Amy N. Brown

Enhanced Recovery After Surgery (ERAS) is an evidence-based, holistic perioperative recovery protocol intended to improve patient outcomes and decrease postoperative complication rates. While ERAS protocols were first introduced in 1997, specific guidelines for cardiac surgery were not established until 2019. Although the core principles of ERAS remain constant across surgical disciplines, ERAS guidelines for cardiac surgery have remained relatively understudied, likely due to the unique complexities posed by cardiac procedures. Within this comprehensive narrative review, we aimed to explore the current guidelines and evidence for ERAS in both cardiac and non-cardiac surgeries. In non-cardiac surgeries, ERAS has been shown to improve various outcomes, including ICU length of stay, patient satisfaction, and pain management. ERAS for cardiac surgery has also shown encouraging results, including shorter ICU and hospital stays, reduced postoperative opioid use, and faster recovery times. However, there is limited consensus across studies, particularly regarding its impact on morbidity and mortality, with mixed results reported. Furthermore, the limited data on the efficacy of ERAS in minimally invasive cardiac surgeries makes it difficult to establish well-supported guidelines for these procedures. Despite its limitations, the overall outcomes of ERAS for cardiac surgery remain promising. As our understanding and application of ERAS in cardiac surgery continue to evolve, these protocols have the potential to redefine cardiac surgical care standards.

Background: Prolonged intravenous (IV) antibiotic therapy may not be optimal for people who inject drugs (PWID) with infective endocarditis (IE) due to unique social and medical needs. The role of partial IV antibiotic therapy with continued oral (PO) antibiotic therapy is unclear. Methods: A systematic review was performed using EMBASE and MEDLINE databases. Included studies compared PO to IV antibiotic treatment for IE in PWID. Results: Four studies met eligibility. Observational studies included full IV treatment groups and partial IV, partial PO treatment groups for severe injection-related infections. PWID with IE comprised 41.0%–64.7% of the study populations but outcomes specific to IE were not separately reported. All-cause 90-day readmission rates were comparable between the IV treatment group (27.9%–31.5%) and partial IV, partial PO treatment group (24.8%–32.5%). Ninety-day mortality was non-significantly different between IV treatment (4.9%–10.7%) and partial IV, partial PO treatment groups (2.4%–13.0%). One small randomized clinical trial compared IV oxacillin or vancomycin with gentamicin to PO ciprofloxacin plus rifampin. The cure rates were 91% and 90%, respectively. Conclusion: There is limited evidence comparing IV treatment to partial IV, partial PO antibiotic treatment in PWID with IE. Observational studies suggest that PO antibiotic therapy after initial IV treatment may be equivalent to full IV treatment alone within specific parameters, but randomized trials are needed to inform recommendations. Substantial clinical and social benefits for PWID and advantages for the health care system will result if PO treatment strategies with equal efficacy can be implemented.