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Lower 5-year death rate with oral versus IV antibiotic therapy for endocarditis

The New England Journal of Medicine
Reuters Health - 09/02/2022 - Selected patients with endocarditis on the left side of the heart are 39% less likely to die from any cause if they receive oral antibiotics instead of IV antibiotics once their condition has stabilized, according to five-year results from the POET trial.

The rate was 23.4% with oral therapy versus 35.2% among those who had received intravenous treatment (hazard ratio, 0.61; 95% CI, 0.42 to 0.88).

The findings, reported in the New England Journal of Medicine, confirm the trend seen in a post hoc exploratory analysis that was done after 3.5 years of follow-up.

The lower death rate was the primary driver behind the 35% reduction in the primary composite outcome that also included unplanned cardiac surgery, embolic events and relapse of bacteremia with the primary pathogen.

"There were no significant differences noted between the groups for the three other components of the composite outcome," Dr. Mia Pries-Heje of Copenhagen University Hospital and colleagues write.

They characterize the new findings as "reassuring."

"The most frequent cause of death was cardiovascular, followed by infection and cancer," the group reports

POET was originally designed to see if step-down therapy with oral therapy after stabilization was non-inferior to continued intravenous antibiotic therapy after nine months. The researchers were surprised to see that it was actually better.

All 400 study participants had endocarditis on the left side of the heart caused by streptococci, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci.

Those in the orally treated group were shifted from IV to oral therapy at the midpoint of their treatment, around day 17. The oral antibiotics were carefully selected for each patient, the researchers note. All of the oral regimens consisted of two antibiotics from different drug classes.

Originally, at the six-month mark, the two treatment strategies didn't seem significantly different. But after three more years, the difference was dramatic.

The chief author of the earlier report, Dr. Henning Bundgaard, also of Copenhagen University Hospital, told Reuters Health by phone at the time that, "One major difference between the two groups is that the IV-treated patients stayed in the hospital 2 weeks longer than the oral-treated patients."

"I think for these elderly, comorbid and often-fragile patients in the IV group, due to their prolonged stay in the hospital, they lose some of their physical and mental capacity and they may never recover," he speculated. "And if that is right, it may make them more vulnerable when they are struck by other diseases such as heart failure, pneumonia or cancers, making them easier victims to the conditions common at a high age."

SOURCE: https://bit.ly/3urBJZq The New England Journal of Medicine, online February 9, 2022.

By Reuters Staff

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