Restrictive OPAT Criteria for Infective Endocarditis May Need Revision

A less restrictive criteria for the use of OPAT for patients with infective endocarditis than current IDSA guidelines was efficacious and safe.

Criteria less restrictive than those proposed by the Infectious Diseases Society of America (IDSA) for the use of outpatient parenteral antibiotic treatment (OPAT) for patients with infective endocarditis were found to be efficacious and safe, according to results published in Clinical Infectious Diseases.

A retrospective analysis of data from the GAMES cohort study of 2000 patients with infective endocarditis in 25 Spanish hospitals from 2008 to 2012 compared the outcomes of OPAT with those of hospital-based antibiotic treatment.

A total of 429 patients (approximately 21.5%) received OPAT, the majority of whom were men (70.5%) with a median age of 68 years (interquartile range, 56-76 years). Of these, 57% had native-valve infective endocarditis, 27% had prosthetic-valve infective endocarditis, and 19% had infective endocarditis associated with a pacemaker/defibrillator; only 21.7% of these patients fulfilled the IDSA criteria for treatment. One-year mortality for these patients was 8% (42% for hospital-based antibiotic treatment; P <.001), 1.4% of patients relapsed, and 10.9% were readmitted within the first 3 months after discharge, with no significant differences compared with patients who received hospital-based antibiotic treatment. The failure to fulfill IDSA criteria was not a risk factor for mortality or readmission, whereas Charlson score (odds ratio [OR], 1.21; 95% CI, 1.04-1.42; P =.01) and cardiac surgery (OR, 0.24; 95% CI, 0.09-0.63; P =.04) were associated with 1-year mortality. Aortic valve involvement was the only predictor of readmission at 1 year (OR, 0.47; 95% CI, 0.22-0.98; P =.007).

Importantly, the investigators noted several limitations to be considered while interpreting the data, such as the study design not allowing for matching of patients who received hospital-based antibiotic vs OPAT treatment. They also noted a “remarkable heterogeneity with regard to OPAT experience among GAMES participating centers,” and that at some centers, referral bias might have influenced the profiles of patients who received hospital-based antibiotic treatment. The GAMES registry was also not designed to collect specific data for OPAT. Investigators noted that extrapolation of the results to other areas is hampered by several epidemiological aspects, and they found “the percentage of cases due to Staphylococcus aureus is remarkably lower than in most general series owing to the exclusion of a large number of cases because of in-hospital mortality or intravenous drug use.” Researchers also highlighted that the performance of early and late cardiac surgery as a prognostic factor was not assessed separately.

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Investigators concluded that the IDSA criteria for OPAT, which were proposed more than 15 years ago, should be replaced with less restrictive criteria. This recommendation is based on their results showing that more than one-fifth of the original GAMES cohort received OPAT and the outcomes were “excellent, in terms of both efficacy and safety.”


Pericàs JM, Llopis J, González-Ramallo V, et al. Outpatient parenteral antibiotic treatment (OPAT) for infective endocarditis: a prospective cohort study from the GAMES cohort [published online January 14 2019]. Clin Infect Dis. doi: 10.1093/cid/ciz030