Partial oral versus full intravenous antibiotic treatment of endocarditis in people who inject drugs: A systematic review

Background: Prolonged intravenous (IV) antibiotic therapy may not be optimal for people who inject drugs (PWID) with infective endocarditis (IE) due to unique social and medical needs. The role of partial IV antibiotic therapy with continued oral (PO) antibiotic therapy is unclear.Methods: A systematic review was performed using EMBASE and MEDLINE databases. Included studies compared PO to IV antibiotic treatment for IE in PWID.Results: Four studies met eligibility. Observational studies included full IV treatment groups and partial IV, partial PO treatment groups for severe injection-related infections. PWID with IE comprised 41.0%-64.7% of the study populations but outcomes specific to IE were not separately reported. All-cause 90-day readmission rates were comparable between the IV treatment group (27.9%-31.5%) and partial IV, partial PO treatment group (24.8%-32.5%). Ninety-day mortality was non-significantly different between IV treatment (4.9%-10.7%) and partial IV, partial PO treatment groups (2.4%-13.0%). One small randomized clinical trial compared IV oxacillin or vancomycin with gentamicin to PO ciprofloxacin plus rifampin. The cure rates were 91% and 90%, respectively.Conclusion: There is limited evidence comparing IV treatment to partial IV, partial PO antibiotic treatment in PWID with IE. Observational studies suggest that PO antibiotic therapy after initial IV treatment may be equivalent to full IV treatment alone within specific parameters, but randomized trials are needed to inform recommendations. Substantial clinical and social benefits for PWID and advantages for the health care system will result if PO treatment strategies with equal efficacy can be implemented. Historique : L'antibioth & eacute;rapie intraveineuse (IV) prolong & eacute;e n'est peut-& ecirc;tre pas optimale chez les utilisateurs de drogues par injection (UDI) atteints d'une endocardite infectieuse (EI) d & eacute;coulant de besoins m & eacute;dicaux et sociaux particuliers. On ne conna & icirc;t pas clairement le r & ocirc;le de l'antibioth & eacute;rapie IV partielle conjugu & eacute;e & agrave; l'antibioth & eacute;rapie par voie orale (PO).M & eacute;thodologie : Les chercheurs ont proc & eacute;d & eacute; & agrave; une analyse syst & eacute;matique au moyen des bases de donn & eacute;es EMBASE et MEDLINE. Les & eacute;tudes incluses comparaient l'antibioth & eacute;rapie PO & agrave; l'antibioth & eacute;rapie IV en cas d'EI chez les UDI.R & eacute;sultats : Quatre & eacute;tudes respectaient les crit & egrave;res d'admissibilit & eacute;. Les & eacute;tudes observationnelles incluaient des groupes de traitement IV complets et des groupes de traitements IV et PO partiels en raison de de graves infections li & eacute;es aux injections. Les UDI atteints d'une IE formaient de 41,0 % & agrave; 64,7 % de la population & agrave; l'& eacute;tude, mais les r & eacute;sultats cliniques propres & agrave; l'IE n'& eacute;taient pas d & eacute;clar & eacute;s s & eacute;par & eacute;ment. Les taux de r & eacute;admission toutes causes confondues au bout de 90 jours & eacute;taient comparables entre le groupe de traitement IV (27,9 % & agrave; 31,5 %) et le groupe de traitement IV et PO partiel (24,8 % & agrave; 32,5 %). La mortalit & eacute; au bout de 90 jours n'& eacute;tait pas sensiblement diff & eacute;rente entre le groupe de traitement IV (4,9 % & agrave; 10,7 %) et le groupe de traitement IV et PO partiel (2,4 % & agrave; 13,0 %). Une petite & eacute;tude clinique randomis & eacute;e a compar & eacute; l'oxacilline ou la gentamicine IV & agrave; la ciprofloxacine conjugu & eacute;e & agrave; la rifampine PO. Les taux de gu & eacute;rison actuels s'& eacute;levaient & agrave; 91 % et & agrave; 90 %, respectivement.Conclusion : Les donn & eacute;es probantes sur la comparaison entre l'antibioth & eacute;rapie IV et l'antibioth & eacute;rapie IV et PO partielle sont limit & eacute;es chez les UDI ayant une IE. Selon les & eacute;tudes observationnelles, l'antibioth & eacute;rapie PO apr & egrave;s un traitement IV initial pourrait & eacute;quivaloir & agrave; un traitement IV complet unique selon des param & egrave;tres pr & eacute;cis, mais des & eacute;tudes randomis & eacute;es s'imposent pour & eacute;tayer les recommandations. Les UDI tireront des avantages cliniques et sociaux importants s'il est possible d'adopter des strat & eacute;gies de traitement PO de m & ecirc;me efficacit & eacute;, et le syst & egrave;me de sant & eacute; en profitera & eacute;galement.Summary: Injection drug use significantly increases the risk of infective endocarditis, a bacterial infection of one or more heart valves. When diagnosed, infective endocarditis typically requires weeks of antibiotic therapy, often intravenous. This can amount to long hospital stays, particularly for people who inject drugs, as outpatient antibiotic therapies are often not feasible. As a result, there can be significant consequences in this population such as loss of housing, childcare, and employment, which may have already been unstable at the time of their hospital admission. As such, some people who inject drugs leave the hospital In the general population with infective endocarditis, the outcomes with oral antibiotics after a short course of intravenous antibiotics has been shown to be similar to a full course of intravenous treatment in some patients or in patients with specific clinical characteristics. Most of the current studies, however, do not include, or include very few people who inject drugs, so limited conclusions can be made for this population. This systematic review examines the current literature for oral compared to intravenous antibiotic treatment of infective endocarditis in people who inject drugs, in order to provide a baseline of our current understanding and advocate for more research.