Long-term outcome of infective endocarditis: the impact of early surgical intervention

Outcomes of double-valve surgery for infective endocarditis are improving in the modern era

BACKGROUND

The incidence of infective endocarditis (IE) is rapidly increasing. Contemporary outcomes following high-risk double valve surgery (DVS) for IE are not well described.

METHODS

Between 2001 and 2021, 211 patients with IE underwent combined aortic and mitral valve surgery at a tertiary care referral center. Data from the Society of Thoracic Surgeons registry, including demographics, operative details, and outcomes, were collected. Risk factors for 30-day and 1-year-mortality were analyzed. Survival was analyzed using Kaplan-Meier and Cox proportional hazards modeling.

RESULTS

The study cohort had a male preponderance (73%), with a median age of 56 years (interquartile range [IQR], 44 to 63 years). Forty-five patients (21%) had a history of intravenous (IV) drug abuse, 50 (24%) were on preoperative dialysis, and 50 (24%) had prosthetic valve endocarditis. Thirty-day and 1-year mortality were 14% (n = 30) and 30% (n = 61), respectively. On multivariable Cox regression adjusting for age, prosthetic valve endocarditis, postoperative intra-aortic balloon pump (IABP), history of dialysis (adjusted hazard ratio [aHR], 1.9; 95% confidence interval [CI], 1.3 to 2.9; P = .002) and IV drug abuse (aHR, 2.0; 95% CI, 1.1-3.5; P = .02) were predictive of decreased survival. Undergoing surgery after 2010 was predictive of improved survival (aHR, 0.5; 95% CI, 0.3 to 0.8; P = .006). These patients were more likely to undergo urgent/emergent surgery (83% vs 29%; P < .001) and less likely to have an aortic root abscess (40% vs 58%; P = .03) or to require the commando procedure (13% vs 33%; P = .002).

CONCLUSIONS

In this large series evaluating outcomes of DVS for IE in the modern era, although the mortality risk remained elevated, improving outcomes may be associated with earlier surgical intervention before significant disease progression. Multidisciplinary evaluation for complex IE may be considered to better understand the optimal timing and repair strategy.

Escalation of antimicrobial resistance among MRSA part 2: focus on infections and treatment

INTRODUCTION

MRSA is associated with causing a variety of infections including skin and skin structure infections, catheter and device-related (e.g. central venous catheter, prosthetic heart valve) infections, infectious endocarditis, blood stream infections, bone, and joint infections (e.g. osteomyelitis, prosthetic joint, surgical site), central nervous system infections (e.g. meningitis, brain/spinal cord abscess, ventriculitis, hydrocephalus), respiratory tract infections (e.g. hospital-acquired pneumonia, ventilator-associated pneumonia), urinary tract infections, and gastrointestinal infections. The emergence and spread of multidrug resistant (MDR) MRSA clones has limited therapeutic options. Older agents such as vancomycin, linezolid and daptomycin and a variety of newer MRSA antimicrobials and combination therapy are available to treat serious MRSA infections.

AREAS COVERED

The authors discuss infections caused by MRSA as well as common older and newer antimicrobials and combination therapy for MRSA infections. A literature search of MRSA was performed via PubMed (up to September 2022), using the keywords: antimicrobial resistance; β-lactams; multidrug resistance, Staphylococcus aureus, vancomycin; glycolipopeptides.

EXPERT OPINION

Innovation, discovery, and development of new and novel classes of antimicrobial agents are critical to expand effective therapeutic options. The authors encourage the judicious use of antimicrobials in accordance with antimicrobial stewardship programs along with infection-control measures to minimize the spread of MRSA.

Importance of early diagnosis and surgical treatment of calcified amorphous tumor-related native valve endocarditis caused by Escherichia coli: a case report

BACKGROUND

Unlike Escherichia coli bacteremia, which is common, E. coli endocarditis is uncommon, particularly in patients with native valve, leading to its delayed diagnosis.

CASE PRESENTATION

We present a case of infective endocarditis caused by E. coli in a 78-year-old Japanese man with type 2 diabetes, involving persistent bacteremia and vegetation on the mitral valve (measuring 18 × 4.2 mm in diameter). He presented with recurrent fever after antimicrobial treatment for pyelonephritis. He received antibiotic therapy for 6 weeks and required surgical removal of a calcified amorphous tumor and vegetation with mitral valvuloplasty 7 days after admission. Despite an episode of multiple cerebral infarctions, he recovered fully from the infection.

CONCLUSIONS

Follow-up blood cultures should be performed for Gram-negative bacilli bacteremia among patients with unknown focus and an atypical clinical course after treatment. Early diagnosis and aggressive surgical intervention are paramount to achieving good clinical outcomes.

A step-by-step guide to implementing a multidisciplinary endocarditis team

Over the last several years multiple studies, primarily from European centers have demonstrated the clinical and outcomes benefits of multidisciplinary endocarditis teams. Despite this literature, adoption of this approach to patient care has been slower in the United States. While there is literature outlining the optimal composition of an endocarditis team, there is little information to guide providers as they attempt to transform practice from a fragmented, disjointed process to an efficient, collaborative care model. In this review, the authors will outline the steps they took to create and implement a successful multidisciplinary endocarditis team at the University of Michigan. In conjunction with existing data, this piece can be used as a resource for clinicians seeking to improve the care of patients with endocarditis at their institutions.

Endovascular Treatment of Right Heart Masses Utilizing the AngioVac System: A 6-Year Single-Center Observational Study

Objective

To describe our institution's experience with the AngioVac system.

Background

Intracardiac and intravascular masses previously required surgical excision, but now, there are a number of minimally invasive options. With the advent of vacuum aspiration, more specifically the AngioVac System (AngioDynamics, NY, USA), there exists a system with both low mortality and minor complications. However, the number of retrospective studies remains limited. Outcome data for high-risk patients are also limited.

Methods

Data were collected and analyzed in patients who underwent AngioVac therapy at our tertiary care center from January 2014 to December 2020.

Results

Our results demonstrated a 93.3% intraoperative success rate and a 100% intraoperative survival rate. However, a number of complications, including but not limited to hematomas, anemia, and hypotension, occurred, as described below.

Conclusions

Our experiences demonstrated good outcomes and continue to support the usefulness of the AngioVac System. The data also support the use of AngioVac as a treatment option for the debulking or removal of right heart masses in critically ill patients.

The Clinical Impact of Implementation of a Multidisciplinary Endocarditis Team

BACKGROUND

Infectious endocarditis is associated with substantial in-hospital mortality of 15-20%. Effective management requires coordination between multiple medical and surgical subspecialties which can often lead to disjointed care. Previous European studies have identified multidisciplinary endocarditis teams as a tool for reducing endocarditis mortality.

METHODS

The multidisciplinary endocarditis Team was formed in May 2018. The group developed an evidence-based algorithm for management of endocarditis that was used to provide recommendations for hospitalized patients over a 1-year period. Mortality outcomes were then retroactively assessed and compared to a historical control utilizing propensity matching.

RESULTS

Between June 2018 and June 2019 the team provided guideline-based recommendations on 56 patients with Duke Criteria definite endocarditis and at least 1 AHA indication for surgery. The historical control included 68 patients with definite endocarditis and surgical indications admitted between July 1^st, 2014 to June 30^th, 2015. In-hospital mortality decreased significantly from 29.4% in 2014-2015 to 7.1% in 2018-2019 (p<0.0001). There was a non-significant increase in the rate of surgical intervention after implementation of the team (41.2% vs 55.4%; p=0.12). Propensity score matching demonstrated similar results.

CONCLUSIONS

Implementation of a multidisciplinary endocarditis team was associated with a significant 1-year decrease in all-cause in-hospital mortality for patients with definite endocarditis and surgical indications, in the presence of notable differences between the two studied cohorts. In conjunction with previous studies demonstrating their effectiveness, this data supports that widespread adoption of endocarditis teams in North America could improve outcomes for this patient population.

Impact of surgical timing on survival in patients with infective endocarditis: a time-dependent analysis

The purpose of this study was to evaluate the impact of surgical timing on survival in patients with left-sided infective endocarditis (IE). This was a retrospective study including 313 patients with left-sided IE between 2009 and 2017. Surgery was defined as urgent (US) or early (ES) if performed within 7 or 28 days, respectively. A multivariable Cox regression analysis including US and ES as time-dependent variables was performed to assess the impact on 1-year mortality. ES was associated with a better survival (aHR 0.349, 95% CI 0.135-0.902), as US (aHR 0.262, 95% CI 0.075-0.915). ES and US were associated with a better prognosis in patients with left-sided IE.

The Role of Coronary Catheterization with Angiography in Surgically Managed Infectious Endocarditis

BACKGROUND

Coronary catheterization with angiography is often performed prior to surgical valve replacement in infectious endocarditis. There are no existing data as to whether this intervention is clinically necessary or leads to a change in surgical management. In order to determine the frequency with which coronary angiography impacts surgical management in infectious endocarditis, we conducted a retrospective review of surgically managed endocarditis cases at a tertiary care medical center.

METHODS

Utilizing the institutional Society of Thoracic Surgeon's database, we identified 598 patients with surgically managed endocarditis between April 29, 2011 and December 31, 2018. Patient variables were recorded, including risk factors for coronary artery disease, whether the patient received coronary angiography prior to surgery, and if the patient underwent coronary artery bypass grafting as part of their valve surgery.

RESULTS

There were 430 patients who received coronary catheterization with angiography prior to surgical valve replacement for infectious endocarditis, and 168 patients proceeded to surgery without coronary angiography. Nine percent of patients underwent coronary artery bypass grafting at the time of valve replacement as a result of coronary angiography findings. There was no significant difference in 30-day mortality for patients with endocarditis who underwent coronary angiography when compared with those who did not receive coronary angiography (2.6 vs 2.4%; P = 0.89).

CONCLUSIONS

Left heart catheterization with coronary angiography prior to surgical valve replacement leads to coronary artery bypass grafting in the minority of infective endocarditis patients.

Clinical Practice Update on Infectious Endocarditis

Infectious endocarditis is a highly morbid disease with approximately 43,000 cases per year in the United States. The modified Duke Criteria have poor sensitivity; however, advances in diagnostic imaging provide new tools for clinicians to make what can be an elusive diagnosis. There are a number of risk stratification calculators that can help guide providers in medical and surgical management. Patients who inject drugs pose unique challenges for the health care system as their addiction, which is often untreated, can lead to recurrent infections after valve replacement. There is a need to increase access to medication-assisted treatment for opioid use disorders in this population. Recent studies suggest that oral and depo antibiotics may be viable alternatives to conventional intravenous therapy. Additionally, shorter courses of antibiotic therapy are potentially equally efficacious in patients who are surgically managed. Given the complexities involved with their care, patients with endocarditis are best managed by multidisciplinary teams.

Embolization of Endocardial Vegetation With Stroke Presentation

This case report details the unique cause of death of a 37-year-old Caucasian woman with a history significant for intravenous drug abuse. Before her death, she complained of extremity weakness and pain. Although her death was discovered to be the result of endocarditis, her symptoms were similar to that of a stroke. Autopsy revealed a large endocardial vegetation infecting both the tricuspid and mitral valves and a patent foramen ovale. The subsequent embolization of this vegetation caused blockages in the lungs, liver, and brain. An acute embolization of these vegetations to the bilateral middle cerebral arteries is the cause of the stroke presentation. Other comorbidities, such as cardiomegaly, microscopic evidence of myocardial infarction, and atherosclerotic disease, also contributed to the cause of death. As the opioid crisis continues in the United States, it is important to review cases involving the effects of drug use. The multiple interactions between endocarditis and the aforementioned conditions are documented to not only serve as references for future autopsies but also for the treatment of patients who have similar symptoms and comorbidities.

Risk Factors and Outcomes of Endocarditis Due to Non-HACEK Gram-Negative Bacilli: Data from the Prospective Multicenter Italian Endocarditis Study Cohort

The objective of this study was to investigate predisposing factors and outcomes of infective endocarditis (IE) caused by non-HACEK Gram-negative bacilli (GNB) in a contemporary multicenter cohort. Patients with IE due to GNB, prospectively observed in 26 Italian centers from 2004 to 2011, were analyzed. Using a case-control design, each case was compared to three age- and sex-matched controls with IE due to other etiologies. Logistic regression was performed to identify risk factors for IE due to GNB. Factors associated with early and late mortality were assessed by Cox regression analysis. The study group comprised 58 patients with IE due to GNB. We found that Escherichia coli was the most common pathogen, followed by Pseudomonas aeruginosa and Klebsiella pneumoniae The genitourinary tract as a source of infection (odds ratio [OR], 13.59; 95% confidence interval [CI], 4.63 to 39.93; P < 0.001), immunosuppression (OR, 5.16; 95% CI, 1.60 to 16.24; P = 0.006), and the presence of a cardiac implantable electronic device (CIED) (OR, 3.57; 95% CI, 1.55 to 8.20; P = 0.003) were factors independently associated with IE due to GNB. In-hospital mortality was 13.8%, and mortality rose to 30.6% at 1 year. A multidrug-resistant (MDR) etiology was associated with in-hospital mortality (hazard ratio [HR], 21.849; 95% CI, 2.672 to 178.683; P = 0.004) and 1-year mortality (HR, 4.408; 95% CI, 1.581 to 12.287; P = 0.005). We conclude that the presence of a genitourinary focus, immunosuppressive therapy, and an indwelling CIED are factors associated with IE due to GNB. MDR etiology is the major determinant of in-hospital and long-term mortality.

Comparison of Outcome of Possible Versus Definite Infective Endocarditis Involving Prosthetic or Bioprosthetic Heart Valves

The objectives of this study were to describe and compare the clinical characteristics and outcomes of patients with definite and possible infective endocarditis (IE) involving prosthetic heart valve, and to identify prognostic factors for long-term mortality, using data from an unselected cohort of consecutive patients. We studied data from 133 consecutive patients with IE involving prosthetic heart valve seen in an academic institution between 1990 and 2012. Patients were classified according to the modified Duke criteria for IE: patients with possible IE (n = 47, 35%) and patients with definite IE (n = 86, 65%). Overall, 55 patients died over a mean ± SD follow-up of 3.6 ± 4.1 years (median 1.8, interquartile range 4.4 years). Patients with definite IE had a higher risk of death (hazard ratio [HR] 2.21, 95% confidence interval [CI] 1.20 to 4.17 p = 0.01). Independent predictors of long-term mortality were increasing age (HR 1.05, 95% CI 1.02 to 1.08, p = 0.002), Staphylococcus aureus infection (HR 3.40, 95% CI 1.00 to 11.76; p = 0.05), infection with unknown microorganism (HR 12.50, 95% CI 2.97 to 52.63; p = 0.0006), and definite IE (HR 8.70, 95% CI 3.55 to 21.28; p <0.0001), whereas infection on pacemaker or defibrillator (HR 0.30, 95%CI 0.10 to 0.87; p = 0.03) was associated with a better prognosis. Patients with definite IE and those with possible IE who underwent surgery had a nonsignificantly better prognosis than their counterparts with no surgery. In conclusion, patients with definite IE (Duke criteria) on a prosthetic heart valve independently had a worse prognosis than those with possible IE.

Comparison of Outcome of Possible Versus Definite Infective Endocarditis Involving Native Heart Valves

There are very few data on the prognosis of possible versus definite infective endocarditis (IE). We studied data from 365 consecutive patients with IE involving native heart valve seen in an academic institution from 1990 to 2012. Patients were classified according to the modified Duke criteria for IE: patients with possible IE (n = 101, 28%) and those with definite IE (n = 264, 72%). Patients with possible IE were older than those with definite IE (66 ± 15 vs 62 ± 16, p = 0.05). A causative microorganism was identified in 66% of patients with possible IE versus all patients with definite IE (p <0.0001) and only 41% had major echocardiographic criteria (vs 100%; p <0.0001). Overall, 139 patients died over a mean ± SD follow-up of 3.9 ± 4.5 years (median 2.2, interquartile range 5.9 years). Patients with possible and definite IE had a similar risk of death. Independent predictors of long-term mortality were increasing age (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.01 to 1.04; p = 0.0009), vegetation length >15 mm (HR 1.87, 95% CI 1.14 to 3.06; p = 0.01), and stroke (HR 4.10, 95% CI 1.84 to 9.17; p = 0.0006), whereas infection of mitral valve (HR 0.57, 95% CI 0.34 to 0.94; p = 0.03) and surgery (HR 0.43, 95% CI 0.19 to 0.99; p = 0.05) were associated with a better prognosis. Patients with definite IE and those with possible IE who did not undergo surgery had a worse prognosis than their counterparts with surgery. In conclusion, unselected patients with possible IE (Duke criteria) had a similar prognosis than those with definite IE.

Role of mitral valve repair in active infective endocarditis: long term results

BACKGROUND

Although mitral valve repair is at present the technique of choice in mitral regurgitation (MR) due to degenerative valve disease, long term results in patients with active mitral infective endocarditis (IE) are still under evaluation.

METHODS

In the study were included 34 consecutive patients (22 males; mean age, 60 years; range 32-84 years) referred to our institution between January 1, 2005 to December 31, 2011 who were treated with valve repair for mitral valve (MV) active infective endocarditis. Eighteen patients underwent isolated MV repair. Aortic valve replacement and respectively repair were performed in 9 and 2 patients with concomitant aortic involvement. Blood cultures were positive in 30 (17 Staphylococcus, 13 Streptococcus, 1 g negative, 2 enterococcus).

RESULTS

Four patients died during hospital stay (11%) due to multi system organ failure as a consequence of severe septic shock (2 patients), cardiogenic shock (1 case) and respiratory failure (1 patient). At an average follow up of 48 months in patients discharged alive from hospital survival was 96.7% (29 out of 30). None developed more than mild- to moderate mitral valve regurgitation during follow-up and we found a significant improvement in functional capacity and left ventricular ejection fraction associated with a significant decrease of pulmonary artery pressure. The only recurrence of endocarditis occurred in a drug addict patient.

CONCLUSIONS

Present investigation suggest that in patients with active mitral valve endocarditis MV repair, when technically feasible, is associated with a favorable clinical long term outcome. None of the patients alive at the end of follow-up developed severe mitral regurgitation. Moreover mortality and reinfection rate are uncommon and functional improvement.

Long-Term Outcome and Valve Surgery for Infective Endocarditis in the Systematic Analysis of a Community Study

BACKGROUND

Information on the long-term prognosis of patients with infective endocarditis (IE) and valve surgical procedures is scarce, and most analyses are based on registries. This study described outcomes and predictors of mortality in a cohort of consecutive patients with IE with a long-term follow-up.

METHODS

A total of 616 of patients with IE seen in an academic institution between 1990 and 2012 were identified and followed. The mean follow-up period was 4.8 ± 5.7 years (median, 2.6 years).

RESULTS

Cardiac surgical procedures were performed in 47% of the patients, among whom 77% had surgical procedures in the first 6 months. Six-month and long-term (≥6 month) mortality rates were 15% and 40%, respectively. Older age, male sex, infection in a mechanical valve, Staphylococcus aureus infection, presence of vegetation, stroke, and atrioventricular block were independent predictors of mortality, whereas Streptococcus infection was independently associated with a better prognosis. Valve surgical procedures were independently associated with a decrease in mortality: hazard ratio (HR): 0.38; 95% confidence interval (CI): 0.26 to 0.56 for surgical treatment within 45 days; HR 0.36; 95% CI: 0.22 to 0.61 for surgical treatment between 45 and 180 days; and HR: 0.42; 95% CI: 0.25 to 0.73 for surgical treatment beyond 6 months. Decrease in mortality with valve surgical procedures was found in the two subgroups of patients with definite IE (adjusted HR: 0.36; 95% CI: 0.24 to 0.54; p < 0.0001) and in those with possible IE (HR: 0.40; 95% CI: 0.24 to 0.67; p = 0.0005).

CONCLUSIONS

In unselected patients with IE, prognostic factors for long-term mortality were consistent with those identified in previous studies for short-term mortality. These results confirm the apparent benefit associated with valve surgical procedures on long-term prognosis.

Beyond Antibiotics: New Therapeutic Approaches for Bacterial Infections

The utility of conventional antibiotics for the treatment of bacterial infections has become increasingly strained due to increased rates of resistance coupled with reduced rates of development of new agents. As a result, multidrug-resistant, extensively drug-resistant, and pandrug-resistant bacterial strains are now frequently encountered. This has led to fears of a "postantibiotic era" in which many bacterial infections will be untreatable. Alternative nonantibiotic treatment strategies need to be explored to ensure that a robust pipeline of effective therapies is available to clinicians. In this review, we highlight some of the recent developments in this area, such as the targeting of bacterial virulence factors, utilization of bacteriophages to kill bacteria, and manipulation of the microbiome to combat infections.

Early versus late surgical intervention or medical management for infective endocarditis: a systematic review and meta-analysis

OBJECTIVE

Infective endocarditis is associated with high morbidity and mortality and optimal timing for surgical intervention is unclear. We performed a systematic review and meta-analysis to compare early surgical intervention with conservative therapy in patients with infective endocarditis.

METHODS

PubMed, Cochrane, EMBASE, CINAHL and Google-scholar databases were searched from January 1960 to April 2015. Randomised controlled trials, retrospective cohorts and prospective observational studies comparing outcomes between early surgery at 20 days or less and conservative management for infective endocarditis were analysed.

RESULTS

A total of 21 studies were included. OR of all-cause mortality for early surgery was 0.61 (95% CI 0.50 to 0.74, p<0.001) in unmatched groups and 0.41 (95% CI 0.31 to 0.54, p<0.001) in the propensity-matched groups (matched for baseline variables). For patients who had surgical intervention at 7 days or less, OR of all-cause mortality was 0.61 (95% CI 0.39 to 0.96, p=0.034) and in those who had surgical intervention within 8-20 days, the OR of mortality was 0.64 (95% CI 0.48 to 0.86, p=0.003) compared with conservative management. In propensity-matched groups, the OR of mortality in patients with surgical intervention at 7 days or less was 0.30 (95% CI 0.16 to 0.54, p<0.001) and in the subgroup of patients who underwent surgery between 8 and 20 days was 0.51 (95% CI 0.35 to 0.72, p<0.001). There was no significant difference in in-hospital mortality, embolisation, heart failure and recurrence of endocarditis between the overall unmatched cohorts.

CONCLUSION

The results of our meta-analysis suggest that early surgical intervention is associated with significantly lower risk of mortality in patients with infective endocarditis.

Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management

Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.

Methicillin Resistance and Risk Factors for Embolism inStaphylococcus aureusInfective Endocarditis

Objective.

Infective endocarditis caused byStaphylococcus aureusis an ominous prognosis associated with a high prevalence of embolic episodes and neurological involvement. Whether methicillin resistance decreases the risk of embolism in infective endocarditis is unclear. We sought to assess the association between methicillin resistance and risk factors for embolism in S.aureusinfective endocarditis.

Design.

Retrospective chart review. Data from patients with infective endocarditis due to methicillin-resistantS. aureus werecompared with data from patients with endocarditis due to methicillin-susceptibleS. aureus.Logistic regression was used to identify independent risk factors for embolism.

Setting.

A 2,000-bed, university-affiliated tertiary care hospital.

Patients.

Between 1995 and 2005, 123 patients withS. aureusinfective endocarditis were included in the study. There were 74 male patients and 49 female patients, with a median age of 54 years (range, 0-89 years).

Results.

Of 123 infections, 30 (24%) were nosocomial infections, and 14 (11%) were prosthetic valve infections. Of 123S. aureusisolates, 48 (39%) were methicillin resistant. In total, embolism occurred in 45 (37%) of these patients: pulmonary embolism in 22 (18%), cerebral embolism in 21 (17%), and peripheral embolism in 6 (5%). The independent risk factors for an embolism were injection drug use, presence of a cardiac vegetation with a size of 10 mm or greater, and absence of nosocomial infection. For 83 patients with aortic or mitral infective endocarditis, independent risk factors for an embolism were the presence of a cardiac vegetation with a size of 10 mm or greater and endocarditis due to methicillin-susceptibleS. aureus.Overall, in-hospital death occurred for 32 (26%) of 123 Patients. Methicillin-resistant infection was not an independent risk factor for death.

Conclusions.

Methicillin-resistant S.aureusinfection was associated with decreased risk of embolism in left-side endocarditis, but was not associated with in-hospital death.

Infective endocarditis epidemiology over five decades: a systematic review

AIMS

To Assess changes in infective endocarditis (IE) epidemiology over the last 5 decades.

METHODS AND RESULTS

We searched the published literature using PubMed, MEDLINE, and EMBASE from inception until December 2011.

DATA FROM

Einstein Medical Center, Philadelphia, PA were also included. Criteria for inclusion in this systematic review included studies with reported IE microbiology, IE definition, description of population studied, and time frame. Two authors independently extracted data and assessed manuscript quality. One hundred sixty studies (27,083 patients) met inclusion criteria. Among hospital-based studies (n=142; 23,606 patients) staphylococcal IE percentage increased over time, with coagulase-negative staphylococcus (CNS) increasing over each of the last 5 decades (p<0.001) and Staphylococcus aureus (SA) in the last decade (21% to 30%; p<0.05). Streptococcus viridans (SV) and culture negative (CN) IE frequency decreased over time (p<0.001), while enterococcal IE increased in the last decade (p<0.01). Patient age and male predominance increased over time as well. In subgroup analysis, SA frequency increased in North America, but not the rest of the world. This was due, in part, to an increase in intravenous drug abuse IE in North America (p<0.001). Among population-based studies (n=18; 3,477 patients) no significant changes were found.

CONCLUSION

Important changes occurred in IE epidemiology over the last half-century, especially in the last decade. Staphylococcal and enterococcal IE percentage increased while SV and CN IE decreased. Moreover, mean age at diagnosis increased together with male:female ratio. These changes should be considered at the time of decision-making in treatment of and prophylaxis for IE.

Early surgical therapy of infective endocarditis in children: a 15-year experience

OBJECTIVES

Infective endocarditis is rare in children but potentially carries high mortality and morbidity. Few data exist regarding surgical therapy and the associated outcomes in children with infective endocarditis. The aim of the present study was to describe the characteristics and outcomes of children undergoing surgery for infective endocarditis.

METHODS

A retrospective review of all patients aged 21 years or younger diagnosed with definitive infective endocarditis at a single center from 1996 to 2010 was performed.

RESULTS

Of 76 identified patients with infective endocarditis (median age, 8.3 years; 73.9% boys), 46 patients (61%) required surgical intervention. Staphylococcus aureus was most commonly isolated (18 patients, 24%) followed by Streptococcus (17 patients, 22%). Common surgical indications included severe valvular insufficiency in 13 patients, septic embolization in 12, concomitant severe valvular insufficiency and ventricular dysfunction in 9, persistent vegetations in 9, and persistent bacteremia in 3. Although early surgery was performed within 7 days of diagnosis in 35 patients (76%), 25 (54%) underwent surgery within 3 days or less. The factors associated with surgery included the presence of ventricular dysfunction, left-sided vegetation, severe valvular insufficiency, septic embolization, and S aureus. Surgery within 3 days or less was associated with the presence of ventricular dysfunction and S aureus. Native valve repair was performed in 50% of patients with native-valve disease. Postoperatively, no septic embolization events occurred and recurrence was low (2%). The 1-, 5-, and 10-year survival was 98% ± 2%, 90% ± 8%, and 81% ± 11%, respectively.

CONCLUSIONS

Children with infective endocarditis can undergo successful early surgical therapy with a low risk of septic embolization, recurrence, and operative mortality.

Neurologic Implications of Critical Illness and Organ Dysfunction

Critical illness has consequences for the nervous system. Patients experiencing critical illness are at risk for common global neurologic disturbances, such as delirium, long-term cognitive dysfunction, ICU-acquired weakness, sleep disturbances, recurrent seizures, and coma. In addition, complications related to specific organ dysfunction may be anticipated. Cardiovascular disease presents the possibility for CNS injury after cardiac arrest, sequelae of endocarditis, aberrancies of blood flow autoregulation, and malperfusion. Respiratory disease is known to cause short-term effects of hypoxia and long-term effects after ARDS. Sepsis encephalopathy and sickness behavior syndrome are early signs of infection in patients. In addition, commonly encountered organ dysfunction including uremia, hepatic failure, endocrine, and metabolic disturbances present with neurologic findings which may manifest in the critically ill patient as well.

Evaluating treatment options for patients with infective endocarditis: when is it the right time for surgery?

Infective endocarditis remains a life-threatening condition with an unchanging incidence and mortality of nearly 30% at 1 year. Surgery is required in 25–50% of acute infections and 20–40% of patients during convalescence. Operative procedures are often technically challenging and high-risk, often due to coexistent multisystem disease. However, international guidelines provide clear indications for surgical intervention, which are applicable for the majority of patients. These are not, however, supported by particularly robust clinical evidence and decision-making often needs to be tailored to the advancing age of the overall patient cohort, the presence of multisystem disease, comorbidities, prior antibiotic therapy of varying duration and the availability of surgical expertise. Native valve endocarditis will be the initial focus of this article, along with subgroups including prosthetic valve endocarditis. We present the treatment options for patients with infective endocarditis, evaluate the evidence-base that supports current clinical practice and attempt to provide an insight and subsequent recommendations for the timing of surgery.

Surgical treatment in active infective endocarditis: results of a four-year experience

Background. Aim of present investigation was to analyze survival and recurrence rate in patients with active endocarditis referred to our centre for surgical treatment. Methods. 80 consecutive patients with active infective endocarditis (52 males, 28 females, mean age 59.2 years) were referred to our institution for surgical treatment. 78 patients underwent surgery, and 2 patients died before intervention. Results. Fifty patients had native valve endocarditis, 30 prosthetic valve involvement. Hospital mortality has been 10.2%. Three discharged patients (4.9%) died at an average 18-month followup. Endocarditis recurred in 4 (2 being S. aureus prosthetic tricuspid endocarditis in drug addicts). All patients who underwent valve repair or homograft implant were alive and free of recurrence. Conclusions. Our results suggest that with proper surgical treatment patients with active endocarditis discharged alive from hospital have a survival >90% at 18 months with a low recurrence rate.

[A case of native valve infective endocarditis in an immunocompromised patient]

Infective endocarditis continues to be associated with high mortality, despite the medical and surgical therapeutic options available. Surgical intervention is indicated in cases of heart failure or uncontrolled infection and sometimes for the prevention of embolic phenomena. The authors present the case of a 56-year-old male patient, with fibro-calcific mitral-aortic valve disease, splenectomized and with recently relapsed Hodgkin's lymphoma, who was admitted with infective endocarditis due to Streptococcus dysgalactiae. On the thirtieth day of directed antibiotic therapy, the mitral vegetation showed a significant increase in size and mobility. Surgery was considered at this point. However, given the patient's clinical stability and laboratory results, it was decided to adopt a conservative approach and to extend antibiotic therapy. The vegetation had regressed considerably seven days later. Given this atypical vegetation behavior, with slower than usual regression for the causative agent, the authors suggest that antibiotic therapy should be extended in patients with some degree of immunosuppression.

Survival of surgically treated infective endocarditis: a comparison with the general Dutch population

BACKGROUND

Infective endocarditis (IE) remains associated with high in-hospital and long-term mortality. The outcome of patients with IE who are operated on has never been put into perspective by comparing it to the age-matched and gender-matched general population. The aim of the present study was to evaluate the long-term mortality of patients with IE who undergo operation in relation to the age-matched and gender-matched general population.

METHODS

A retrospective observational cohort study of 138 patients with IE who underwent consecutive operations (1998-2007) was conducted. Cumulative survival was analyzed using the Kaplan-Meier method. Comparison of patient survival with the general population was done using the Dutch population life table. The standardized mortality ratio was used to assess the degree of late deaths.

RESULTS

The observed in-hospital mortality risk was 10.9%. The observed long-term survival was 85% (95% confidence interval, 78% to 90%), 74% (95% confidence interval, 65% to 79%), 71% (95% confidence interval, 62% to 78%) after 1, 5, and 10 years, respectively. Age-matched and gender-matched survival in the general population was 99%, 93%, and 80% after a follow-up period of 1, 5, and 10 years, respectively. The standardized mortality ratio was 0.99 (95% confidence interval, 0.67 to 1.31).

CONCLUSIONS

Although mortality of IE patients who have undergone operation remains considerable during the immediate postoperative period, the mortality of hospital survivors is, with increasing follow-up time, comparable with the general population.

Surgery in current therapy for infective endocarditis

The introduction of the Duke criteria and transesophageal echocardiography has improved early recognition of infective endocarditis but patients are still at high risk for severe morbidity or death. Whether an exclusively antibiotic regimen is superior to surgical intervention is subject to ongoing debate. Current guidelines indicate when surgery is the preferred treatment, but decisions are often based on physician preferences. Surgery has shown to decrease the risk of short-term mortality in patients who present with specific symptoms or microorganisms; nevertheless even then it often remains unclear when surgery should be performed. In this review we i) systematically reviewed the current literature comparing medical to surgical therapy to evaluate if surgery is the preferred option, ii) performed a meta-analysis of studies reporting propensity matched analyses, and iii), briefly summarized the current indications for surgery.

Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children

Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system (CNS) infections. Recommendations are provided regarding vancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibility to vancomycin, and vancomycin treatment failures.

Surgical intervention for infective endocarditis in a veteran population

BACKGROUND

Surgical management of infective endocarditis can be challenging. Veteran patients are unique because they often have significant comorbidities, and surgical management of endocarditis in this population has not been well described.

METHODS

Using a prospective database, 46 consecutive patients who underwent valve surgery for acute infective endocarditis between 1987 and 2009 were identified. Survival was assessed using the Kaplan-Meier method.

RESULTS

All patients were men (mean age, 56 ± 9 years). The most common indication for surgical intervention was congestive heart failure (60%). The aortic valve was the only valve infected in most patients (65%). Operative morbidity and mortality were 33% and 9%, respectively. The 1-year, 3-year, 5-year, and 10-year unadjusted survival rates were 72%, 57%, 51%, and 30%, respectively.

CONCLUSIONS

Although acceptable short-term outcomes can be achieved in veterans undergoing surgical treatment for endocarditis, unadjusted long-term survival may be poor.

Infective endocarditis at a hospital in Saudi Arabia: epidemiology, bacterial pathogens and outcome

BACKGROUND AND OBJECTIVE

Data on infective endocarditis prevalence, epidemiology and etiology from Saudi Arabia and the Gulf region are sparse. We undertook this study to describe the pattern and the causative agents of endocarditis at a hospital in Saudi Arabia.

METHODS

We conducted a retrospective analysis of all reported endocarditis cases at the Dhahran Health Center from January 1995 to December 2008.

RESULTS

Of the 83 cases of endocarditis, 54 (65%) were definite endocarditis and the remaining 29 (35%) were possible endocarditis based on the Duke criteria. Patients with definite endocarditis included 39 males and 15 females (ratio of 2.6:1) with a mean age (SD) of 59.7 (18.2) years. Of the definite endocarditis cases, native valve endocarditis occurred in 44 (81.5%) cases of and prosthetic valve endocarditis was observed in 10 (18.5%). The most commonly involved valves were mitral (n=24; 44.4%) and aortic (n=20; 39.2%). The most common organisms were S aureus (n=23; 42.6%), Enterococcus faecalis (n=12; 22.2%) and viridans streptococci (n=9; 16.7%). Surgical intervention was required in 17 (31.4%) cases and the in-hospital mortality rate was 29.4% (n=15). Of all the patients, 3 (5.5%) had embolic stroke as a complication.

CONCLUSION

Native valve endocarditis is the predominant type of endocarditis. The patients were older adults and the most common organisms were S aureus, E faecalis and viridans streptococci.

Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study

BACKGROUND

We sought to provide a contemporary picture of the presentation, etiology, and outcome of infective endocarditis (IE) in a large patient cohort from multiple locations worldwide.

METHODS

Prospective cohort study of 2781 adults with definite IE who were admitted to 58 hospitals in 25 countries from June 1, 2000, through September 1, 2005.

RESULTS

The median age of the cohort was 57.9 (interquartile range, 43.2-71.8) years, and 72.1% had native valve IE. Most patients (77.0%) presented early in the disease (<30 days) with few of the classic clinical hallmarks of IE. Recent health care exposure was found in one-quarter of patients. Staphylococcus aureus was the most common pathogen (31.2%). The mitral (41.1%) and aortic (37.6%) valves were infected most commonly. The following complications were common: stroke (16.9%), embolization other than stroke (22.6%), heart failure (32.3%), and intracardiac abscess (14.4%). Surgical therapy was common (48.2%), and in-hospital mortality remained high (17.7%). Prosthetic valve involvement (odds ratio, 1.47; 95% confidence interval, 1.13-1.90), increasing age (1.30; 1.17-1.46 per 10-year interval), pulmonary edema (1.79; 1.39-2.30), S aureus infection (1.54; 1.14-2.08), coagulase-negative staphylococcal infection (1.50; 1.07-2.10), mitral valve vegetation (1.34; 1.06-1.68), and paravalvular complications (2.25; 1.64-3.09) were associated with an increased risk of in-hospital death, whereas viridans streptococcal infection (0.52; 0.33-0.81) and surgery (0.61; 0.44-0.83) were associated with a decreased risk.

CONCLUSIONS

In the early 21st century, IE is more often an acute disease, characterized by a high rate of S aureus infection. Mortality remains relatively high.

Endocarditis caused by Staphylococcus aureus: A reappraisal of the epidemiologic, clinical, and pathologic manifestations with analysis of factors determining outcome

Staphylococcus aureus is the leading cause of infectious endocarditis and its mortality has remained high despite better diagnostic and therapeutic procedures over time. We conducted a retrospective review of 133 cases of definite S. aureus endocarditis seen at a single tertiary care hospital over 22 years to assess changes in the epidemiology and incidence of the infection, manifestations, outcome, risk factors for mortality, and impact of cardiac surgery on prognosis.Patients were classified into 2 groups: 1) right-sided endocarditis (64 patients) and 2) left-sided endocarditis (69 patients). While the number of cases of left-sided endocarditis remained steady at 1-3 cases per 10,000 admissions, the incidence of right-sided endocarditis, after a peak in the early 1990s, declined to almost disappear in 2001. Among the cases of right-sided endocarditis, we found 2 subsets of patients with different clinical features and prognosis: the first subset comprised 53 intravenous drug abusers, and the second subset comprised 11 patients with catheter-associated S. aureus bacteremia and endocarditis. Fifty-one patients were human immunodeficiency virus (HIV)-positive drug abusers, most of whom (80.3%) had right-sided endocarditis. We did not find differences in mortality between HIV-positive and HIV-negative individuals; mortality seemed to depend more on the site of the heart involved than on HIV status.Among the cases of left-sided endocarditis, the mitral valve was more commonly involved than the aortic valve (61% vs. 30%). Overall, 74% of patients with left-sided endocarditis developed 1 or more cardiac or extracardiac complication. In comparison, only 23.4% of patients with right-sided endocarditis developed complications.Prosthetic valve endocarditis (PVE) was hospital-acquired more frequently than native valve endocarditis (NVE). Patients with PVE had a shorter duration of symptoms until diagnosis and presented with or developed cardiac murmurs less frequently than patients with NVE. Cardiac failure (49%), renal failure (43%) and central nervous system (CNS) events (35%) were frequently observed in patients with both PVE and NVE. Valve replacement was more frequently needed and more rapidly performed in patients with PVE than in their counterparts with NVE.The overall mortality of patients with right-sided endocarditis was 17%. While the mortality of right-sided endocarditis in injection drug users was 3.7%, the mortality of patients with right-sided endocarditis associated with infected intravenous catheters was 82% (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.001-0.07). For left-sided endocarditis mortality was 38% and was not significantly different in patients with NVE or PVE (OR, 0.65; 95% CI, 0.23-1.87). CNS complications were associated with mortality in both NVE (OR, 6.55; 95% CI, 1.78-24.04) and PVE (OR, 32; 95% CI, 2.63-465.40). Development of 2 or 3 complications was associated with an increased risk of mortality (OR, 5.59; 95% CI, 1.08-28.80 and OR, 9.25; 95% CI, 1.36-62.72 for 2 vs. 1 complication and for 3 vs. 2 complications, respectively).Surgical treatment did not significantly influence mortality in cases of NVE, (OR, 3.19; 95% CI, 0.76-13.38) but significantly improved the prognosis of patients with PVE (OR, 69; 95% CI, 2.89-1647.18).S. aureus endocarditis is an aggressive, often fatal, infection. The results of the current study suggest that valve replacement will improve the outcome of infection, particularly in patients with PVE.

Long-term outcome of infective endocarditis: a study on patients surviving over one year after the initial episode treated in a Finnish teaching hospital during 25 years

Background

Only a few previous studies have focused on the long-term prognosis of the patients with infective endocarditis (IE). Our purpose was to delineate factors potentially associated with the long-term outcome of IE, recurrences of IE and requirement for late valve surgery.

Methods

A total of 326 episodes of IE in 303 patients were treated during 1980–2004 in the Turku University Hospital. We evaluated the long-term outcome and requirement for late valve surgery for 243 of these episodes in 226 patients who survived longer than 1 year after the initial admission. Factors associated with recurrences were analysed both for the 1-year survivors and for all 303 patients.

Results

The mean (SD) follow-up time for the 1-year survivors was 11.5 (7.3) years (range 25 days to 25.5 years). The overall survival was 95%, 82%, 66%, 51% and 45% at 2, 5, 10, 15 and 20 years. In age and sex adjusted multivariate analyses, significant predictors for long-term overall mortality were heart failure within 3 months of admission (HR 1.97, 95% CI 1.27 to 3.06; p = 0.003) and collagen disease (HR 2.54, 95% CI 1.25 to 5.19; p = 0.010) or alcohol abuse (HR 2.39, 95% CI 1.30 to 4.40; p = 0.005) as underlying conditions, while early surgery was significantly associated with lower overall mortality rates (HR 0.31, 95% CI 0.17 to 0.58; p < 0.001). Heart failure was also significantly associated with the long-term cardiac mortality (p = 0.032). Of all 303 patients, 20 had more than 1 disease episode. Chronic dialysis (p = 0.002), intravenous drug use (p = 0.002) and diabetes (p = 0.015) were significant risk factors for recurrent episodes of IE, but when analysed separately for the 1-year survivors, only chronic dialysis remained significant (p = 0.017). Recurrences and late valve surgery did not confer a poor prognosis.

Conclusion

Heart failure during the index episode of IE was the complication, which significantly predicted a poor long-term outcome. Patients who underwent surgery during the initial hospitalisation for IE faired significantly better than those who did not.

Mannan-binding lectin is a determinant of survival in infective endocarditis

Mannan-binding lectin (MBL) is a collectin plasma protein activating the lectin pathway of the complement system, enhancing opsonophagocytosis and modulating the cytokine response to inflammation. Deficiency of MBL, caused by structural mutations or promoter polymorphisms in the MBL2 gene, has been associated with increased susceptibility to infection and autoimmune disease. Thus, as infective endocarditis remains a severe disease requiring intensive and long-term treatment with antibiotics, we examined whether there was an association between MBL and clinical outcome in 39 well-characterized patients with infective endocarditis. Five patients (13%) had MBL concentrations < 100 microg/l and were considered MBL-deficient. This proportion was similar to that in a healthy control group of blood donors. Mortality 3 months after diagnosis was 20% in patients with MBL-deficiency and 9% in patients with normal MBL. The 5-year mortality was 80% and 25%, respectively. MBL-deficiency was on univariate survival statistics associated with significantly higher mortality on follow-up (P=0 x 03). In conclusion, this is the first report of an association between MBL-deficiency and survival in infective endocarditis. The present observation is important, as replacement therapy in MBL-deficient patients is possible. For certain high-risk subgroups, it opens new perspectives for improvement of treatment and outcome in infective endocarditis.

Prognostic stratification of patients with left-sided endocarditis determined at admission

BACKGROUND

The prognosis of patients with left-sided endocarditis remains poor despite the progress of surgical techniques. Identification of high-risk patients within the first days after admission to the hospital would permit a more aggressive therapeutic approach.

METHODS

We designed a prospective multicenter study to find out the clinical, microbiologic, and echocardiographic characteristics available within 72 hours of admission that might define the profile of high-risk patients. Of 444 episodes, 317 left-sided endocarditis cases were included and 76 variables were assessed. Events were surgery in the active phase of the disease and in-hospital death. A stepwise logistic regression analysis was undertaken to determine variables predictive of events.

RESULTS

Multivariate analysis of the clinical variables found to have statistical significance in the univariate analysis identified the following as predictive: patient referred from another hospital (odds ratio [OR]: 1.8; confidence interval [CI], 1.1-2.9), atrioventricular block (OR: 2.5; CI, 1.1-5.9), acute onset (OR: 1.7; CI, 1.1-2.9), and heart failure at admission (OR: 2.3; CI, 1.4-3.8). When the echocardiographic and microbiological variables statistically significant in the univariate analysis were introduced, the presence of heart failure at admission (OR: 2.9; CI, 1.8-4.8), periannular complications (OR: 1.8; CI, 1.1-3.1), and Staphylococcus aureus infection (OR: 2.0; CI, 1.1-3.8) retained prognostic power. Risk could be accurately stratified when combining the 3 variables with predictive power: 0 variables present: 25% of risk; 1 variable present: 38% to 49% of risk; 2 variables present: 56% to 66% of risk; and 3 variables present: 79% of risk.

CONCLUSIONS

The risk of patients with left-sided endocarditis can be accurately stratified with the assessment of variables easily available within 72 hours of admission to the hospital.

Long-term outcomes in valve replacement surgery for infective endocarditis

BACKGROUND

Infective endocarditis is associated with a high rate of long-term mortality. Patients with a history of intravenous drug use (IVDU) are at increased risk for infective endocarditis. However, few studies have reported results of surgical treatment on this population. We present 19.5 years of experience with surgically treated patients with infective endocarditis.

METHODS

A retrospective study of all cardiac surgeries with a diagnosis of infective endocarditis at a single institution from 1986 to 2005 was performed. Logistic stepwise regression with an end point of operative mortality was done. Variables were age, gender, race, history of drug use, previous valve surgery, and previous valve replacement. Perioperative and outcome variables were compared between IVDU and non-IVDU populations.

RESULTS

The IVDU population required surgery at a younger age (39 +/- 9 years versus 54 +/- 15 years; p < 0.001). Overall operative mortality was 12% (41/346). The perioperative complication rate was similar for both groups. When adjusted for age, the two groups had similar long-term survival (p = 0.78). Kaplan-Meier estimator showed that survival at 10 and 15 years was 66% and 54% for IVDU and 56% and 42% for non-IVDU (number at risk, 19, 11, and 61, 28, respectively; p = 0.137). Reoperation for recurrent infective endocarditis was necessary in 9 (17%) of 52 of the IVDU group versus 14 (5%) of 270 of the non-IVDU group (p = 0.03).

CONCLUSIONS

Patients with a history of IVDU required reoperation for recurrent infective endocarditis at a significantly higher rate than the non-IVDU patients. Long-term survival was similar between the younger IVDU population and the older non-IVDU population. Anticipated life span is one of many factors when considering prosthetic valve choice in this population.

Endocarditis at a tertiary hospital: reduced acute mortality but poor long term prognosis

The outcome in 132 patients with infective endocarditis diagnosed in accordance with the Duke criteria at a tertiary hospital in Denmark in the period 1998-2000 is reported. The total in-hospital mortality was 15%. Indications are that in-hospital mortality over the last decade has been reduced by around a quarter. Mortality after 3 months was 17% (CI 29%), after 3 years 32% (CI 16-47%) and after 5 years 39% (CI 22-55%). This 5-years mortality was 5 times that of an age and gender matched background population. After follow-up for 5-8 y, mortality was highest for prosthetic valve endocarditis (63% vs. 39%, p = 0.05). Heart surgery was performed in 51% of the cases. Patients who underwent surgery had a lower mortality at follow-up (36% vs. 52%, p = 0.04). The 5-year mortality was 30% (CI 9-52%) for patients treated with surgery and 48% (CI 23-72%) for patients treated without surgery. In multivariable analysis surgery was not an independent predictor for lower long-term mortality. Surgery was however an independent predictor for lower intermediate-term mortality. It is concluded that surgery may be associated with lower short- and intermediate-term mortality, while the effect might decline in the long-term. High age, prosthetic valve endocarditis, and Staphylococcus aureus endocarditis were independent predictors for high mortality. Although improvements have occurred over recent years, infective endocarditis is still a high mortality disease.