Risk factors for failure of outpatient parenteral antibiotic therapy (OPAT) in infective endocarditis

Abstract

ObjectivesTo identify risk factors for failure of outpatient antibiotic therapy (OPAT) in infective endocarditis (IE).Patients and methodsWe identified IE cases managed at a single centre over 12 years from a prospectively maintained database. ‘OPAT failure’ was defined as unplanned readmission or antibiotic switch due to adverse drug reaction or antibiotic resistance. We analysed patient and disease-related risk factors for OPAT failure by univariate and multivariate logistic regression. We also retrospectively collected follow-up data on adverse disease outcome (defined as IE-related death or relapse) and performed Kaplan–Meier survival analysis up to 36 months following OPAT.ResultsWe identified 80 episodes of OPAT in IE. Failure occurred in 25/80 episodes (31.3%). On multivariate analysis, cardiac or renal failure [pooled OR 7.39 (95% CI 1.84–29.66), P = 0.005] and teicoplanin therapy [OR 8.69 (95% CI 2.01–37.47), P = 0.004] were independently associated with increased OPAT failure. OPAT failure with teicoplanin occurred despite therapeutic plasma levels. OPAT failure predicted adverse disease outcome up to 36 months (P = 0.016 log-rank test).ConclusionsThese data caution against selecting patients with endocarditis for OPAT in the presence of cardiac or renal failure and suggest teicoplanin therapy may be associated with suboptimal OPAT outcomes. Alternative regimens to teicoplanin in the OPAT setting should be further investigated.

Risk Factors for Failure of OPAT (Outpatient Parenteral Antimicrobial Therapy) in Veterans with Staphylococcus aureus Bacteremia

“…Duncan and colleagues identified either heart failure or CKD as risk factors for OPAT failure in patients with SAB/IE (pooled OR 7.48, 95% CI 2.52-22.21) [5]. Although only significant on univariate analysis, results from this study and from the Duncan study suggest that CKD warrants further investigation as a potential risk factor for OPAT failure in SAB.…”

“…Previous studies have addressed risk factors for failure of OPAT in other infections including endocarditis and bone and joint infections [5,7]; however, risk factors specifically in SAB are largely unknown. This is an important treatment question as SAB is associated with a high cost burden on health care systems and is associated with considerable morbidity and mortality [2,4].…”

“…This is an important treatment question as SAB is associated with a high cost burden on health care systems and is associated with considerable morbidity and mortality [2,4]. We used broad criteria for treatment failure, which are consistent with definitions outlined in previous studies, current BSAC (British Society for Antimicrobial Chemotherapy) best practice recommendations, and IDSA (Infectious Diseases Society of America) guidelines for OPAT [3][4][5]8]. While these criteria likely overestimated the number of treatment failures in our study, the failure rate of 35.6% was similar to previous OPAT studies evaluating patients with SAB or SAB/IE (range 13-31%) [4,5].…”

“…OPAT (outpatient parenteral antimicrobial therapy) is frequently used to complete this treatment and has several advantages including cost savings, decreased risk of hospital-acquired infection, and increased patient autonomy [3]. While OPAT is generally considered safe and effective, recent studies have reported failure rates in patients with SAB from 13-31% suggesting opportunities for process improvement [4,5]. Certain risk factors in these studies, such as heart failure and chronic kidney disease, have been associated with treatment failure.…”

Outpatient parenteral ­antimicrobial therapy (OPAT) and the general ­physician

“…Contraindications to outpatient therapy include the presence of a prosthetic valve, persistently positive blood cultures, congestive cardiac failure, vegetations greater than 10 mm in length, recurrent embolic events, conduction abnormalities and Staphylococcus aureus aetiology. 15 It is, however, clear from more recent cohort reports that OPAT services are successfully treating S aureus and prosthetic valve endocarditis, [16][17][18] and recent European Society of Cardiology recommendations do not explicitly preclude this practice (Table 3). 19 It remains standard practice to initially manage endocarditis with a minimum inpatient stay of 2 weeks prior to OPAT, with the possible exception of clinically stable patients with 'oral' streptococcal infection.…”