Completion of antibiotic therapy ‘overwhelmingly more important’ than mode of therapy
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A recent study suggests that incomplete antibiotic therapy should be avoided and that transition to oral antibiotics should be offered to people who inject drugs being treated for bacteremia who have declined the standard IV antibiotics.
“Like many infectious disease physicians around the country, our hospital has seen an increasing number of patient's admitted for [Staphylococcus aureus] bacteremia in the setting of injection drug use. These can be really challenging cases,” Laura R. Marks, MD, PhD, assistant professor of medicine in the division of infectious Diseases at the Washington University St. Louis School of Medicine, told Healio. “While my goal is to offer the very best possible care to every patient, I often struggle with the fact that our current guidelines for 6 weeks of IV antibiotics may not be something that works well for all of our patients.”
Marks explained that there are many reasons that patients may need to leave the hospital before completing their 6 weeks of antibiotics, including court dates, avoiding loss of their jobs, caring for sick family members, child care and many other reasons.
“When that would happen, I would always find myself unsure of what the best path forward was and wishing there [were] data available about outcomes with different antibiotic treatment strategies,” she said. “So, our team pulled together data from our hospital which formed the basis of this study.”
According to the study, Marks and colleagues evaluated all adult patients with a history of injection drug use hospitalized between January 2016 and December 2021 with complicated S. aureus bloodstream infections, including infective endocarditis, epidural abscess, vertebral osteomyelitis and septic arthritis. The researchers compared patients by antibiotic treatment using the primary composite endpoint of death or readmission due to microbiologic failure within 90 days of discharge.
According to the study, substance use characteristics and MRSA prevalence at baseline did not significantly differ between the treatment groups, although the groups did vary in rates of infective endocarditis (P = .007), and Elixhauser comorbidity score (P = .004), both of which were highest in the standard-of-care group.
Data showed that the duration of bacteremia differed across all groups, with the shortest average duration among patients in the incomplete IV antibiotic treatment group (P = .03), although, there was no significant difference between patients in the standard-of-care and partial-oral-antibiotic treatment groups for prolonged bacteremia (standard of care vs. partial oral: 36.1% vs. 36.2%; P > .9) or duration of bacteremia (median 3 days; interquartile range = 1-6 for standard of care and partial oral; P = .9).
In terms of primary endpoint among patients who had cleared bacteremia before discharge, patients in strategy B were the most likely across all groups to experience microbiologic failure or death within 90 days after discharge (P < .001).
The researchers added that discharge before clearance of bacteremia universally resulted in microbiologic failure for patients discharged without oral antibiotics, and results “remained poor” even for patients discharged with oral antibiotics, with half of these patients being readmitted for microbiologic failure.
The researchers summarized these data and determined that, overall, patients who received oral antibiotics after an incomplete IV antibiotic course were significantly less likely to experience microbiologic failure or death than patients discharged without oral antibiotics (P < .001).
Marks added that these findings demonstrate that “completion of antibiotic therapy is overwhelmingly more important than the mode of antibiotic therapy.”
“If you can't give someone 6 weeks of IV antibiotics, either because they aren't a candidate for [outpatient parenteral antimicrobial therapy (OPAT)] or they are choosing not to stay in the hospital, then it is critically important to work with the patient to offer an alternative mode of antibiotics like oral antibiotics in order to complete out antibiotic treatment for complicated S. aureus bacteremia,” she said.
Marks added that safe discharge planning is really important and that transition to oral antibiotics should never be offered in isolation. Instead, Marks said, it should always come with an offer of infectious disease clinic follow-up and close outpatient management, similar to what is offered to patients on OPAT.
“These are complicated infections, and patients deserve the best possible care, even if they choose to pursue that care in an outpatient setting rather than completing guideline- directed inpatient IV antibiotics,” she concluded.
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