Enterococcus faecalis Infective Endocarditis

Abstract

Background-Because of the nephrotoxic effects of aminoglycosides, the Danish guidelines on infective endocarditis were changed in January 2007, reducing gentamicin treatment in enterococcal infective endocarditis from 4 to 6 weeks to only 2 weeks. In this pilot study, we compare outcomes in patients with Enterococcus faecalis infective endocarditis treated in the years before and after endorsement of these new recommendations. Methods and Results-A total of 84 consecutive patients admitted with definite left-sided E faecalis endocarditis in the period of 2002 to 2011 were enrolled. Forty-one patients were treated before and 43 patients were treated after January 1, 2007. There were no significant differences in baseline characteristics. At hospitalization, the 2 groups had similar estimated glomerular filtration rates of 66 and 75 mL/min (P=0.22). Patients treated before January 2007 received gentamicin for a significantly longer period (28 versus 14 days; P<0.001). The primary outcome, 1-year event-free survival, did not differ: 66% versus 69%, respectively (P=0.75). At discharge, the patients treated before 2007 had a lower estimated glomerular filtration rate (45 versus 66 mL/min; P=0.008) and a significantly greater decrease in estimated glomerular filtration rate (median, 11 versus 1 mL/min; P=0.009) compared with those treated after 2007. Conclusions-Our present pilot study suggests that the recommended 2-week treatment with gentamicin seems adequate and preferable in treating non-high-level aminoglycoside-resistant E faecalis infective endocarditis. The longer duration of gentamicin treatment is associated with worse renal function. Although the certainty of the clinical outcomes is limited by the sample size, outcomes appear to be no worse with the shorter treatment duration. Randomized, controlled studies are warranted to substantiate these results. Dahl et al Gentamicin in Enterococcal Endocarditis 1811 Methods DatabaseData from consecutive patients diagnosed with IE in 2 tertiary heart centers in Copenhagen, Denmark, were prospectively collected beginning on October 1, 2002. These 2 highly specialized university hospitals serve as the only referral centers for IE patients in the eastern part of Denmark and cover a catchment area of 2.4 million people. The diagnosis of IE was based on clinical, microbiological, and echocardiographic findings. Patients were enrolled in the database if they met the revised Duke criteria 25 of definite or possible IE. Patients with possible IE were included only if they received treatment as patients with definite IE. All data were collected with a standardized case report form with >250 variables, including demographics; medical history; physical examination findings; results of blood tests, including blood cultures; ECG; antibiotic use; surgical treatment; and findings of both transthoracic and transesophageal echocardiography. Duration of symptoms was defined as the time from the appearance of the first symptoms of IE (reported by the patient or his or her close famil...

2015 ESC Guidelines for the management of infective endocarditis

“…Wskazania do stosowania aminoglikozydów i schemat leczenia uległy zmianie. Leków tych nie zaleca się w gronkowcowym NVE, ponieważ nie potwierdzono korzyści klinicznych takiego postępowania, a leki z tej grupy cechują się nefrotoksycznością [128]; w przypadku istnienia innych wskazań aminoglikozydy należy stosować w pojedynczej dawce dobowej w celu zmniejszenia nefrotoksyczności [129]. 2.…”

“…Ponadto jest to schemat terapii z wyboru w leczeniu IZW wywołanego przez E. faecalis z HLAR. Po drugie, zaleca się, aby całkowitą dawkę gentamicyny podawać w pojedynczej dawce, zamiast 2 lub 3 dawek podzielonych, a czas leczenia w przypadku IZW wywołanego przez szczepy E. faecalis bez HLAR, można bezpiecznie skrócić z 4-6 tygodni do 2 tygodni, zmniejszając odsetek powikłań nefrotoksycznych do bardzo niskiego poziomu [129,186,187].…”

A New Era for Treating Enterococcus faecalis Endocarditis

“…In this issue of Circulation, Dahl et al 8 report on the efficacy and safety of ampicillin plus short-course gentamicin for treating non-HLAR EFIE in Denmark. 8 The rationale of the study relies on the good results reported in 2002 in Sweden by Olaison and Schadewitz,9 who performed a 5-year prospective study including 93 cases of EFIE.…”

“…8 The rationale of the study relies on the good results reported in 2002 in Sweden by Olaison and Schadewitz,9 who performed a 5-year prospective study including 93 cases of EFIE. Clinical cure was achieved in 75 episodes (81%) that had been treated with a median 2-week course of aminoglycosides.…”

“…However, using a human-like pharmacokinetic model, Gavaldà et al 13 found that the therapeutic efficacy of ampicillin plus gentamicin was not significantly affected by the gentamicin dosing interval, with once-daily dosing similar to thrice-daily dosing. 13 The study by Dahl et al 8 is the first to provide data from a large number of patients treated with a daily gentamicin schedule. Seventy-two of the 84 patients (86%) received a daily regimen, only 10 received a thricedaily regimen, and 2 received a twice-daily regimen, with no association between poor outcome and dosing interval.…”