results

Safer@Home provided care to 876 patients (mean [SD] age, 54.0 [14.5] years; 541 men [61.8%]) during the study period, compared with a cohort of 1590 patients (mean [SD] age, 52.3 [19.6] years; 901 men [56.7%]) with matching diagnoses who received standard, hospital-based care. Safer@Home patients had significantly shorter mean (SD) lengths of inpatient stay than the comparison cohort (1.3 [2.0] vs 5.3 [10.4] days; P < .001), totaling 3505 bed-days avoided (mean [SD], 4.0 [10.6] bed-days saved per patient), with no significant difference in all-cause mortality at last follow-up (2.6% [23 of 876] vs 4.0% [64 of 1590]; P = .07). Safer@Home patients and control patients also had no significant difference in the proportion experiencing 30-day hospital readmission (19.9% [174 of 876] vs 16.7% [266 of 1590]; P = .06). As intended, more Safer@Home than control patients had at least one 30-day return urgent care visit (37.3% [327 of 876] vs 5.2% [82 of 1590]; P < .001). In contrast, the Safer@Home and control cohorts did not significantly differ in experiencing at least one 30-day return ED visit (15.2% [133 of 876] vs 12.5% [199 of 1590]; P = .06). Safer@Home patients had significantly fewer mean (SD) total 30-day return ED visits per patient than control patients (0.19 [0.50] vs 0.21 [0.85]; P < .001).

Conclusions and Relevance

In this cohort study, patients receiving acute, virtual, home care with remote monitoring and as-needed return urgent care visits had markedly shorter hospital stays than patients receiving standard inpatient hospital care, with no significant increase in mortality, ED revisits, or return hospitalizations. This new care model is promising for systems that cannot staff Medicare-compliant hospital-at-home visits.

Epidemiology, Diagnosis, Treatment, and Prognosis of Infective Endocarditis

Infective endocarditis (IE) has experienced enormous changes in recent decades [...].