Managing infective endocarditis in the elderly: new issues for an old disease

Abstract

The incidence of infective endocarditis (IE) rises in industrialized countries. Older people are more affected by this severe disease, notably because of the increasing number of invasive procedures and intracardiac devices implanted in these patients. Peculiar clinical and echocardiographic features, microorganisms involved, and prognosis of IE in elderly have been underlined in several studies. Additionally, elderly population appears quite heterogeneous, from healthy people without past medical history to patients with multiple diseases or who are even bedridden. However, the management of IE in this population has been poorly explored, and international guidelines do not recommend adapting the therapeutic strategy to the patient’s functional status and comorbidities. Yet, if IE should be treated according to current recommendations in the healthiest patients, concerns may rise for older patients who suffer from several chronic diseases, especially renal failure, and are on polypharmacy. Treating frailest patients with high-dose intravenous antibiotics during a prolonged hospital stay as recommended for younger patients could also expose them to functional decline and toxic effect. Likewise, the place of surgery according to the aging characteristics of each patient is unclear. The aim of this article is to review the recent data on epidemiology of IE and its peculiarities in the elderly. Then, its management and various therapeutic approaches that can be considered according to and beyond guidelines depending on patient comorbidities and frailty are discussed.

Role of age and comorbidities in mortality of patients with infective endocarditis

“…Infective endocarditis (IE) is a life-threatening disease with high morbidity and mortality [1][2][3][4]. Its incidence in older patients has increased for different reasons, such as the aging of the general population and the increasing percentage of comorbidities [5][6][7][8][9][10][11][12][13][14].…”

“…Its incidence in older patients has increased for different reasons, such as the aging of the general population and the increasing percentage of comorbidities [5][6][7][8][9][10][11][12][13][14]. Clinical presentation seems to be similar between the younger and older population [15][16][17][18][19]; however, there is no agreement on the role of age in general mortality or in the mortality related to surgery as a treatment for IE [2,8,10].…”

The clinical features and prognosis of infective endocarditis in the elderly from 2007-2016 in a tertiary hospital in China

“…In our study, we found the in-hospital mortality rate and one-year mortality rate in older patients was much higher than the younger patients, which was consistent with previous reports. [3,14,15,18,19] As reported previously, older adults were prone to require complex care needs and suffer from multiple comorbidities, which made them vulnerable to health-associated exposure and poor outcomes. [14,[20][21][22]Besides, the lower operative rate in older patients compared with the younger in our cohort may be another important reason for the higher mortality in older patients.…”

“…This phenomenon was frequently presented in previous reports. [3,26,27] The main consideration may be the increasing risks during the perioperative period owing to the decline in organ function and the presence of comorbidities associated with aging. These factors made the choice of surgical treatment for elderly patients more difficult.…”

It is not how old you are, it is how you are old: need for changes in the management of infective endocarditis in the elderly

“…Modifications of fat mass alter the volume of distribution of antibiotic according to their lipophilia. Decreased albumin level reduces transport of highly protein-bound drugs (such as vancomycin) and the resulting drug-free fraction 7. Decreased renal function reduces the renal drug clearance.…”