Outpatient Parenteral Antibiotic Treatment for Infective Endocarditis: Insights From Real Life

Comparative effectiveness of empirical antibiotic treatments in methicillin-susceptible Staphylococcus aureus infective endocarditis: A post hoc analysis of a prospective French cohort study

OBJECTIVES

The empirical treatment of infective endocarditis is still debated. The aim of this study was to compare the impact of empirical treatment with antistaphylococcal penicillin (ASP) or cefazolin vs. other treatments in methicillin-susceptible Staphylococcus aureus (MSSA) endocarditis.

METHODS

A post hoc analysis of a prospective cohort study of patients hospitalized in a French reference centre with MSSA endocarditis was conducted between 2013 and 2022. The primary outcome was the duration of bacteraemia under treatment.

RESULTS

Of the 208 patients included, 101 patients (48.6%) were classified in the reference group (ASP or cefazolin) and 107 (52.4%) in the non-reference group. Empirical treatment with ASP/cefazolin was associated with a shorter duration of bacteraemia compared to other treatments (3.6 d vs. 4.6 d, P = 0.01). This difference was not corrected by the addition of an aminoglycoside (3.6 d vs. 4.7 d, P < 0.01). In multivariate analysis, empirical treatment with ASP/cefazolin was associated with a duration of bacteraemia ≤72 h (P = 0.02), whereas endocarditis on native valves (P = 0.01), and intracardiac abscess were associated with longer duration of bacteraemia (P = 0.01).

CONCLUSIONS

Empirical treatment of endocarditis with ASP or Cefazolin is more effective than other treatments in MSSA endocarditis, even when the other treatments are combined with aminoglycosides.

Strengths and limitations of patient registries in infective endocarditis

BACKGROUND

Infective endocarditis (IE) is a serious albeit relatively infrequent disease. Given the paucity of cases, particularly in non-referral centres, patient registries have progressively gained relevance to inform about the epidemiology, clinical presentation, and natural history of IE in the last two decades. Although they have become key to advancing knowledge of IE, registries also have shortcomings that lead to relevant consequences that are often overlooked.

OBJECTIVES

We aimed to discuss the strengths and limitations of registries in IE.

SOURCES

We conducted a PubMed search of relevant articles published between January 2000 and June 2022.

CONTENT

The backbone of the contemporary knowledge on IE has been built upon data collected in prospective registries, which has allowed us to collect data on relatively unknown aspects of the disease, identify knowledge gaps, and generate new hypotheses, serving as platforms for further research endeavours. Well-exploited registries can provide key information on how IE is distributed across populations and how it differentially impacts patients and subgroups. However, registries face several difficulties, such as the definition of IE, which includes subjective variables and changes over time. Other limitations include difficulty achieving a comprehensive collection of cases (which depends on both project funding and information systems), over-representation of the centres that created the registry, lack of inclusion of variables to assess endpoints that are relevant to patients in terms of quality of life and prognosis, and ethical issues.

IMPLICATIONS

The review of the advantages and disadvantages of registries aims to improve the quality of the information collected, the viability of the registry itself, and the ability to answer questions that are relevant to both researchers and patients.

Disparities in United States hospitalizations for serious infections in patients with and without opioid use disorder: A nationwide observational study

BACKGROUND

Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD.

METHODS AND FINDINGS

We utilized the 2016 National Inpatient Sample-a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were female. 46% had Medicare (government-based insurance coverage for people age 65+ years), and 70% were non-Hispanic white. After adjustment for potential confounders, OUD was associated with a lower probability of discharge at any given LOS (aHR 0.61; 95% CI 0.59-0.63; p < 0.001). OUD was also associated with lower odds of discharge to home (aOR 0.38; 95% CI 0.33-0.43; p < 0.001) and higher odds of discharge to a post-acute care facility (aOR 1.85; 95% CI 1.57-2.17; p < 0.001) or patient-directed discharge (also referred to as "discharge against medical advice") (aOR 3.47; 95% CI 2.80-4.29; p < 0.001). There was no significant difference in average total hospital charges, though daily hospital charges were significantly lower for patients with OUD. Limitations include the potential for unmeasured confounders and the use of billing codes to identify cohorts.

CONCLUSIONS

Our findings suggest that among hospitalizations for some serious infections, those involving patients with OUD were associated with longer LOS, higher odds of discharge to post-acute care facilities or patient-directed discharge, and similar total hospital charges, despite lower daily charges. These findings highlight opportunities to improve care for patients with OUD hospitalized with serious infections, and to reduce the growing associated costs.