Elsevier

The Lancet

Volume 379, Issue 9819, 10–16 March 2012, Pages 965-975
The Lancet

Review
Management of infective endocarditis: challenges and perspectives

https://doi.org/10.1016/S0140-6736(11)60755-1Get rights and content

Summary

Despite improvements in medical and surgical therapies, infective endocarditis is associated with poor prognosis and remains a therapeutic challenge. Many factors affect the outcome of this serious disease, including virulence of the microorganism, characteristics of the patients, presence of underlying disease, delays in diagnosis and treatment, surgical indications, and timing of surgery. We review the strengths and limitations of present therapeutic strategies and propose future directions for better management of endocarditis according to the most recent research. Novel perspectives on the management of endocarditis are emerging and offer hope for decreasing the rate of residual deaths by accelerating the process of diagnosis and risk stratification, reducing delays in starting antimicrobial therapy, rapid transfer of high-risk patients to specialised medico-surgical centres, development of new surgical methods, and close long-term follow-up.

Introduction

Infective endocarditis is a serious disease with an incidence of 30 to 100 episodes per million patient-years.1, 2, 3 Mortality is high: more than a third of patients will die within the first year of diagnosis.4, 5 Since the first analysis of 209 cases by Sir William Osler in 1885,6 the epidemiological pattern of infective endocarditis has changed7, 8 and prevention strategies have not lowered the incidence of this life-threatening disease.1, 2, 8, 9 Mortality has been affected by modifications in therapeutic management. Thus, three distinct periods are evident: (1) before the antibiotic era, infective endocarditis was always fatal; (2) the introduction of penicillin in the 1940s greatly reduced the number of deaths, but the mortality rate did not substantially fall thereafter despite the development of valvular surgery, done during the active phase of infection (early surgery);10 and (3) during the past decade, surgical indications have greatly increased, so we have entered into the era of early surgery.11, 12 Although aggressive therapy has become indispensable to save lives and to eradicate infection in many patients, reported rates of surgery remain heterogeneous (webappendix), and the beneficial effect of surgery on mortality is still difficult to show. These difficulties result from the scarcity of randomised trials and several confounding factors that hamper the analysis of observational studies. Nevertheless, the results from most investigations are favourable for early surgical management in complicated infective endocarditis. Thus, an appropriate identification of high-risk patients and their quick transfer to specialised medicosurgical centres seem to be crucial to improve the prognosis. Indeed, standardised management by a skilled multidisciplinary team has proven to decrease significantly mortality.13, 14 Despite this trend in treatment, most centres report an in-hospital fatality rate of about 20%, possibly because many patients are referred too late to medicosurgical institutions that are experienced in infective endocarditis. Therefore, challenges in management of this disease include improvement of diagnostic strategies to reduce delays for the start of appropriate treatment, better identification of patients who require close monitoring and urgent surgery, and development of new medical and surgical therapeutic methods.

The aims of this Review are to identify the therapeutic factors that have affected mortality from infective endocarditis throughout the years and to discuss new challenges and perspectives in management to reduce residual causes of death for this severe disease.

Section snippets

Antimicrobial therapy: benefits and limits

Infective endocarditis was always fatal before the era of antibiotics. The promise of a definitive treatment for this disease appeared with the advent of sulphonamide therapy in 1938,15 but the potential to definitively cure patients came with the introduction of penicillin in 1944, which greatly reduced mortality.16, 17, 18 Despite the emergence of resistant staphylococci, this rate of death remained constant thereafter, because of the development of vancomycin in 1956, and of

Challenges and perspectives

Despite improvements in the diagnostic and therapeutic strategies, the fatality rate due to infective endocarditis has not significantly decreased since the end of the 1970s. Important changes in the epidemiological profile of this disease that have occurred in the past few decades can explain part of this situation. The age of patients has increased and the incidence of health-care-associated infective endocarditis has increased as a consequence of medical progress.7, 50, 51 Thus, the more

Conclusion

Infective endocarditis remains among the deadliest of infectious diseases. Novel methods in management are emerging and offer hope in decreasing the rate of residual deaths (panel). These methods aim to accelerate the process of diagnosis and risk stratification, reduce delay in starting antimicrobial therapy, and transfer high-risk patients to specialised medicosurgical centres (figure 4). These future management strategies will implicate more physicians from different specialties, which will

Search strategy and selection criteria

We searched PubMed for articles using the search term “endocarditis” in combination with terms relevant for every section of the article, including “epidemiology”, “diagnosis”, “prognosis”, “management”, “therapy”, “treatment”, “antibiotics”, “surgery”, “outcome”, “survival”, and “mortality”. This search was limited to English articles and adult patients. We also searched the reference lists of articles identified by this search strategy, and selected those additional references that we judged

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