Breaking the Dogma of Intravenous Treatment for Infective Endocarditis: A Systematic Review and Meta-Analysis

Introduction: The treatment of infective endocarditis (IE) is based on long intravenous administration of antibiotics. This is still a hard-to-die dogma. Throughout the years, different researchers have attempted to demonstrate the safety and efficacy of an oral switch of the antibiotic regimen, with only scarce success. Nevertheless, in recent years, different reports have evaluated the efficacy of oral switch therapy in selected patients. Due to the lack of large trials, a meta-analysis could be useful to evaluate the potential benefits of early oral switch therapy not only in terms of microbiological cure but also in terms of relapse, mortality, and length of hospital stay (LOS). Methods: We conducted a Medline search, from which we were able to extrapolate 29 papers on IE treatment; the inclusion criteria were met by six papers only. Three trials were not randomized studies; therefore, we conducted the analysis both including and excluding the mentioned papers. Results: Overall, we conducted our analysis on 840 patients who received intravenous treatment and 677 who received oral treatment. Our results confirmed that oral switch therapy represents an option in selected patients, with a reduction in the relapse rate (OR: 0.54, 95% CI: 0.31-0.92). No statistically significant differences were observed for treatment failure (OR: 0.74, 95% CI: 0.48-1.14), length of hospitalization (OR: -0.42, 95% CI: -1.55-0.71), complication rate (OR: 0.38, 95% CI: 0.1-1.54), and mortality (OR: 0.52, 95% CI: 0.22-1.22). Discussion: Our results allow us to conclude that oral switch therapy is a feasible option in clinically stable patients with infective endocarditis. Moreover, oral switch therapy seems to perform significantly better than intravenous treatment in terms of relapse of infection. The data further support the implementation of oral switch therapy in infective endocarditis.