Infective Endocarditis
Conditions
Keywords
PWID, oral antibiotics, endocarditis
Brief summary
Infective endocarditis (IE) is a serious infection associated with significant morbidity and mortality. Recent studies demonstrated an increased risk of infective endocarditis in people who inject drugs (PWIDs). PWIDs have a high rate of non-compliance with hospital admissions and leaving against medical advice. A recent landmark randomized controlled trial demonstrated similar outcomes when comparing partial oral antimicrobial therapy to continued intravenous antimicrobial therapy in the general population. Performing a trial to explore the non-inferiority of oral compared to intravenous antimicrobial therapy in PWIDs is essential in advancing patient care in this high risk increasing population.
Detailed description
This is a randomized open-label study. Participants will be randomized 1:1 in blocks of 5 to either continued intravenous antimicrobial therapy or oral antimicrobial therapy after a minimum of 10 days of IV therapy. The antimicrobial choice will be based on antimicrobial susceptibility. All oral regimens for gram-positive organisms will include 2 different agents. Gram-negative pathogens will be treated with oral quinolones if susceptibility results are compatible. Decisions regarding ongoing inpatient or outpatient therapy will be made at the discretion of the attending physician. Outpatient follow up will be once weekly for 6 weeks and then at 3 months. At each follow-up visit, participants will undergo a general physical exam, and their adherence to therapy and general wellbeing will be assessed as well. Blood samples will be sent for a complete blood count, creatinine, C-reactive protein by the investigators to ensure continued improvement in response to therapy. Within 72 hours of stopping therapy, a transthoracic echocardiogram will be performed to determine response to therapy and to establish a new baseline to which subsequent echocardiograms if medically indicated would be compared to assess for relapse or development of a new IE. All lab tests are done at our affiliated hospitals. Investigators plan first on performing a feasibility study. In the feasibility study, investigators recruit a total of 50 patients and randomize 25 in each arm. Baseline characteristics, of clinical interest with a potential impact on prognosis, and patients' outcomes will be compared using the Chi-square test for categorical variables and the t-test and the Mann-Whitney test for continuous variables, when appropriate. To examine the association between oral antimicrobial therapy and 90-day mortality, investigators plan to perform a multivariable logistic regression analysis with oral therapy being the independent variable. The model will also include variables of clinical interest: diabetes, renal impairment, immune-compromising condition, age \> 50, and evidence of embolization.
Interventions
OTHERPartial oral antimicrobial therapy
Switch intravenous antimicrobial therapy to oral after an initial period of 10 days to oral antimicrobial therapy. Antimicrobial choices will be guided by antimicrobial susceptibilities.
Sponsors
London Health Sciences Centre Research Institute OR Lawson Research Institute of St. Joseph's
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
1. Adults ≥ 18 years with self-reported intravenous drug use within 3 months of admission 2. Transthoracic and/or transesophageal echocardiogram for IE diagnosis should be done within 48 hours of randomization 3. Patients meet the modified Duke criteria for possible or definite infective endocarditis diagnosis 4. Infection with an organism susceptible to at least two oral antimicrobial agents from different classes. In gram-negative bacterial endocarditis, susceptibility to fluoroquinolones only would be acceptable for inclusion 5. Polymicrobial infections may be enrolled if an acceptable oral regimen can be constructed containing at least 2 agents against each gram-positive organism and one against each gram-negative 6. Fungal Endocarditis may be enrolled if susceptibility to an oral azole is confirmed 7. IE Patients who demonstrate improvement with initial intravenous therapy will be recruited 8. Patients should receive a minimum of 10 days initial IV therapy and should have a minimum of 14 days remaining of their antimicrobial therapy
Exclusion criteria
1. Undrained valvular, perivalvular, or cardiac abscess on echocardiogram studies 2. Failure to show improvement to initial intravenous antimicrobial therapy 3. Oral antibiotic malabsorption due to gastrointestinal disorders 4. Acutely intoxicated patients who are not able to provide informed consent
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| The number of eligible participants who are approached for consent to participate will be recorded. | 18 months | Number of individuals who are eligible to be enrolled during the study time frame. |
| The percentage who consent for enrollment will be determined as well as the reasons for refusal. | 18 months | Number of patients that participate as well as those who refuse to enroll during the study time frame. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Percentage of enrolled patients for whom 90 day survival data is able to be confirmed. | 3 months after randomization | Number of patients with all cause death or survival documented at 90 days post enrollment. |
| Percentage of enrolled patients who continue in their assigned treatment arm (Oral or Parenteral) throughout the treatment interval. | 6 weeks post enrollment | The assessment of compliance with oral or parenteral antibiotics will be carried out during treatment. |
Countries
Canada
Contacts
Primary ContactMichael Silverman, MD,FRCP
Backup ContactSarah Shalhoub, MD
Outcome results
None listed