Abstract
BackgroundInternational guidelines recommend 4 weeks of treatment with ampicillin plus gentamicin (A+G) for uncomplicated native valve Enterococcus faecalis infective endocarditis (EFIE) and 6 weeks in the remaining cases. Ampicillin plus ceftriaxone (A+C) is always recommended for at least 6w, with no available studies assessing its suitability for 4w. We aimed to investigate differences in the outcome of EFIE according to the duration (4 versus 6 weeks) of antibiotic treatment (A+G or A+C).MethodsRetrospective analysis from a prospectively collected cohort of 78 EFIE patients treated with either A+G or A+C.Results32 cases (41%) were treated with A+G (9 for 4w, 28%) and 46 (59%) with A+C (14 for 4w, 30%). No significant differences were found in 1-year mortality according to the type of treatment (31% and 24% in A+G and A+C, respectively; P = 0.646) or duration (26% and 27% at 4 and 6w, respectively; P = 0.863). Relapses were more frequent among survivors treated for 4w than in those treated for 6w (3/18 [17%] at 4w and 1/41 [2%] at 6w; P = 0.045). Three out of 4 (75%) relapses occurred in cirrhotic patients.ConclusionsA 4-week course of antibiotic treatment might not be suitable neither for A+G nor A+C for treating uncomplicated native valve EFIE.
Highlights
Enterococci are the third most common causal agent of infective endocarditis (IE) worldwide [1] and are becoming increasingly prevalent [2]
The aim of this study was to compare the outcome of patients with Enterococcus faecalis infective endocarditis (EFIE) treated with either ampicillin/ gentamicin or ampicillin/ceftriaxone according to the duration of treatment (4 weeks vs 6 weeks) in order to address if the short-course treatment was adequate and whether a subgroup of patients could be identified to be safely treated for only 4 weeks
We diagnosed 92 episodes of enterococcal IE, 14 of which were excluded from the analysis (2 cases of E. faecium IE, 3 treated with combinations other than ampicillin/gentamicin or ampicillin/ceftriaxone, 2 because of early death –less than 72h from diagnosis, and 7 with pacemaker-lead–associated IE)
Summary
Enterococci are the third most common causal agent of infective endocarditis (IE) worldwide [1] and are becoming increasingly prevalent [2]. The combination of beta-lactams and aminoglycosides, mainly ampicillin/gentamicin, has been the treatment of choice from the 1950s until the publication of the latest American Heart Association (AHA) and European Society of Cardiology (ESC) guidelines [3,4,5,6,7]. Until the publication of the last European and American guidelines, ampicillin/ceftriaxone was only recommended as a second-line rescue option for high-level aminoglycoside-resistant (HLAR) strains and always using an 8-week course [3, 4]. International guidelines recommend 4 weeks of treatment with ampicillin plus gentamicin (A +G) for uncomplicated native valve Enterococcus faecalis infective endocarditis (EFIE) and 6 weeks in the remaining cases. We aimed to investigate differences in the outcome of EFIE according to the duration (4 versus 6 weeks) of antibiotic treatment (A+G or A+C)
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