Management Considerations in Infective Endocarditis

Abstract

ndocarditis is an infection of the cardiac endothelium and can present as either acute or subacute disease. Acute infective endocarditis advances rapidly, presenting with a sudden onset of high fever, rigors, sepsis, and systemic complications. This presentation alone is indistinguishable from other causes of sepsis, but when there is also a new-onset heart murmur, a diagnosis of acute infective endocarditis should be considered. In contrast, subacute infective endocarditis can be difficult to diagnose. Patients develop nonspecific symptoms such as fatigue, dyspnea, or weight loss over several weeks to months. Fever may or may not be present. Although endocarditis is commonly associated with a heart murmur due to valve regurgitation, new murmurs are present in less than half of cases (Table 1). 1,2 Janeway lesions or Osler nodes are classic diagnostic findings (Figure 1), but they are present in fewer than 5% of cases. Imaging can reveal embolic phenomena such as pulmonary and splenic emboli (Figure 2). Infective endocarditis should be suspected when patients present with either an acute or subacute illness when infective endocarditis risk factors are present (Box 1). In general, Staphylococcus aureus infection causes acute, aggressive infections, and the more indolent pathogens, viridans group streptococci or coagulase-negative staphylococci, cause subacute infective endocarditis. MethodsWe conducted a literature search of the PubMed database from January 2008 through March 2018. The selection, including clinical trials, observational studies, review articles, and society guidelines, was limited to studies published in English. We reviewed the reference articles that were cited in the guidelines IMPORTANCE Infective endocarditis occurs in approximately 15 of 100 000 people in the United States and has increased in incidence. Clinicians must make treatment decisions with respect to prophylaxis, surgical management, specific antibiotics, and the length of treatment in the setting of emerging, sometimes inconclusive clinical research findings.OBSERVATIONS Community-associated infective endocarditis remains the predominant form of the disease; however, health care accounts for one-third of cases in high-income countries. As medical interventions are increasingly performed on older patients, the disease incidence from cardiac implanted electronic devices is also increasing. In addition, younger patients involved with intravenous drug use has increased in the past decade and with it the proportion of US hospitalization has increased to more than 10%. These epidemiological factors have led to Staphylococcus aureus being the most common cause in high-income countries, accounting for up to 40% of cases. The mainstays of diagnosis are still echocardiography and blood cultures. Adjunctive imaging such as cardiac computed tomographic and nuclear imaging can improve the sensitivity for diagnosis when echocardiography is not conclusive. Serological studies, histopathology, and polymerase chain reaction assays have distinct ro...

Repeat Infective Endocarditis in Persons Who Inject Drugs: “Take Another Little Piece of my Heart”*

“…Second, surgery was less commonly performed with rIE even though vegetations were more frequently visualized. This observation likely reflects the ongoing concerns over repeat surgical intervention in a patient population at high risk for repeat infection [1, 28–31]. Third, mortality at 1 year after an episode of rIE was high at ~36%, compared with a 1-year mortality of ~5% in PWID with sIE.…”

“…Injection drug use (IDU) is a well-known risk factor for infective endocarditis (IE), and people who inject drugs (PWID) now account for an increasing proportion of cases of community-onset IE [1]. As a consequence, approximately 16% of cases of IE in North America are now attributable to IDU [2].…”

Contemporary trends and outcomes of mitral valve surgery for infective endocarditis

“…Whether this trend is a result of an increasing incidence of MV IE vs a mere population growth, remains unknown. Recent studies suggested an increasing burden of IE in the United States in the last decade, but no data specific to MV endocarditis have been published . Regardless, given the increasing utilization of surgery in MV IE, assessing the utility and outcomes of various surgical techniques in this setting is warranted.…”

Saving patients by pulling their teeth out ‐ but killing them softly afterwards with dental implants?

“…(Duval, Delahaye, Alla, Tattevin, Obadia, et al, 2012). Bacteremia due to invasive procedures in the dental clinic rarely cause I.E., according to the American Heart Association (Baddour et al, 2015), the European Society of Cardiology (Habib et al, 2015), the French Society of Cardiology (Millot et al, 2017) and by others (Wang, Gaca, & Chu, 2018). These authoritative sources instead endorse the perspective that “everyday bacteremia” is a far more important risk factor for contracting I.E.…”