Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy.
OBJECTIVE
To compare the efficacy and safety of inpatient oral antibiotic treatment (oral) versus standard parenteral antibiotic treatment (intravenous) for right-sided staphylococcal endocarditis in injection drug users.


METHODS
In a prospective, randomized, non-blinded trial, febrile injection drug users were assigned to begin oral or intravenous (IV) treatment on admission, before blood culture results were available. Oral therapy consisted of ciprofloxacin and rifampin. Parenteral therapy was oxacillin or vancomycin, plus gentamicin for the first 5 days. Antibiotic dosing was adjusted for renal dysfunction. Administration of other antibacterial drugs was not permitted during the treatment or follow-up periods. Bacteremic subjects having right-sided staphylococcal endocarditis received 28 days of inpatient therapy with the assigned antibiotics. Test-of-cure blood cultures were obtained during inpatient observation 6 and 7 days after the completion of antibiotic therapy, and again at outpatient follow-up 1 month later. Criteria for treatment failure and for drug toxicity were prospectively defined.


RESULTS
Of 573 injection drug users who were hospitalized because of a febrile illness and suspected right-sided staphylococcal endocarditis, 93 subjects (16.2%) had two or more sets of blood cultures positive for staphylococci; 85 of these bacteremic subjects (14.8%) satisfied diagnostic criteria for at least possible right-sided staphylococcal endocarditis (no other source of bacteremia was apparent) and entered the trial. Forty-four (oral, 19; IV, 25) of these 85 subjects completed inpatient treatment and evaluation including test-of-cure blood cultures. There were four treatment failures (oral, 1 [5.2%]; IV, 3 [12.0%]; not significant, Fisher's exact test). Drug toxicity was significantly more common in the parenterally treated group (oral, 3%; IV, 62%; P < 0.0001), consisting largely of oxacillin-associated increases in liver enzymes.


CONCLUSIONS
For selected patients with right-sided staphylococcal endocarditis, oral ciprofloxacin plus rifampin is effective and is associated with less drug toxicity than is intravenous therapy.
Heldman
A W
AW
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Hartert
T V
TV
Ray
S C
SC
Daoud
E G
EG
Kowalski
T E
TE
Pompili
V J
VJ
Sisson
S D
SD
Tidmore
W C
WC
vom Eigen
K A
KA
Goodman
S N
SN
Lietman
P S
PS
Petty
B G
BG
Flexner
C
C
D000284:Administration, Oral; D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D000890:Anti-Infective Agents / Q000008:administration & dosage*; D000904:Antibiotics, Antitubercular / Q000008:administration & dosage; D002939:Ciprofloxacin / Q000008:administration & dosage; D004697:Endocarditis, Bacterial / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality; D005260:Female; D005839:Gentamicins / Q000008:administration & dosage; D006801:Humans; D007262:Infusions, Intravenous; D007902:Length of Stay; D008297:Male; D010068:Oxacillin / Q000008:administration & dosage; D010406:Penicillins / Q000008:administration & dosage; D011446:Prospective Studies; D012293:Rifampin / Q000008:administration & dosage; D013203:Staphylococcal Infections / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality; D015819:Substance Abuse, Intravenous / Q000150:complications*; D016896:Treatment Outcome; D014640:Vancomycin / Q000008:administration & dosage
D000900:Anti-Bacterial Agents; D000890:Anti-Infective Agents; D000904:Antibiotics, Antitubercular; D005839:Gentamicins; D010406:Penicillins; D002939:Ciprofloxacin; D014640:Vancomycin; D010068:Oxacillin; D012293:Rifampin