Importance The requirement of prolonged intravenous antibiotic courses to treat infective endocarditis (IE) is a time-honored dogma of medicine. However, numerous antibiotics are now available that achieve adequate levels in the blood after oral administration to kill bacteria. Moreover, prolonged intravenous antibiotic regimens are associated with high rates of adverse events. Accordingly, recent studies of oral step-down antibiotic treatment have stimulated a reevaluation of the need for intravenous-only therapy for IE. Observations PubMed was reviewed in October 2019, with an update in February 2020, to determine whether evidence supports the notion that oral step-down antibiotic therapy for IE is associated with inferior outcomes compared with intravenous-only therapy. The search identified 21 observational studies evaluating the effectiveness of oral antibiotics for treating IE, typically after an initial course of intravenous therapy; none found such oral step-down therapy to be inferior to intravenous-only therapy. Multiple studies described an improved clinical cure rate and an improved mortality rate among patients treated with oral step-down vs intravenous-only antibiotic therapy. Three randomized clinical trials also demonstrated that oral step-down antibiotic therapy is at least as effective as intravenous-only therapy in right-sided, left-sided, or prosthetic valve IE. In the largest trial, at 3.5 years of follow-up, patients randomized to receive oral step-down antibiotic therapy had a significantly improved cure rate and mortality rate compared with those who received intravenous-only therapy. Conclusions and Relevance This review found ample data demonstrating the therapeutic effectiveness of oral step-down vs intravenous-only antibiotic therapy for IE, and no contrary data were identified. The use of highly orally bioavailable antibiotics as step-down therapy for IE, after clearing bacteremia and achieving clinical stability with intravenous regimens, should be incorporated into clinical practice.

中文翻译：

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评估从静脉注射抗生素到口服降压疗法治疗感染性心内膜炎的范式转变

重要性 需要延长静脉抗生素疗程来治疗感染性心内膜炎 (IE) 是一个由来已久的医学教条。然而，现在有许多抗生素可以在口服后在血液中达到足够的水平以杀死细菌。此外，长期静脉注射抗生素方案与高不良事件发生率相关。因此，最近关于口服降压抗生素治疗的研究激发了对仅静脉注射治疗 IE 的必要性的重新评估。观察 PubMed 于 2019 年 10 月进行了审查，并于 2020 年 2 月进行了更新，以确定证据是否支持 IE 的口服降压抗生素治疗与仅静脉注射治疗相比结果较差的观点。搜索确定了 21 项观察性研究，这些研究评估了口服抗生素治疗 IE 的有效性，通常是在初始静脉治疗过程之后；没有人发现这种口服降压疗法不如仅静脉注射疗法。多项研究描述了口服降压药与仅静脉注射抗生素治疗的患者的临床治愈率和死亡率的提高。三项随机临床试验还表明，口服降压抗生素治疗在右侧、左侧或人工瓣膜 IE 中至少与仅静脉内治疗一样有效。在最大的试验中，在 3.5 年的随访中，随机接受口服降压抗生素治疗的患者与仅接受静脉注射治疗的患者相比，治愈率和死亡率显着提高。结论和相关性 本综述发现了大量数据，证明口服降压与仅静脉注射抗生素治疗 IE 的治疗效果，并且没有发现相反的数据。在清除菌血症并通过静脉给药达到临床稳定性后，使用高口服生物利用度抗生素作为 IE 的降压治疗，应纳入临床实践。