Five 'Quick Hits' in Hospital Medicine

William J. Collins, MD

Disclosures

June 18, 2019

In This Article

Uncomplicated Gram-Negative Bacteremia: How Long to Treat

The question at hand was whether the duration of antibiotic therapy (7 vs 14 days) influenced outcomes in hospitalized patients with uncomplicated gram-negative bacteremia.[3] Patients were recruited on day 7 of antibiotic therapy if they had been afebrile and hemodynamically stable for the previous 48 hours. In the treatment group, antibiotics were stopped on day 7, whereas the control group received 14 days of antibiotics. Patients could also be recruited if they were clinically stable and ready for discharge before 7 days. Immunosuppressed patients, including those with HIV, were excluded.

The primary outcome—a composite of all-cause mortality, clinical failure,

readmission, or extended hospital stay—did not differ among the groups. A 7-day course was not inferior to a 14-day course of antibiotics in this population of stable adults with bacteremia. Given that the patients were recruited for the trial once they were clinically stable for discharge, these data are most instructive when selecting a treatment course at the time of discharge.

Six Weeks of IV Antibiotics for Endocarditis or Bone Infection?

In other big antibiotic news, two recent studies challenge the need for 6 weeks of intravenous (IV) antibiotics in the treatment of left-sided endocarditis or bone and joint infections. The POET[4] and OVIVA[5] trials both showed noninferiority in switching from IV to oral antibiotics before 6 weeks compared with completing the entire course with parenteral antibiotic therapy.

Both trials were open-label. OVIVA's findings are more generalizable given the variety of patients enrolled, which included many with surgical hardware. Of note, the number of patients in OVIVA with at least one serious adverse event was essentially the same for both groups (all-IV or early switch to oral therapy); thus, the early switch strategy didn't clearly improve safety.

A few limitations of POET, as well: Some of the recommended oral antibiotic regimens used in that study have significant side-effect profiles (eg, linezolid, moxifloxacin) or are not available in the United States (eg, fusidic acid). POET also did not include any patients with methicillin-resistant Staphylococcus aureus endocarditis. Furthermore, the study patients either remained in the hospital for treatment or were seen in clinic twice or three times per week and had multiple transesophageal echocardiograms during the study to confirm they were without valve abscess. This intensity of care would be hard to recreate in the US healthcare system.

These data are exciting, but it's not clear whether either study's findings are enough to change current care. In the end, we probably need to consult with infectious disease specialists for these patients anyway, and it's possible they can help us identify appropriate candidates for early switch to oral therapy with close follow up.

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