title: Changes in the treatment of Enterococcus faecalis infective endocarditis in Spain in the last 15 years: from ampicillin plus gentamicin to ampicillin plus ceftriaxone.
abstract: The aim of this study was to assess changes in antibiotic resistance, epidemiology and outcome among patients with Enterococcus faecalis infective endocarditis (EFIE) and to compare the efficacy and safety of the combination of ampicillin and gentamicin (A+G) with that of ampicillin plus ceftriaxone (A+C). The study was a retrospective analysis of a prospective cohort of EFIE patients treated in our centre from 1997 to 2011. Thirty patients were initially treated with A+G (ampicillin 2 g/4 h and gentamicin 3 mg/kg/day) and 39 with A+C (ampicillin 2 g/4 h and ceftriaxone 2 g/12 h) for 4-6 weeks. Increased rates of high-level aminoglycoside resistance (HLAR; gentamicin MIC ≥512 mg/L, streptomycin MIC ≥1024 mg/L or both) were observed in recent years (24% in 1997-2006 and 49% in 2007-2011; p 0.03). The use of A+C increased over time: 1997-2001, 4/18 (22%); 2002-2006, 5/16 (31%); 2007-2011, 30/35 (86%) (p <0.001). Renal failure developed in 65% of the A+G group and in 34% of the A+C group (p 0.014). Thirteen patients (43%) in the A+G group had to discontinue treatment, whereas only one patient (3%) treated with A+C had to discontinue treatment (p <0.001). Only development of heart failure and previous chronic renal failure were independently associated with 1-year mortality, while the individual antibiotic regimen (A+C vs. A+G) did not affect outcome (OR, 0.7; 95% CI, 0.2-2.2; p 0.549). Our study shows that the prevalence of HLAR EFIE has increased significantly in recent years and that alternative treatment with A+C is safer than A+G, with similar clinical outcomes, although the sample size is too small to draw firm conclusions. Randomized controlled studies are needed to confirm these results.
authors.affiliation: Infectious Diseases Service, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
authors.forename: J M
authors.initials: JM
authors.lastname: Pericas
authors.forename: C
authors.initials: C
authors.lastname: Cervera
authors.forename: A
authors.initials: A
authors.lastname: del Rio
authors.forename: A
authors.initials: A
authors.lastname: Moreno
authors.forename: C
authors.initials: C
authors.lastname: Garcia de la Maria
authors.forename: M
authors.initials: M
authors.lastname: Almela
authors.forename: C
authors.initials: C
authors.lastname: Falces
authors.forename: S
authors.initials: S
authors.lastname: Ninot
authors.forename: X
authors.initials: X
authors.lastname: Castañeda
authors.forename: Y
authors.initials: Y
authors.lastname: Armero
authors.forename: D
authors.initials: D
authors.lastname: Soy
authors.forename: J M
authors.initials: JM
authors.lastname: Gatell
authors.forename: F
authors.initials: F
authors.lastname: Marco
authors.forename: C A
authors.initials: CA
authors.lastname: Mestres
authors.forename: J M
authors.initials: JM
authors.lastname: Miro
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000667:Ampicillin / Q000009:adverse effects / Q000627:therapeutic use*; D000900:Anti-Bacterial Agents / Q000009:adverse effects / Q000627:therapeutic use*; D002443:Ceftriaxone / Q000009:adverse effects / Q000627:therapeutic use*; D015331:Cohort Studies; D024881:Drug Resistance, Bacterial; D004359:Drug Therapy, Combination / Q000379:methods; D004696:Endocarditis / Q000188:drug therapy* / Q000453:epidemiology / Q000382:microbiology; D013293:Enterococcus faecalis / Q000187:drug effects / Q000302:isolation & purification*; D005260:Female; D005839:Gentamicins / Q000009:adverse effects / Q000627:therapeutic use*; D016908:Gram-Positive Bacterial Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000382:microbiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D051437:Renal Insufficiency / Q000139:chemically induced / Q000453:epidemiology; D013030:Spain / Q000453:epidemiology; D016019:Survival Analysis; D016896:Treatment Outcome; D028761:Withholding Treatment
chemical_list: D000900:Anti-Bacterial Agents; D005839:Gentamicins; D002443:Ceftriaxone; D000667:Ampicillin
keywords: Ampicillin plus ceftriaxone; Enterococcus faecalis; antimicrobial treatment; high-level aminoglycoside resistance; infective endocarditis; outcomes