Table of Contents
Credits
Hosts: Hannah Chute, Sara Dong
Discussants: Paloma Reta-Impey, Brad Spellberg
Writing: Kusha Davar, Devin Clark, Paloma Reta-Impey, Hannah Chute
Edited and produced by Sara Dong
Our Guests
Hannah Chute
Hannah is a 4th-year medical student at Keck School of Medicine of USC, currently applying into Internal Medicine. Her interests include HIV medicine, LGBTQ care, and medical education. Prior to medical school, she worked as a French-to-English translator, publishing 8 works of French literature including several graphic novels highlighting the stories of Syrian and Afghan refugees. In her free time, she can be found reading science fiction and fantasy, playing the harp, or hiking with her Australian shepherd.
Paloma Reta-Impey, MD
Dr. Reta-Impey is a 1st year ID fellow at USC/LAGMC. She completed Internal Medicine residency at Case Western Reserve University. After residency, she joined the CWRU Internal Medicine faculty as an academic hospitalist for 2 years prior to pursuing ID fellowship. Her interests in ID include antibiotic stewardship, travel medicine, and global health. Outside of medicine she enjoys photography, camping, nail art and cooking.
Brad Spellberg, MD
Dr. Spellberg is Chief Medical Officer at the Los Angeles General Medical Center, one of the largest public hospitals in the US. He also staffs Internal Medicine ward teams, Infectious Diseases consulting service, and the antibiotic stewardship service at LA General, and maintains an active NIH-funded basic science laboratory that focuses on novel solutions to combatting antibiotic-resistant infections. In 2009, he published the book Rising Plague to inform and educate the public about the crisis in antibiotic resistant infections and lack of antibiotic development. His latest book, Broken, Bankrupt, and Dying: How to Solve the Great American Healthcare Rip-Off, was published in June of 2020.
Culture
Hannah recommended the podcast Home Cooking with Samin Nosrat and Hrishikesh Hirway
Paloma loves being outdoors and camping – she shared a recent trip to Joshua Tree National Park
Brad shared his kids and his dog
Consult Notes
Case Summaries and Key References
Case 1: 58 year old female with DM2, HTN, and OA of bilateral hips and R knee who presented with worsening diabetic foot ulcer and was found to have MSSA osteomyelitis, now s/p debridement
- Paloma discussed:
- Assessing the severity of diabetic foot infection (DRI) using the proposed classification schema in available guidelines
- From the 2023 International Working Group on the Diabetic Foot (IWGDF) / IDSA Guidelines on Diabetes-related Foot Infections: Senneville É, Albalawi Z, van Asten SA, et al. IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023). Clin Infect Dis. Published online October 2, 2023. doi:10.1093/cid/ciad527
- Initial antibiotic selection and considerations regarding duration of therapy
- Assessing the severity of diabetic foot infection (DRI) using the proposed classification schema in available guidelines
- Brad shared:
- He finds the guidelines meaningless and instead focuses on the question “does the patient have bone infection or not?” (as trials showed longer durations of therapy are needed for bone infections compared to non-bone infections)
- His thoughts on duration and several trials listed below
- RCT of shorter treatment for soft tissue (non-osteomyelitis) diabetic foot infection: Pham TT, Gariani K, Richard JC, et al. Moderate to Severe Soft Tissue Diabetic Foot Infections: A Randomized, Controlled, Pilot Trial of Post-debridement Antibiotic Treatment for 10 versus 20 days. Ann Surg. 2022;276(2):233-238. doi:10.1097/SLA.0000000000005205 Largest 2 randomized controlled trials that compared duration of therapy for osteomyelitis treated 6 vs 12 wks, both showing 6 wks non-inferior to 12 weeks:
- Bernard L, Dinh A, Ghout I, et al. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Lancet. 2015;385(9971):875-882. doi:10.1016/S0140-6736(14)61233-2
- Tone A, Nguyen S, Devemy F, et al. Six-week versus twelve-week antibiotic therapy for nonsurgically treated diabetic foot osteomyelitis: a multicenter open-label controlled randomized study. Diabetes Care. 2015;38(2):302-307. doi:10.2337/dc14-1514
- Data on IV vs PO
- He shared that there is abundant data that we can deliver antibiotic into bone at concentrations necessary to kill bacteria as well as clinical data to validate that it works
- You can see a compilation of the RCT data on oral antibiotics on his page: https://www.bradspellberg.com/oral-antibiotics
Case 2: 37 year old unhoused male with DM2, polysubstance abuse, and multiple prior hospitalizations for skin-soft tissue infections who presented with tricuspid valve endocarditis and knee septic arthritis
- Paloma discussed:
- Some relevant take-aways from the AHA 2015 infectious endocarditis guidelines: Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015;132(15):1435-1486. doi:10.1161/CIR.0000000000000296
- Use of OPAT in patients with history of IV drug use
- Brad noted:
- The WikiGuidelines, which an organization he believes in and helped found – he specifically mentions the osteomyelitis WikiGuideline: Spellberg B, Aggrey G, Brennan MB, et al. Use of Novel Strategies to Develop Guidelines for Management of Pyogenic Osteomyelitis in Adults: A WikiGuidelines Group Consensus Statement. JAMA Netw Open. 2022;5(5):e2211321. Published 2022 May 2. doi:10.1001/jamanetworkopen.2022.11321
- The data for use of oral antibiotic therapy for endocarditis, including RCTs:
- Stamboulian D, Bonvehi P, Arevalo C, et al. Antibiotic management of outpatients with endocarditis due to penicillin-susceptible streptococci. Rev Infect Dis. 1991;13 Suppl 2:S160-S163. doi:10.1093/clinids/13.supplement_2.s160
- Heldman AW, Hartert TV, Ray SC, et al. Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy. Am J Med. 1996;101(1):68-76. doi:10.1016/s0002-9343(96)00070-8
- Iversen K, Ihlemann N, Gill SU, et al. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. N Engl J Med. 2019;380(5):415-424. doi:10.1056/NEJMoa1808312
- (quasi-experimental, pre-post) Tissot-Dupont H, Gouriet F, Oliver L, et al. High-dose trimethoprim-sulfamethoxazole and clindamycin for Staphylococcus aureus endocarditis. Int J Antimicrob Agents. 2019;54(2):143-148. doi:10.1016/j.ijantimicag.2019.06.006
- https://www.bradspellberg.com/oral-antibiotics
Case 3: 94 year old female with HTN, moderate dementia, CKD, and chronic pain pain who was found to have MSSA vertebral osteomyelitis
- Paloma shared:
- 2015 IDSA guidelines on vertebral osteomyelitis: Berbari EF, Kanj SS, Kowalski TJ, et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis. 2015;61(6):e26-e46. doi:10.1093/cid/civ482
- Brad discussed:
- His approach to the question of do we need a bone biopsy?
- PO vs IV, also available at https://www.bradspellberg.com/oral-antibiotics
Infographics
Goal
Listeners will be able to discuss the role of oral antibiotics for treatment of endocarditis and osteomyelitis
Learning Objectives
After listening to this episode, listeners will be able to:
- Identify currently available guidelines related to diabetes-related foot infection, endocarditis, and vertebral osteomyelitis
- Discuss the available data supporting use of oral antibiotics for treatment of endocarditis and osteomyelitis
Disclosures
Our guests as well as Febrile podcast and hosts report no relevant financial disclosures
Citation
Chute, H., Reta-Impey, P., Spellberg, B., Dong, S. “#126: IV vs PO”. Febrile: A Cultured Podcast. https://player.captivate.fm/episode/dd686bb5-e99e-4eac-80ea-15a3231420b0/