Update on Infective Endocarditis
Section snippets
Historical Background and Introduction
Although Sir William Osler’s famed Gulstonian lectures of 18851 are often referred to as one of the earliest descriptions of infective endocarditis, Osler himself was quick to recognize the contribution of many previous investigators. The earliest description of the vegetative lesions of endocarditis has been attributed to Lazarus Riverius (1589-1655)2; later, Giovanni Lancisi (1654-1720) provided a more complete description of these pathologic lesions of the heart in “De Subitaneis Mortibus”
Epidemiology
The incidence of infective endocarditis (IE) is difficult to estimate because true population characteristics, including both cases and total population at risk, are difficult to obtain. Over the past 10 years, several well-designed epidemiologic studies have provided both data on the incidence of endocarditis and insight into populations at risk. In an urban setting, Hogevik and colleagues conducted an epidemiologic study of IE in Goteborg, Sweden from 1984 to 1988 and found, after adjusting
Pathogenesis of Endocarditis
The endothelial lining of the heart and valves is generally resistant to bacterial or fungal infection. A few highly virulent organisms are capable of infecting apparently normal heart valves, but this is the exception. The interactions that finally result in endocarditis involve a complex interaction between the host and the invading microorganisms that includes the vascular endothelium, the host immune system, hemostatic mechanisms, cardiac anatomical characteristics, the surface properties
Pathophysiology of Endocarditis
About three-fourths of all patients with endocarditis have a preexisting structural abnormality of the cardiac valve involved.25 While rheumatic disease was the most common lesion in the early 1900s, mitral prolapse is now reported in about a quarter of the cases.26 Aortic valve disease (either stenosis or regurgitation or both) appears to account for anywhere from 12 to 30% of cases,27 with from 10 to 20% of patients with endocarditis having preexisting congenital heart disease.
Endocarditis
Complications of Endocarditis
Despite improvements in our diagnostic tests and antibiotics, the incidence of complications in patients with endocarditis has not changed much over the last few decades.32 Table 1 provides a “ballpark estimate” of the incidence of clinical complications in the modern-day era.22
The Diagnosis of Infective Endocarditis
Historically, infective endocarditis has been defined as an infection of the valves and chordae within the cardiac chambers. In recent years this definition has been expanded to include an infection on any structure within the heart including normal endothelial surfaces (eg, myocardium and valvular structures), prosthetic heart valves (eg, mechanical, bioprosthetic, homografts, and autografts), and implanted devices (eg, pacemakers, implantable cardioverter defibrillators, and ventricular
General Approach to the Patient
A general approach to the evaluation and treatment of uncomplicated IE is outlined in Table 5. Most patients with IE become afebrile within several days of the initiation of antimicrobial therapy. Prolonged fever or recurrence of fever needs further evaluation. Some patients with S. aureus may remain febrile, though, for up to 2 weeks. When fever recurs, there should be concern that the antibiotics are ineffective, that there is an abscess or other infection somewhere that is not being
When to Operate in Infective Endocarditis
Based on the observation by Hasbun et al,68 medical therapy alone may be associated with an increase in mortality at 6 months compared to surgery. Vikram and colleagues78 used the same data to determine whether valve surgery reduced mortality in adults with complicated, left-sided, IE. In this study, propensity modeling was used to create a matched case-control study. The authors found that valve surgery was strongly associated with improved survival (OR 0.40, 95% CI 0.18 to 0.91) at 6 months
Streptococci
Streptococci and staphylococci account for 80 to 90% of IE cases in which identification is made. The streptococci have traditionally been the most common cause of IE,83 and many community hospitals still report viridans streptococci as the most common isolates among patients with IE.84 However, staphylococci have assumed increasing importance among isolates in community hospitals in recent years.85 Viridans streptococci remain the major cause of IE in children; IE in young women with isolated
Antimicrobial Treatment
While decisions regarding specific antibiotic therapy for patients with IE are always individualized, certain general therapeutic principles provide the framework for the current recommendations for treatment of endocarditis: (1) complete eradication takes weeks to achieve; (2) the infection exists in a sequestered area of impaired host defense; (3) the bacteria in valvular vegetations may exist in a state of reduced metabolic activity and cell division,155 rendering them less susceptible to
Prophylaxis and Prevention
Although definitive prophylaxis against IE is a challenging goal for patients at risk for its development, it remains an integral aspect of medical care. It is also an area of controversy because of the lack of evidence from well-designed human trials regarding its efficacy. However, it is generally accepted that certain groups of patients are at an increased risk for the acquisition of IE224: (1) High-risk group: prosthetic cardiac valves (eg, bioprosthetic xenograft, homograft, and mechanical
How to Study a Rare Disease
Definitive studies of IE have been difficult to perform due to the low incidence of disease, a limitation that is compounded by the heterogeneous nature of the populations at risk, variable underlying risk factors, and a wide array of infecting organisms. Out of necessity, most studies are derived from case reports or series of cases collected at a single clinical site. There have been few case-control studies or large prospective cohort studies, and even fewer randomized controlled trials.
References (234)
- et al.
Incidence of infective endocarditis in the Delaware Valley, 1988-1990
Am J Cardiol
(1995) - et al.
Pathogenesis of streptococcal and staphylococcal endocarditis
Infect Dis Clin North Am
(2002) - et al.
The intracellular status of Streptococcus pyogenesrole of extracellular matrix-binding proteins and their regulation
Int J Med Microbiol
(2004) - et al.
Natural history of vegetations during successful medical treatment of endocarditis
Am Heart J
(1994) - et al.
Underlying cardiac lesions in adults with infective endocarditis
Am J Med
(1987) - et al.
Early onset prosthetic valve endocarditisthe Cleveland Clinic experience 1992-1997
Ann Thorac Surg
(2000) - et al.
Determinants of the occurrence of and survival from prosthetic valve endocarditis. Experience of the VA Cooperative Study on Valve Disease
J Thorac Cardiovasc Surg
(1994) - et al.
Comparison of bioprosthesis and mechanical valves, a meta-analysis of randomised clinical trials
Cardiovasc Surg
(2000) - et al.
The risk of stroke and death in patients with aortic and mitral valve endocarditis
Am Heart J
(2001) - et al.
New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service
Am J Med
(1994)
Value of transesophageal echocardiography as an adjunct to transthoracic echocardiography in evaluation of native and prosthetic valve endocarditis
Chest
Echocardiography in patients with suspected endocarditisa cost effectiveness analysis
Am J Med
Prediction of rapid versus prolonged healing of infective endocarditis by monitoring vegetation size
J Am Soc Echocardiogr
Periprocedural thromboprophylaxis in patients receiving chronic anticoagulation therapy
Am Heart J
Infective Endocarditis
Lancet
Progress toward a global understanding of infective endocarditis
Infect Dis Clin North Am
Echocardiographic assessment of patients with infectious endocarditis
J Am Coll Cardiol
The ability of vegetation size on echocardiography to predict clinical complicationsa meta-analysis
J Am Soc Echocardiogr
Echocardiography predicts embolic events in infective endocarditis
J Am Coll Cardiol
Value of transthoracic echocardiography in predicting embolic events in active infective endocarditis
Am J Cardiol
Infective endocarditis in intravenous drug abusers and HIV-1 infected patients
Infect Dis Clin North Am
The risk of stroke and death in patients with aortic and mitral valve endocarditis
Am Heart J
Results of surgical treatment for infective endocarditis in intravenous drug users
Chest
Current best practices and guidelines Indications for surgical intervention in infective endocarditis
Infect Dis Clin North Am
Increasing rates of cardiac device infections among Medicare beneficiaries1990-1999
Am Heart J
Surgical management of infective endocarditis associated with cerebral complications. Multi-center retrospective study in Japan
J Thorac Cardiovasc Surg
Pacemaker infective endocarditis
Am J Cardiol
Endocarditis after mitral valve repair
Ann Thorac Surg
Bacterial endocarditis at a small community hospital
Am J Med Sci
Pneumococcal endocarditis updateanalysis of 10 cases diagnosed between 1974 and 1984
Am Heart J
Centenary of William Osler’s 1885 gulstonian lectures and their place in the history of bacterial endocarditis
J R Soc Med
De Subitaneis Mortibus
Gulstonian lectures on malignant endocarditis
Br Med J
Epidemiologic aspects of infective endocarditis in an urban population. A 5-year prospective study
Medicine (Baltimore)
Characteristics of infective endocarditis in France 1991a one year survey
Eur Heart J
Changing profile of infective endocarditisresults of a 1-year survey in France
JAMA
Endocarditis in the elderly; Incidence, surgery, and survival in 16,921 patients over 12 years
Circulation
Changing patient characteristics and the effect on mortality in endocarditis
Arch Intern Med
Changing profile of infective endocarditisresults of a 1-year survey in France
JAMA
Risk factors for infective endocarditisoral hygiene and nondental exposures
Circulation (Online)
Procedures associated with infective endocarditis in adults. A case control study
Eur Heart J
Epidemiology of bacterial endocarditis in The Netherlands. II
Antecedent procedures and use of prophylaxis Arch Int Med
Cardiovascular risk factors and outcomes in patients with definite endocarditisfindings from 1024 patients in the ICE Prospective Cohort Study
Circulation
Infective endocarditis
Blood velocity and endocarditis
Circulation
In vivo efficacy of silver-coated (Silzone) infection-resistant polyester fabric against a biofilm-producing bacteria, Staphylococcus epidermidis
J Heart Valve Dis
The Silzone effecthow to reconcile contradictory reports?
Eur J Cardiothorac Surg
Infective endocarditis
Bacteremia in narcotic addicts at the Detroit Medical Center. II. Infectious endocarditis: a prospective comparative study
Rev Infect Dis
Cited by (216)
Approach to Cardiac Masses Using Multimodal Cardiac Imaging
2023, Current Problems in CardiologyCardiac Magnetic Resonance Imaging for the Diagnosis of Infective Endocarditis in the COVID-19 Era
2023, Current Problems in CardiologyEmergency Considerations of Infective Endocarditis
2022, Emergency Medicine Clinics of North AmericaEvaluation of penicillin‐gentamicin and dual beta-lactam therapies in Enterococcus faecalis infective endocarditis
2022, International Journal of Antimicrobial AgentsCitation Excerpt :Enterococci species account for 10% of all cases of infective endocarditis (IE), with Enterococcus faecalis (E. faecalis) being the causative organism in most instances [1]. Factors that predispose to the development of enterococcal IE include advanced age and persons who inject drugs (PWID), with sources of infection primarily being genitourinary or intraabdominal [1–3]. A first-line treatment regimen for E. faecalis infective endocarditis (EFIE) caused by penicillin-susceptible isolates has historically been the combination of intravenous penicillin G or ampicillin with an aminoglycoside for a duration of 4–6 weeks [4].
Echocardiographic assessment of infectious endocarditis
2022, Infective Endocarditis: A Multidisciplinary Approach
The authors have no conflict of interests to disclose.