Endocarditis: innovations, issues and controversies

Abstract

Over the course of the last few decades, infective endocarditis has seen epidemiological upheaval, diagnostic and therapeutic advances. It has become an elderly person’s disease, often with no identified valve condition. It is increasingly associated with in and out-patient care. The occurrence of staphylococcal infections has doubled. Echocardiography and blood cultures remain essential diagnostic investigations. However, new microbiological tools are in the process of being evaluated. Imaging techniques (magnetic resonance imaging and positron emission tomography) frequently allow previously clinically silent septic metastases to be diagnosed. However, the impact of these diagnostic tests on treatment and in the future is yet to be determined. Surgery for left heart endocarditis is carried out in 50% of cases during the active phase and it is established that it improves the prognosis. Alongside recognised surgical procedures for severe heart failure, paravalvular extension or multiple embolisms, a recent random trial suggests that early surgical intervention in cases of valve disorders with thickening greater than 10 mm reduces the occurrence of embolic events. Neurological complications are the most common extracardiac complications. They are a frequent cause of admission to intensive care units and are given a poor prognosis. In the absence of a significant cerebral haemorrhage or ischemic lesions resulting from severe neurological impairment, surgery may be performed with a low postoperative risk of any worsening in neurological problems. Antibiotic regimens have been updated in numerous recommendations. Prophylactic antibiotics have been considerably less recommended. Endocarditis is still associated with high hospital mortality rates of between 10% and 40%.