POET Trial: Earlier shift to oral antibiotics at home
“Another very important point is the increasing use of oral outpatient antibiotic therapy based on the Partial Oral Treatment of Endocarditis (POET) randomized trial,” Dr. Borger observed. “That’s a new recommendation,” he said, “with significant implications for the care of patients with this oftentimes life-threatening disease.”
In POET, patients in stable condition who had endocarditis on the left side of the heart caused by streptococci, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci were randomly assigned to continue treatment with intravenous antibiotics (199 patients) or to shift to step-down treatment with oral antibiotics (201 patients) after at least 10 days of initial treatment with IV antibiotics.
The 5-year results were published in 2019 in the New England Journal of Medicine and presented at ESC that year. “We were hoping or expecting to see that oral outpatient therapy would be equivalent to inpatient IV therapy,” Dr. Borger said, “but we were surprised to see that oral outpatient therapy was actually statistically significantly better in terms of survival, a very hard outcome, at 5 years after the randomization.”
“This was an important part of our new guideline document. In select patients who are ‘clinically stable’,” as defined in the guidelines, he said, “they could be successfully managed at home with oral antibiotics, rather than keeping them in hospital the whole 6 weeks.”
“In the U.S. and in Canada, a lot of patients are sent home for intravenous therapy, whereas that practice doesn’t exist in a lot of places in Europe. The patients are sitting in the hospital here for 6 weeks, oftentimes for no other reason – just to get their IV antibiotic therapy. The POET trial has shown us that that is probably the wrong thing to be doing.”
Earlier surgical intervention
The new guidelines also recommend that “once there is an indication to do cardiac surgery, it should be promptly performed,” Dr. Borger noted.
Surgery to remove infected material and drain abscesses is indicated for patients with heart failure or uncontrolled infection and to prevent embolism.
“We have defined emergency indications that should be done within 24 hours; urgent, which should be done within 3-5 days; and nonurgent, more than 5 days but within the same hospitalization,” he elaborated. “We’re basically trying to encourage surgeons and nonsurgeons that once there is an indication for surgery, there’s not a lot of benefit to just waiting. You should proceed with operation in a timely manner” to improve survival.
The guidelines recommend surgery for early prosthetic valve endocarditis, within 6 months of valve surgery, with new valve replacement and complete debridement.
Patients who present with stroke and require surgery are not uncommon, Dr. Borger noted. Ischemic stroke should not be a reason to delay surgery, and patients with hemorrhagic stoke, with favorable features, can undergo surgery.
The guidelines provide a figure for the management of CIED-related infective endocarditis. They also include a new section devoted to patient-centered care and shared decision-making.
The guidelines were endorsed by the European Association for Cardio-Thoracic Surgery and the European Association of Nuclear Medicine. The writing task force included representatives from EACTS, EANM, and the European Society of Clinical Microbiology and Infectious Diseases.
The complete guidelines, as well as pocket guidelines, essential messages, a pocket guidelines app, and an official guidelines slide set, all addressing endocarditis, are available from the ESC website.
The guidelines did not receive any funding. The disclosure forms of all experts involved in their development are available on the ESC website.
A version of this article appeared on Medscape.com.