Guidelines provide clear recommendation that oral transitional therapy is at least as effective as intravenous-only therapy for the treatment of infective endocarditis.
The second WikiGuidelines consensus statement addresses the evidence-based management and diagnosis of bacterial infective endocarditis (IE) in adults and found a lack of high-quality evidence that supports most of the modern practices in treating the infection, according to guidelines published in the Journal of the American Medical Association.
Compiled by an authorship team of 51 members from 10 countries, including 31 MDs and 16 PharmDs, the only clear recommendation the researchers could make in their guidelines was that transitioning from initial intravenous (IV) therapy to oral therapy is at least as effective as IV-only therapy for the treatment of IE.
A clear recommendation from the group is enabled by high-quality, hypothesis-confirming data. They are based on at least 1 properly conducted, adequately powered, randomized, controlled trial and at least 1 other concordant, prospective, controlled clinical study, the authors wrote.
Top questions were submitted by interested members on the diagnosis and management of endocarditis. Questions were then thematically grouped into topic sections, and individual members volunteered to write sections of interest. The guidelines underwent 3 rounds of revisions by all members.
The guidelines are separated into 17 total questions in 4 parts: establishing the diagnosis of IE, multidisciplinary IE teams, prophylaxis, and treatment.
Investigators wrote that the reference standard for diagnosing IE is pathological confirmation, although they noted such information is typically unavailable when therapeutic decisions must be made. They discussed several schemas that have been developed to guide clinicians in diagnosing IE, but no high-quality studies exist that determine which schema is most accurate.
Other questions the investigators examined in part 1 include whether blood culture parameters should be used to inform suspicion for IE, the role of molecular rapid diagnostic testing in the diagnosis of IE, and the role of an echocardiogram in the diagnosis of IE.
In part 2, which addresses multidisciplinary IE teams, investigators found that observational studies indicate that the involvement of a multidisciplinary IE team may improve patient outcomes, including time to surgical intervention and mortality. Despite these observations, no randomized clinical trials exist to confirm the finding.
Additionally, there is insufficient evidence that supports routine transfer to a specialized referral center for treatment. Part 3 discusses prophylaxis and how it should be used in patients with IE.
WikiGuidelines authors preferred limiting antibiotic prophylaxis to patients who may be at higher risk for IE, as treatment risks toxic effects and antibiotic resistance. More evidence is required to support any recommendation, and if used, the risks may be partly mitigated by a single dose rather than longer courses, the investigators wrote.
Study authors found no high-quality data to inform the relative efficacy of various prophylaxis regimens to prevent IE, though they said it was rational to select prophylactic antibodies that are active against viridans group Streptococci (VGS), such as penicillin and amoxicillin.
Finally, part 4 discusses treatment options for IE. Little high-quality evidence is available to guide selection of an empirical therapy for known or suspected IE, the investigators determined. They provided a list of reasonable options based largely on historical practice with little clinical data to validate efficacy and reaffirmed that regimens should be picked based on specific clinical situations and patient epidemiology.
As previously discussed, the investigators provided a clear recommendation that oral therapy to treat IE was at least as effective as IV-only therapy. This suggestion was supported by 3 randomized clinical trials in addition to pharmacologic data.
The study authors emphasized that the primary limitation of their guidelines was the lack of high-quality studies, and that very few—or no—head-to-head trials of different therapeutic options exist.
McDonald EG, Aggrey G, Tarık Aslan A, et al. Guidelines for diagnosis and management of infective endocarditis in adults: a WikiGuidelines group consensus statement. JAMA Netw Open. 2023;6(7):e2326366. doi:10.1001/jamanetworkopen.2023.26366