Rusty Phillips, MD

Background: Patients with left-sided infective endocarditis often are treated with prolonged courses of intravenous (IV) antibiotics. The safety of switching from IV to oral antibiotics is unknown.

Study design: Randomized, multicenter, noninferiority study.

Setting: Cardiac centers in Denmark during July 2011–August 2017.

Synopsis: The study enrolled 400 patients with left-sided infective endocarditis and positive blood cultures from Streptococcus, Enterococcus, Staphylococcus aureus, or coagulase-negative staph (non–methicillin-resistant Staphylococcus aureus), without evidence of valvular abscess. Following at least 7 days (for those who required surgical intervention) or 10 days (for those who did not require surgical intervention) of IV antibiotics, patients with ongoing fever, leukocytosis, elevated C-reactive protein, or concurrent infections were excluded from the study. Patients were randomized to receive continued IV antibiotic treatment or switch to oral antibiotic treatment. The IV treatment group received a median of 19 additional days of therapy, compared with 17 days in the oral group. The primary composite outcome of death, unplanned cardiac surgery, embolic event, and relapse of bacteremia occurred in 12.1% in the IV therapy group and 9% in the oral therapy group (difference of 3.1%; 95% confidence interval, –3.4 to 9.6; P = .40), meeting the studies prespecified noninferiority criteria. Poor representation of women, obese patients, and patients who use IV drugs may limit the study’s generalizability. An accompanying editorial advocated for additional research before widespread change to current treatment recommendations are made.

Bottom line: For patients with left-sided infective endocarditis who have been stabilized on IV antibiotic treatment, transitioning to an oral antibiotic regimen may be a noninferior approach.

Citation: Iverson K et al. Partial oral versus intravenous antibiotic treatment of endocarditis. N Eng J Med. 2019 Jan 31;380(5):415-24.

Dr. Phillips is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.

Background: Patients with left-sided infective endocarditis often are treated with prolonged courses of intravenous (IV) antibiotics. The safety of switching from IV to oral antibiotics is unknown.

Study design: Randomized, multicenter, noninferiority study.

Setting: Cardiac centers in Denmark during July 2011–August 2017.

Synopsis: The study enrolled 400 patients with left-sided infective endocarditis and positive blood cultures from Streptococcus, Enterococcus, Staphylococcus aureus, or coagulase-negative staph (non–methicillin-resistant Staphylococcus aureus), without evidence of valvular abscess. Following at least 7 days (for those who required surgical intervention) or 10 days (for those who did not require surgical intervention) of IV antibiotics, patients with ongoing fever, leukocytosis, elevated C-reactive protein, or concurrent infections were excluded from the study. Patients were randomized to receive continued IV antibiotic treatment or switch to oral antibiotic treatment. The IV treatment group received a median of 19 additional days of therapy, compared with 17 days in the oral group. The primary composite outcome of death, unplanned cardiac surgery, embolic event, and relapse of bacteremia occurred in 12.1% in the IV therapy group and 9% in the oral therapy group (difference of 3.1%; 95% confidence interval, –3.4 to 9.6; P = .40), meeting the studies prespecified noninferiority criteria. Poor representation of women, obese patients, and patients who use IV drugs may limit the study’s generalizability. An accompanying editorial advocated for additional research before widespread change to current treatment recommendations are made.

Bottom line: For patients with left-sided infective endocarditis who have been stabilized on IV antibiotic treatment, transitioning to an oral antibiotic regimen may be a noninferior approach.

Citation: Iverson K et al. Partial oral versus intravenous antibiotic treatment of endocarditis. N Eng J Med. 2019 Jan 31;380(5):415-24.

Dr. Phillips is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.

Background: Patients with left-sided infective endocarditis often are treated with prolonged courses of intravenous (IV) antibiotics. The safety of switching from IV to oral antibiotics is unknown.

Study design: Randomized, multicenter, noninferiority study.

Setting: Cardiac centers in Denmark during July 2011–August 2017.

Synopsis: The study enrolled 400 patients with left-sided infective endocarditis and positive blood cultures from Streptococcus, Enterococcus, Staphylococcus aureus, or coagulase-negative staph (non–methicillin-resistant Staphylococcus aureus), without evidence of valvular abscess. Following at least 7 days (for those who required surgical intervention) or 10 days (for those who did not require surgical intervention) of IV antibiotics, patients with ongoing fever, leukocytosis, elevated C-reactive protein, or concurrent infections were excluded from the study. Patients were randomized to receive continued IV antibiotic treatment or switch to oral antibiotic treatment. The IV treatment group received a median of 19 additional days of therapy, compared with 17 days in the oral group. The primary composite outcome of death, unplanned cardiac surgery, embolic event, and relapse of bacteremia occurred in 12.1% in the IV therapy group and 9% in the oral therapy group (difference of 3.1%; 95% confidence interval, –3.4 to 9.6; P = .40), meeting the studies prespecified noninferiority criteria. Poor representation of women, obese patients, and patients who use IV drugs may limit the study’s generalizability. An accompanying editorial advocated for additional research before widespread change to current treatment recommendations are made.

Bottom line: For patients with left-sided infective endocarditis who have been stabilized on IV antibiotic treatment, transitioning to an oral antibiotic regimen may be a noninferior approach.

Citation: Iverson K et al. Partial oral versus intravenous antibiotic treatment of endocarditis. N Eng J Med. 2019 Jan 31;380(5):415-24.

Dr. Phillips is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.

 

Background: Identifying paroxysmal atrial fibrillation (AFib) as the etiology of a transient ischemic attack (TIA) or stroke has implications for treatment as well as secondary prevention. Currently, there is not a universal, practical way to help determine which patients would benefit from prolonged cardiac monitoring to establish the diagnosis of AFib.

Study design: Logistic regression analysis of three prospective multicenter trials examining TIA and stroke patients who received Holter-ECG monitoring.

Setting: Patients who presented with TIA or stroke in Central Europe.

Synopsis: Using data from 1,556 patients, the authors identified age and NIH stroke scale score as being predictive of which patients were at highest risk for AFib detection within 72 hours of Holter-ECG monitor initiation. The authors developed a formula, titled AS5F; this formula scores each year of age as 0.76 points and then an NIH stroke scale score of 5 or less as 9 points or greater than 5 as 21 points. The authors found that the high-risk group (defined as those with AS5F scores of 67.5 or higher) had a predicted risk of 5.2%-40.8%, with a number needed to screen of 3. Given that a majority of the European patients included in the study were white, generalizability to other populations is unclear.

Bottom line: AS5F score may be able to predict those TIA and stroke patients who are most likely to be diagnosed with AFib with 72-hour cardiac monitoring.

Citation: Uphaus T et al. Development and validation of a score to detect paroxysmal atrial fibrillation after stroke. Neurology. 2019 Jan 8. doi. 10.1212/WNL.0000000000006727.

Dr. Phillips is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.

 

Background: Identifying paroxysmal atrial fibrillation (AFib) as the etiology of a transient ischemic attack (TIA) or stroke has implications for treatment as well as secondary prevention. Currently, there is not a universal, practical way to help determine which patients would benefit from prolonged cardiac monitoring to establish the diagnosis of AFib.

Study design: Logistic regression analysis of three prospective multicenter trials examining TIA and stroke patients who received Holter-ECG monitoring.

Setting: Patients who presented with TIA or stroke in Central Europe.

Synopsis: Using data from 1,556 patients, the authors identified age and NIH stroke scale score as being predictive of which patients were at highest risk for AFib detection within 72 hours of Holter-ECG monitor initiation. The authors developed a formula, titled AS5F; this formula scores each year of age as 0.76 points and then an NIH stroke scale score of 5 or less as 9 points or greater than 5 as 21 points. The authors found that the high-risk group (defined as those with AS5F scores of 67.5 or higher) had a predicted risk of 5.2%-40.8%, with a number needed to screen of 3. Given that a majority of the European patients included in the study were white, generalizability to other populations is unclear.

Bottom line: AS5F score may be able to predict those TIA and stroke patients who are most likely to be diagnosed with AFib with 72-hour cardiac monitoring.

Citation: Uphaus T et al. Development and validation of a score to detect paroxysmal atrial fibrillation after stroke. Neurology. 2019 Jan 8. doi. 10.1212/WNL.0000000000006727.

Dr. Phillips is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.

 

Background: Identifying paroxysmal atrial fibrillation (AFib) as the etiology of a transient ischemic attack (TIA) or stroke has implications for treatment as well as secondary prevention. Currently, there is not a universal, practical way to help determine which patients would benefit from prolonged cardiac monitoring to establish the diagnosis of AFib.

Study design: Logistic regression analysis of three prospective multicenter trials examining TIA and stroke patients who received Holter-ECG monitoring.

Setting: Patients who presented with TIA or stroke in Central Europe.

Synopsis: Using data from 1,556 patients, the authors identified age and NIH stroke scale score as being predictive of which patients were at highest risk for AFib detection within 72 hours of Holter-ECG monitor initiation. The authors developed a formula, titled AS5F; this formula scores each year of age as 0.76 points and then an NIH stroke scale score of 5 or less as 9 points or greater than 5 as 21 points. The authors found that the high-risk group (defined as those with AS5F scores of 67.5 or higher) had a predicted risk of 5.2%-40.8%, with a number needed to screen of 3. Given that a majority of the European patients included in the study were white, generalizability to other populations is unclear.

Bottom line: AS5F score may be able to predict those TIA and stroke patients who are most likely to be diagnosed with AFib with 72-hour cardiac monitoring.

Citation: Uphaus T et al. Development and validation of a score to detect paroxysmal atrial fibrillation after stroke. Neurology. 2019 Jan 8. doi. 10.1212/WNL.0000000000006727.

Dr. Phillips is a hospitalist at Beth Israel Deaconess Medical Center and instructor in medicine at Harvard Medical School.