Therapy for Enterococcus faecalis Infective Endocarditis in the Era of A Dual Beta-Lactam Regimen: An Institutional Experience 2008-2015

Background:

Enterococcus faecalis infective endocarditis (EFIE) treatment has changed in recent years with the use of dual beta-lactam therapy [ampicillin plus ceftriaxone (A+C)] as an alternative treatment option to ampicillin plus gentamicin (A+G). Our goal was to evaluate the outcomes of EFIE associated with treatment regimens at our institution.

Methods:

A retrospective cohort study of adult (≥18 years) patients diagnosed with EFIE and treated with A+C or A+G at the Mayo Clinic from January 1, 2008 to December 31, 2015. Primary outcome were death at 3 months, 6 months and 1 year, adverse events leading to treatment withdrawal, and EFIE relapse.

Results:

Seventy-two cases of EFIE were included. A total of 14 (19%) patients received A+C as initial treatment. Patients who received A+C therapy had a significantly higher Charlson comorbidity index [median (IQR), 4 (3, 5) vs 2 (1, 4), P= 0.008] and a higher rate of health care-associated EFIE (57% vs 24%, P= 0.014). There were no differences in mortality rates among A+C vs A+G treatment groups at 3-month (14% vs 10%), 6-month (14 vs 12 %), and 1-year (14% vs 12%) [P=0.995]. Each treatment group had one case of EFIE relapse. Patients receiving A+G had worsened kidney function based on a greater rise in serum creatinine at the end of therapy Table1.

Conclusion:

A+C combination had similar outcomes in terms of overall mortality and relapse rates as compared to A+G. However, A+G was associated with high rates of nephrotoxicity. Our results should be interperted with cauation due to the relatively small cohort size however our results are comparable to previous studies with large cohorts. The use of A+C as first line regimen for EFIE treatment was less common than expected.

Table 1: Kidney function outcomes comparison between patients treated with A+ G vs A+C

Variable	Ampicillin + Gentamicin (n=58)	Ampicillin + Ceftriaxone (n=14)	P-value
Acute kidney Injury	12 (21%)	2 (14%)	0.722
- Risk	5 (42%)	1 (50%)	•
- Injury	5 (42%)	1 (50%)	•
- Failure	2 (16%)	0	•
Failed to complete therapy	24 (41%)	4 (29%)	0.543
Reason for not completing therapy
- Nephrotoxicity	13 (54%)	0	0.059
- Death	6 (10.3%)	1 (7.1%)	1.000
- Other	5 (8.6%)	3 (21.4%)	0.180
Cr difference between end of therapy and beginning, median (IQR)	+ 0.3 (0.2, 0.8)	- 0.1 (-0.3, 0.3)	0.002*
GFR decrease , median (IQR)	-9.5 (-16.0, 0)	0 (-5.0, 0.0)	0.443
Total duration of antimicrobial therapy, days	39 (21.0, 46.0)	42.0 (32.0, 43.0)	0.540

Abdelghani El Rafei, MD¹, Daniel C. Desimone, MD¹, Muhammad R. Sohail, MD, FIDSA¹, James Steckelberg, MD, FIDSA¹, Walter R. Wilson, MD, FIDSA¹ and Larry M. Baddour, MD, FIDSA², (1)Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN, (2)Infectious Diseases, Mayo Clinic, Rochester, MN

Disclosures:

A. El Rafei, None

D. C. Desimone, None

M. R. Sohail, Medtronic: Consultant , Consulting fee and Research support
Spectranetics: Consultant , Consulting fee
Boston Scientific: Consultant , Consulting fee

J. Steckelberg, None

W. R. Wilson, None

L. M. Baddour, UpToDate: Consultant , Licensing agreement or royalty
Massachusetts Medical Society: NEJM Journal Watch Infectious Diseases – Editor-in-Chief , Editor-in-Chief duties

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