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INTRODUCTION

Key Clinical Questions

  • image Does the patient have symptoms consistent with infective endocarditis?

  • image What tests and studies are indicated to evaluate infective endocarditis?

  • image What infectious etiologies should be considered?

  • image What treatments should be considered?

  • image What complications should be expected?

Infective endocarditis (IE) is a relatively common infection in the hospital setting, with an inpatient mortality rate of about 18%. The incidence of IE rises linearly with age, from around 1 case per 100,000 person-years among young adults to over 10 cases per 100,000 person-years among those older than 75 years. The hallmark lesion of IE is the endocardial vegetation. Although the heart valves are affected most commonly, IE also may involve septal defects, mural endocardium, or prosthetic cardiac structures. Vegetations may result in valvular regurgitation or obstruction, myocardial abscess, or mycotic aneurysm. Definitive diagnosis requires identification of the causative organism in blood, cardiac structures, or emboli. Cure requires prolonged antimicrobial treatment and often valve replacement surgery, leading to substantial expense.

EPIDEMIOLOGY

Historically, IE was a disease of younger patients with rheumatic heart disease, and mainly involved viridans group streptococci. In the past two decades, a new form of the disease, health care associated IE, has emerged. This new form of IE is distinct in its microbiology (predominantly Staphylococcus aureus) and risk factors (eg, intravenous catheters, hyperalimentation lines, pacemakers, dialysis shunts). The incidence of S. aureus IE has significantly increased over the last decade, such that it is now estimated to be the most common causative organism of IE in the developed world.

RISK FACTORS FOR IE

Almost any type of structural heart disease may predispose to IE, especially when the defect results in turbulent blood flow. ­Right-sided IE is primarily an infection of injection drug users and patients with indwelling transvenous pacemakers. In developed countries, the proportion of cases related to rheumatic heart disease has declined to 5% or less in the past two decades, while in developing countries, rheumatic heart disease remains the most common predisposing cardiac condition. Congenital bicuspid aortic valve is the underlying lesion in more than 15% of IE cases in patients (especially men) older than 60 years, and is associated with a poor prognosis, despite rapid valve replacement. Degenerative cardiac lesions (eg, calcified mitral annulus, calcific nodular lesions secondary to arteriosclerotic cardiovascular disease, and postmyocardial infarction thrombus) assume the greatest importance in the 30% to 40% of IE patients without any demonstrable underlying valvular disease. Marfan syndrome, when associated with aortic insufficiency, also has been associated with IE. Intravascular infections involving cardiac devices (eg, permanent cardiac pacemakers, defibrillators) also have increased significantly since the 1990s. Injection drug users are at high risk for recurrent and polymicrobial IE.

PATHOGENESIS AND PATHOPHYSIOLOGY

Mitral and aortic valvular involvements are most common in IE. ­Distributions of valvular involvement range from 28% to 45% of cases for isolated ...

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