Oral Therapy for Infective Endocarditis: Where Do We Stand?
Abstract
Standard therapy for infective endocarditis (IE) usually requires 4-6 weeks of intravenous (IV) antibiotics, ensuring sustained bactericidal concentrations, yet resulting in prolonged hospitalization and increased cost of care. These challenges have driven interest in oral antibiotic therapy (OAT) as a step-down strategy for selected, clinically stable patients. This review summarizes the clinical evidence and pharmacokinetic and pharmacodynamic (PK/PD) rationale and practical considerations supporting step-down OAT in IE. Antibiotics such as amoxicillin, fluoroquinolones, linezolid, and rifampicin have high bioavailability and maintain effective serum and tissue concentrations, and can be used as a safe transition from IV to oral therapy. The pivotal POET randomized controlled trial (RCT) demonstrated noninferiority of OAT compared with continued IV therapy in stable patients with left-sided IE caused by Streptococcus spp., Enterococcus faecalis, methicillin-susceptible Staphylococcus aureus, or coagulase-negative staphylococci. Further real-world studies and meta-analyses confirmed comparable efficacy and safety, with reduced catheter-related complications and shorter hospitalization length for patients receiving OAT. The latest European Society of Cardiology (ESC) guidelines have incorporated OAT regimens derived from the POET protocol for stable patients meeting specific criteria, while the American Heart Association guidelines have not yet been revised. Many areas…
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