Infective Endocarditis in the 21st Century

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Abstract

Infective endocarditis (IE) continues to be a disease characterized by high mortality and morbidity that has not been affected by significant advances in the last century. Despite considerable improvements in diagnosis and medical and surgical therapy, mortality has remained high for the past 25 years, in contrast to the majority of cardiovascular diseases such as heart failure and acute coronary syndromes, which have demonstrated noticeable improvements in terms of prognosis. IE has an exceptionally varied clinical presentation, from a severely ill patient with symptoms of acute infection and sepsis to an apparently healthy individual with only occasional night sweats, weight loss, and low-grade fever. Clinical manifestations of IE can be caused by symptoms or complications of the infection or by its frequent non-infectious complications, such as vascular and immunologic phenomena. IE remains a deadly disease, frequently associated with a difficult diagnosis. Significant changes in epidemiology and microbiology have increased the differences between patients seen in the US and Europe and those in countries with a higher incidence of rheumatic heart disease, such as South America and India. Therefore, specific regional approaches to IE are necessary.

Disclosure
The authors have no conflicts of interest to declare.
Correspondence
Antonio Carlos Palandri Chagas, MD, Heart Institute, University of S├úo Paulo, Av En├®as de Carvalho Aguiar, 44, 05403-000 - S├úo Paulo, Brazil. E: antonio.chagas@incor.usp.br
Received date
10 June 2010
Accepted date
20 July 2010
Citation
US Cardiology - Volume 7 Issue 2;2010:7(2):61-64
Correspondence
Antonio Carlos Palandri Chagas, MD, Heart Institute, University of S├úo Paulo, Av En├®as de Carvalho Aguiar, 44, 05403-000 - S├úo Paulo, Brazil. E: antonio.chagas@incor.usp.br

Pages

Infective endocarditis (IE) continues to be a disease characterized by high mortality and morbidity that has not been affected by significant advances in the last century. Despite considerable improvements in diagnosis and medical and surgical therapy, mortality has remained high for the past 25 years, in contrast to the majority of cardiovascular diseases such as heart failure and acute coronary syndromes, which have demonstrated noticeable improvements in terms of prognosis. The current in-hospital mortality for patients with IE is 15–20%, with one-year mortality approaching 40%. In a 16-year follow-up of patients discharged with the diagnosis of IE, only 5% of the patients remained alive free of a new episode of endocarditis and without valve replacement surgery.
As with most valvular heart diseases, studies of IE in the literature are mainly series of reports and/or case studies; there is a marked absence of prospective controlled studies on this disease, perhaps because of its relative rarity and clinical polymorphism. The only multicentric prospective registry of IE is the International Collaboration on Endocarditis–Prospective Cohort Study (ICE-PCS), in which 58 hospitals from 25 countries took part.
The purpose of this article is to review the epidemiology of IE, modern therapy, both clinical and surgical, and to discuss the need for IE prophylaxis.

A Difficult Diagnosis

Endocarditis has an exceptionally varied clinical presentation, from a severely ill patient with symptoms of acute infection and sepsis to an apparently healthy individual with only occasional night sweats, weight loss, and low-grade fever. Clinical manifestations in IE can be caused by symptoms or complications of the infection or by its frequent non-infectious complications, such as vascular and immunologic phenomena. Immunologic symptoms such as arthritis and glomerulonephritis are especially frequent because of the high quantity of circulating immunocomplexes in IE. Vascular complications such as mycotic aneurysms and septic emboli can lead to neurologic or peripheral symptoms as the initial manifestation of the disease.

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References
  1. Murdoch DR, Corey R, Hoen B, et al., Clinical Presentation, Etiology, and Outcome of Infective Endocarditis in the 21st Century The International Collaboration on Endocarditis– Prospective Cohort Study, Arch Intern Med, 2009;169(5):463–73.
    Crossref | PubMed
  2. Issa VS, Fabri J Jr, Pomerantzeff PMA, et al., Duration of symptoms in infective endocarditis, Int Heart J, 2003;89:63–70.
    Crossref | PubMed
  3. Durack DT, Lukes AS, Bright DK, New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service, Am J Med, 1994;96:200–209.
    Crossref | PubMed
  4. Li JS, Sexton DJ, Mick N, et al., Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis, Clin Infect Dis, 2000;30:633–8.
    Crossref | PubMed
  5. Neuerburg CK, Breuckmann F, Buhr C, et al., Duke-Kriterien zur Diagnostik der infektiösen Endokarditis: Metaanalyse von 3557 Fällen und Ergebnisse eine prospektiven Studie (Abstract), Clin Res Cardiol, 2007;(Suppl. 1):V1148.
  6. Weinstein L, Rubin RH, Infective endocarditis: 1973, Prog Cardiovasc Dis, 1973;16(3):239–74.
    Crossref | PubMed
  7. Wang A, Athan P, Pappas PA, Contemporary Clinical Profile and Outcome of Prosthetic Valve Endocarditis, JAMA, 2007:297:1354.
    Crossref | PubMed
  8. Cabell CH, Jollis JG, Peterson GE, et al., Changing patient characteristics and the effect on mortality in endocarditis, Arch Intern Med, 2002;162(1):90–94.
    Crossref | PubMed
  9. Spies C, Madison JR, Schatz IJ, Infective endocarditis in patients with endstage renal disease: clinical presentation and outcome, Arch Intern Med, 2004;164(1):71–5.
    Crossref | PubMed
  10. Mansur AJ, Dal Bó C, Fukushima JT, et al., Relapses, recurrences, valve replacements, and mortality during the long-term follow-up after infective endocarditis, Am Heart J, 2001;141:78–86.
    Crossref | PubMed
  11. Hoen B, Alla F, Selton-Suty C, et al., Association pour l’Etude et la Pre´vention del’Endocardite Infectieuse (AEPEI) Study Group. Changing profile of infective endocarditis:results of a 1-year survey in France, JAMA, 2002;288(1):75–81.
    Crossref
  12. Mullany CJ, Chua YL, Schaff HV, et al., Early and late survival after surgical treatment of culture-positive active endocarditis, Mayo Clin Proc, 1995;70(6):517–25.
    Crossref | PubMed
  13. Sanabria TJ, Alpert JS, Goldberg R, et al., Increasing frequency of staphylococcal infective endocarditis: experience at a university hospital, 1981 through 1988, Arch Intern Med, 1990;150(6):1305–9.
    Crossref | PubMed
  14. Naimi TS, LeDell KH, Como-Sabetti K, et al., Comparison of community- and health care–associated methicillin-resistant Staphylococcus aureus infection, JAMA, 2003;290(22):2976–84.
    Crossref | PubMed
  15. Centers for Disease Control and Prevention. Vancomycinresistant Staphylococcus aureus: New York, 2004, MMWR Morb Mortal Wkly Rep, 2004;53(15):322–3.
    PubMed
  16. Whitener CJ, Park SY, Browne FA, et al., Vancomycinresistant Staphylococcus aureus in the absence of vancomycin exposure, Clin Infect Dis, 2004;38(8):1049–55.
    Crossref | PubMed
  17. Paul M, Silbiger I, Grozinsky S, et al., Beta lactam antibiotic monotherapy versus beta lactam, aminoglycoside antibiotic combination therapy for sepsis, Cochrane Database Syst Rev, 2006;CD003344.
    Crossref | PubMed
  18. Falagas ME, Matthaiou DK, Bliziotis IA, The role of aminoglycosides in combination with a beta-lactam for the treatment of bacterial endocarditis: a meta-analysis of comparative trials, J Antimicrob Chemother, 2006;57:639–47.
    Crossref | PubMed
  19. Baddour LM, Wilson WR, Bayer AS, et al., Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications, Circulation, 2005;14;111(23): e394–434.
    Crossref | PubMed
  20. Werner M, Andersson R, Olaison L, Hogevik H, Swedish Society of Infectious Diseases Quality Assurance Study Group for Endocarditis: A 10-year survey of blood culture negative endocarditis in Sweden: aminoglycoside therapy is important for survival, Scand J Infect Dis, 2008;40:279–85.
    Crossref | PubMed
  21. Fowler VG Jr, Boucher HW, Corey GR, et al., Daptomycin versus standard therapy for bacteremia and endocarditis caused by Staphylococcus aureus, N Engl J Med, 2006;355(7): 653–65.
    Crossref | PubMed
  22. Falagas ME, Manta KG, Ntziora F, Vardakas KZ, Linezolid for the treatment of patients with endocarditis: a systematic review of the published evidence, J Antimicrob Chemother, 2006;58(2):273–80.
    Crossref | PubMed
  23. Wilson W, Taubert KA, Gewitz M, Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group, Circulation, 2007;116(15):1736–54.
    Crossref | PubMed
  24. Bonow RO, Carabello BA, Lytle BW, et al., ACC/AHA 2006 Guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the society of cardiovascular anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons, J Am Coll Cardiol, 2006;48:e1 - e148.
    Crossref | PubMed
  25. Vikram HR, Buenconsejo J, Hasbun R, Quagliarello VJ, Impact of valve surgery on 6-month mortality in adults with complicated, left-sided native valve endocarditis: a propensity analysis, JAMA, 2003;290(24):3207–14.
    Crossref | PubMed
  26. Vongpatanasin W, Hillis LD, Lange RA, Prosthetic heart valves, N Engl J Med, 1996;335:407–16.
    Crossref | PubMed
  27. Blackstone EH, Kirklin JW, Death and other time-related events after valve replacement, Circulation, 1985;72:753–67.
    Crossref | PubMed
  28. Wolff M, Witchitz S, Chastang C, et al., Prosthetic valve endocarditis in the ICU. Prognostic factors of overall survival in a series of 122 cases and consequences for treatment decision, Chest, 1995;108:688–94.
    Crossref | PubMed
  29. Tornos P, Almirante B, Olona M, et al., Clinical outcome and long-term prognosis of late prosthetic valve endocarditis: a 20-year experience, Clin Infect Dis, 1997;24:381–6.
    Crossref | PubMed
  30. Akowuah EF, Davies W, Oliver S, et al., Prosthetic valve endocarditis: early and late outcome following medical or surgical treatment, Heart, 2003;89:269–72.
    Crossref | PubMed
  31. Horstkotte D, Follath F, Gutschik E, et al., Guidelines on prevention, diagnosis and treatment of infective endocarditis executive summary; the task force on infective endocarditis of the European Society of Cardiology, Eur Heart J, 2004;25:267–76.
    Crossref | PubMed
  32. Tornos P, Iung B, Permanyer-Miralda G, et al., Infective endocarditis in Europe: lessons from the Euro heart survey, Heart, 2005;91:571–5.
    Crossref | PubMed