Institutional Review of Patients Operated for Infective Endocarditis: Time to Rethink Strategies?

Objectives: Since the guidelines for infective endocarditis (IE) have been revised in 2009 recommendations for antibiotic, prophylaxis has been largely restricted. In Germany, the incidence of IE has increased by more than 70% during that time. The aim was to review all patients who underwent cardiac surgery for IE at our institution during the past 5 years with a focus on microbiology, infectious foci, and extent of surgery.

Methods: A review of 3,952 consecutive patients who underwent cardiac surgery at our institution between January 2013 and December 2017 revealed 160 patients (4.0%) who were operated due to IE. Data are presented as medians (25th–75th percentiles) or absolute numbers and percentages, respectively.

Results: The median EuroSCORE II was 14.5% (5.7–39.9). The most affected valve was the aortic valve (30.0%) followed by the mitral valve (26.9%). Double valve endocarditis occurred in 10.7% of patients. A minority of patients presented with right-sided IE (tricuspid and pulmonary valve endocarditis was diagnosed in 1.3% of the patients, respectively). A total of 28.8% of surgical procedures were reoperations for prosthetic valve endocarditis, with a median time between the first and second operations of 62.8 months (21.2–135.0). A total of 53% of patients were operated as urgent or emergency cases. In 28.8% of patients, preoperative septic cerebral infarctions have been diagnosed. The most frequent causative organisms were methicillin-sensitive Staphylococcus aureus (22.5%), Streptococcus sp. (22.5%), Staphylococcus sp. (17.5%), and Enterococcus sp. (15.0%). MRSA was the causative organism in 2.5% of patients. No causative organisms have detected in 11.3% of patients. The most frequent infectious foci were dental (15.0%), soft tissue infections (15.0%), spondylodiscitis (10.0%), and immunosuppression (9.4%). Other relevant foci were intravascular implants as well as intravenous drug abuse. In our cohort, the infectious focus remained unknown in 17.5% of patients. Postoperative mortality was 22.5%.

Conclusion: Infective endocarditis is a life-threatening disease especially when the extent of valvular destruction requires surgical intervention. As the predominant infectious foci as well as the most frequent pathogens are still the “old acquaintances,” such as previous dental and other medical interventions and based on the significantly increased incidence of IE, the issue of prophylaxis may need to be revisited.

No conflict of interest has been declared by the author(s).