Outpatient follow-up and management of infective endocarditis

Introduction

The management of patients with infective endocarditis (IE) has developed markedly during the past several decades. From being a disease treated primarily conservatively with long-term intravenous antibiotics during hospital admission to a disease frequently treated with cardiac surgery, combinations of intravenous and oral antibiotics administered both in and out of hospital.

This chapter is about how to manage the treatment and follow-up of endocarditis patients after hospital discharge. When the decision to discharge an IE patient is made, it is mandatory that the outpatient follow-up plan is in place. At the time of discharge, there are basically three different scenarios. The first scenario is that the patient is considered cured from the infection and therefore terminates the antibiotic treatment before discharge. The second scenario is that the patient is stable enough to allow hospital discharge before the full course of antibiotic treatment is completed and as a result the antibiotic treatment will be finished as outpatient therapy. The third scenario is that the patient is considered incurable due to a combination of age, comorbidity, and severity of IE and therefore discharged to an individualized plan that can span from life-long antibiotics to palliative care (not discussed here).

This chapter will describe the criteria for finishing the antimicrobial therapy at home, either as oral or intravenous administration. In addition, the clinical, microbiological, and surgical follow-up as well as perspectives for future research will be discussed.

Outpatient antimicrobial therapy

There are several benefits of finishing the antimicrobial therapy outside the hospital. Firstly, the patients benefit from being discharged earlier and removed from the stressful hospital environment to the increased comfort in their own homes. Secondly, the patients experience a reduced duration of exposure to hospital acquired infections [ ]. Thirdly, the society profits by reducing the number of hospital admission days and thereby reducing the related health-care costs [ ]. On the other hand, potential downsides of discharging patients before the end of antibiotic treatment must be kept in mind. One possible disadvantage is that the antibiotic treatment might be completed less stringently at home, which in turn could lead to treatment failure. Another challenge is that a latent deterioration of the patient's condition due to IE might be discovered later when the patient is less frequently assessed at home as compared to in hospital [ ]. While it would be appealing if all patients could finish the treatment in their homes, this is not likely to accomplish and instead the key question is “in which cases will it be safe to finish the treatment out of hospital”? To answer this question, several different criteria have been suggested over time. In the following section, the criteria will be divided in intravenous treatment also called Outpatient Parenteral Antibiotic Therapy (OPAT) and oral treatment, in this chapter named partial oral endocarditis treatment (POET).