Clinical predictors of outcome in patients with infective endocarditis receiving outpatient parenteral antibiotic therapy (OPAT)

Published:October 02, 2021DOI:https://doi.org/10.1016/j.jinf.2021.09.021

      Highlights

      • Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat infective endocarditis (IE).
      • Pre-existing renal failure and multimorbidity were associated with OPAT failure.
      • Previous IE and cardiac complication were associated with poor long-term outcomes; cardiac surgery was a protective factor.
      • OPAT is safe and effective for treating IE, including cases deemed to be at increased risk of complications.
      • We examined risk factors for treatment failure and poor outcomes in patients with IE managed with OPAT.

      Summary

      Objectives

      Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat infective endocarditis (IE) with documented success. This study aims to identify risk factors for treatment failure and poor outcomes in patients with IE treated through OPAT.

      Methods

      We conducted a retrospective analysis of all episodes of IE treated over 13 years (September 2006 - September 2019) at a large teaching hospital in Sheffield, UK. We defined OPAT failure as unplanned readmission or death within 30 days of discharge from the OPAT service. Major adverse cardiac events (MACE) were defined as a composite of IE-related death, cardiac surgery, and recurrence of IE within the first year of completion of OPAT.

      Results

      Overall, 168 episodes of IE were reviewed. OPAT failure and MACE occurred in 44 episodes (26.2%) and 29 episodes (17.3%) respectively. On multivariable analysis, pre-existing renal failure (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.08–8.30; P = 0.034) and Charlson comorbidity score (aOR, 1.29 per unit increase; 95% CI, 1.06–1.57; P = 0.011) were associated with increased risk of failure. Previous endocarditis (aOR, 3.60; 95% CI, 1.49–8.70; P = 0.004) and cardiac complications (aOR, 3.85; 95% CI, 1.49–9.93; P = 0.005) were risk factors for MACE, whereas cardiac surgery during the initial hospitalisation for IE (aOR, 0.34; 95% CI, 0.12–0.22; P < 0.001) was a protective factor.

      Conclusions

      Our findings suggest that OPAT is safe and effective for completing antibiotic treatment for IE, including cases deemed to be at increased risk of complications. However, careful patient selection and monitoring of patients with pre-existing comorbidities and cardiac complications are recommended to optimise clinical outcomes.

      Keywords

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      References

        • Pericà S.J.M
        • Llopis J.
        • González-Ramallo V.
        • Goenaga M.A.
        • Munoz P.
        • Garcia-Leoni M.E.
        • et al.
        Outpatient parenteral antibiotic treatment for infective endocarditis: a prospective cohort study from the GAMES cohort.
        Clin Infect Dis. 2019; 69: 1690-1700https://doi.org/10.1093/cid/ciz030
        • Rajaratnam D.
        • Rajaratnam R.
        Outpatient antimicrobial therapy for infective endocarditis is safe.
        Heart Lung Circ. 2021; 30: 207-215https://doi.org/10.1016/j.hlc.2020.08.016
        • Cervera C.
        • del Río A.
        • García L.
        • Sala M.
        • Almela M.
        • Moreno A.
        • et al.
        Efficacy and safety of outpatient parenteral antibiotic therapy for infective endocarditis: a ten-year prospective study.
        Enferm Infecc Microbiol Clin. 2011; 29: 587-592https://doi.org/10.1016/j.eimc.2011.05.007
        • Htin A.K.
        • Friedman N.D.
        • Hughes A.
        • O'Brien D.P.
        • Huffam S.
        • Redden A.M.
        • et al.
        Outpatient parenteral antimicrobial therapy is safe and effective for the treatment of infective endocarditis: a retrospective cohort study.
        Intern Med J. 2013; 43: 700-705https://doi.org/10.1111/imj.12081
        • Pajarón M.
        • Fernández-Miera M.F.
        • Allende I.
        • Arnaiz A.M.
        • Gutierrez-Cuadra M.
        • Cobo-Belaustegui M.
        • et al.
        Self-administered outpatient parenteral antimicrobial therapy (S-OPAT) for infective endocarditis: a safe and effective model.
        Eur J Intern Med. 2015; 26: 131-136https://doi.org/10.1016/j.ejim.2015.01.001
        • Gil-Navarro M.V.
        • Lopez-Cortes L.E.
        • Luque-Marquez R.
        • Galvez-Acebal J.
        • de Alarcon-Gonzalez A.
        Outpatient parenteral antimicrobial therapy in enterococcus faecalis infective endocarditis.
        J Clin Pharm Ther. 2018; 43: 220-223https://doi.org/10.1111/jcpt.12635
        • Kortajarena X.
        • Goenaga M.A.
        • Ibarguren M.
        • Azkune H.
        • Bustinduy M.J.
        • Fuertes A.
        • et al.
        Outpatient parenteral antimicrobial therapy for infective endocarditis in patients over 80 years.
        Rev Esp Quimioter. 2017; 30: 276-279
        • Chapman A.L.N.
        • Patel S.
        • Horner C.
        • Green H.
        • Guleri A.
        • Hedderwick S.
        • et al.
        Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK.
        JAC Antimicrob Resist. 2019; 1: dlz026https://doi.org/10.1093/jacamr/dlz026
        • Li J.S.
        • Sexton D.J.
        • Mick N.
        • Nettles R.
        • Fowler V.G.
        • Ryan T.
        • et al.
        Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis.
        Clin Infect Dis. 2000; 30: 633-638https://doi.org/10.1086/313753
        • Durojaiye O.C.
        • Bell H.
        • Andrews D.
        • Ntziora F.
        • Cartwright K.
        Clinical efficacy, cost analysis and patient acceptability of outpatient parenteral antibiotic therapy (OPAT): a decade of Sheffield (UK) OPAT service.
        Int J Antimicrob Agents. 2018; 51: 26-32https://doi.org/10.1016/j.ijantimicag.2017.03.016
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383https://doi.org/10.1016/0021-9681(87)90171-8
        • Ofer-Shiber S.
        • Yair Molad
        Association of the Charlson comorbidity index with renal outcome and all-cause mortality in antineutrophil cytoplasmatic antibody-associated vasculitis.
        Medicine. 2014; 93 (Baltimore): e152https://doi.org/10.1097/MD.0000000000000152
        • Durojaiye O.C.
        • Kritsotakis E.I.
        • Johnston P.
        • Kenny T.
        • Ntziora F.
        • Cartwright K.
        Developing a risk prediction model for 30-day unplanned hospitalization in patients receiving outpatient parenteral antimicrobial therapy.
        Clin Microbiol Infect. 2019; 25 (905.e1-905.e7)https://doi.org/10.1016/j.cmi.2018.11.009
        • Duncan C.J.
        • Barr D.A.
        • Ho A.
        • Sharp E.
        • Semple L.
        • Seaton R.A.
        Risk factors for failure of outpatient parenteral antibiotic therapy (OPAT) in infective endocarditis.
        J Antimicrob Chemother. 2013; 68: 1650-1654https://doi.org/10.1093/jac/dkt046
      1. González-Ramallo V.J., Mirón-Rubio M., Garcia-Leoni M.E., Vena A., Mujal A., Estrada J.O., et al. Outpatient parenteral antimicrobial therapy for native valve infective endocarditis in hospital at home units in Spain identification of risk factors for failure and 30 days readmission. In: proceedings of the 27th ECCMID conference; 2017 April 22-25; Vienna, Austria. Available from: https://www.escmid.org/escmid_publications/escmid_elibrary/material/?mid=43111

        • Murai R.
        • Funakoshi S.
        • Kaji S.
        • Kitai T.
        • Kim K.
        • Koyama T.
        • et al.
        Outcomes of early surgery for infective endocarditis with pre cerebral complications.
        J Thorac Cardiovasc Surg. 2017; 153 (e8): 831-840https://doi.org/10.1016/j.jtcvs.2016.10.074
        • Amodeo M.R.
        • Clulow T.
        • Lainchbury J.
        • Murdoch D.R.
        • Gallagher K.
        • Dyer A.
        • et al.
        Outpatient intravenous treatment for infective endocarditis: safety, effectiveness and one-year outcomes.
        J Infect. 2009; 59: 387-393https://doi.org/10.1016/j.jinf.2009.09.009
        • Goenaga M.A.
        • Kortajarena X.
        • Ibarguren O.
        • García R.
        • Bustinduy M.J.
        • Azkune H.
        • Group GAMEGI
        Outpatient parenteral antimicrobial therapy (OPAT) for infectious endocarditis in Spain.
        Int J Antimicrob Agents. 2014; 44: 89-90https://doi.org/10.1016/j.ijantimicag.2014.04.009
        • Larioza J.
        • Heung L.
        • Girard A.
        • Brown R.B.
        Management of infective endocarditis in outpatients: clinical experience with outpatient parenteral antibiotic therapy.
        South Med J. 2009; 102: 575-579https://doi.org/10.1097/SMJ.0b013e3181a4eef2
        • Donzé J.
        • Lipsitz S.
        • Bates D.W.
        • Schnipper J.L.
        Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study.
        BMJ. 2013; 347: f7171
        • Mansur A.J.
        • Dal Bó C.M.
        • Fukushima J.T.
        • Issa V.S.
        • Grinberg M.
        • Pomerantzeff P.M
        Relapses, recurrences, valve replacements, and mortality during the long-term follow-up after infective endocarditis.
        Am Heart J. 2001; 141: 78-86https://doi.org/10.1067/mhj.2001.111952
        • Heiro M.
        • Helenius H.
        • Hurme S.
        • Savunen T.
        • Metsarinne K.
        • Engblom E.
        • et al.
        Long-term outcome of infective endocarditis: a study on patients surviving over one year after the initial episode treated in a Finnish teaching hospital during 25 years.
        BMC Infect Dis. 2008; 8: 49https://doi.org/10.1186/1471-2334-8-49
        • Lauridsen T.K.
        • Park L.
        • Tong S.Y.
        • Selton-Suty C.
        • Peterson G.
        • Cecchi E.
        • et al.
        Echocardiographic findings predict in-hospital and 1-year mortality in left-sided native valve Staphylococcus aureus endocarditis: analysis from the international collaboration on endocarditis-prospective echo cohort study.
        Circ Cardiovasc Imaging. 2015; 8e003397https://doi.org/10.1161/CIRCIMAGING.114.003397
        • Ali A.S.
        Predictors of mortality in valvular infective endocarditis: a single-center study.
        J Med Sci Res. 2020; 3: 150-156
        • Park L.P.
        • Chu V.H.
        • Peterson G.
        • Skoutelis A.
        • Lejko-Zupa T.
        • Bouza E.
        • et al.
        Validated risk score for predicting 6-month mortality in infective endocarditis.
        J Am Heart Assoc. 2016; 5e003016https://doi.org/10.1161/JAHA.115.003016
        • Liang F.
        • Song B.
        • Liu R.
        • Yang L.
        • Tang H.
        • Li Y.
        Optimal timing for early surgery in infective endocarditis: a meta-analysis.
        Interact Cardiovasc Thorac Surg. 2016; 22: 336-345https://doi.org/10.1093/icvts/ivv368
        • Suzuki J.
        • Johnson J.
        • Montgomery M.
        • Hayden M.
        • Price C.
        Outpatient parenteral antimicrobial therapy among people who inject drugs: a review of the literature.
        Open Forum Infect Dis. 2018; 5: ofy194https://doi.org/10.1093/ofid/ofy194
        • Ho J.
        • Archuleta S.
        • Sulaiman Z.
        • Fisher D.
        Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service.
        J Antimicrob Chemother. 2010; 65: 2641-2644https://doi.org/10.1093/jac/dkq355
        • Hakim A.
        • Braun H.
        • Thornton D.
        • Strymish J.
        Successful treatment of methicillin-sensitive Staphylococcus aureus tricuspid-valve endocarditis with dalbavancin as an outpatient in a person who injects drugs: a case report.
        Int J Infect Dis. 2020; 91: 202-205https://doi.org/10.1016/j.ijid.2019.12.008
        • Lampejo T.
        Dalbavancin and telavancin in the treatment of infective endocarditis: a literature review.
        Int J Antimicrob Agents. 2020; 56106072https://doi.org/10.1016/j.ijantimicag.2020.106072
        • Li H.K.
        • Rombach I.
        • Zambellas R.
        • Walker A.S.
        • McNally M.A.
        • Atkins B.L.
        • et al.
        OVIVA trial collaborators oral versus intravenous antibiotics for bone and joint infection.
        N Engl J Med. 2019; 380: 425-436https://doi.org/10.1056/NEJMoa1710926
        • Iversen K.
        • Ihlemann N.
        • Gill S.U.
        • Madsen T.
        • Elming H.
        • Jensen K.T.
        • et al.
        Partial oral versus intravenous antibiotic treatment of endocarditis.
        N Engl J Med. 2019; 380: 415-424https://doi.org/10.1056/NEJMoa1808312
        • Seaton R.A.
        • Ritchie N.D.
        • Robb F.
        • Stewart L.
        • White B.
        • Vallance C.
        From 'OPAT' to 'COpAT': implications of the OVIVA study for ambulatory management of bone and joint infection.
        J Antimicrob Chemother. 2019; 74: 2119-2121https://doi.org/10.1093/jac/dkz122
        • McMahon J.H.
        • JM; O'keeffe
        Victorian hith outcomes study group, grayson ML. Is hospital-in-the-home (HITH) treatment of bacterial endocarditis safe and effective?.
        Scand J Infect Dis. 2008; 40: 40-43https://doi.org/10.1080/00365540701522942
        • Andrews M.M.
        • von Reyn C.F.
        Patient selection criteria and management guidelines for outpatient parenteral antibiotic therapy for native valve infective endocarditis.
        Clin Infect Dis. 2001; 33: 203-209https://doi.org/10.1086/321814