Introduction

Infective endocarditis (IE) is uncommon but important because it is difficult to manage and universally fatal unless appropriately treated. The estimated incidence is 3–10 episodes each year per 100 000 population.1 In industrially developed countries, IE increasingly occurs in older adults with intracardiac devices (pacemakers and implantable defibrillators), replacement heart valves and medical interventions such as haemodialysis.2–4 Younger age groups are also affected, particularly intravenous drug users and those with adult congenital heart disease.5 Staphylococci are now the most common causative organisms in international series and streptococci the second most common.6 Resistance to antimicrobial agents, particularly vancomycin, is increasing.1 ,7

Patients with IE remain in hospital for a median of 4–6 weeks8 ,9 and approximately a half require inpatient cardiac surgery.1 ,10 ,11 The inhospital mortality rate is about 20%8 ,12 but varies widely according to age, comorbidity, heart failure, the presence of prosthetic material and the organism.13 For example, in prosthetic valve IE with associated renal failure, the reported mortality may be 40%–50%14 ,15 and with severe heart failure as high as 64%.15 The outcome can be improved by prompt diagnosis and antibiotic therapy and by early surgery when indicated.8 ,10 ,16 ,17 Despite this, the diagnosis may be delayed, mistakes may be made in the type, duration or dose of antibiotic18 or the antibiotic may be started before blood cultures are obtained.11 Patients are still frequently referred to a specialist only at an advanced stage with heart failure6 ,11 ,18–20 or may not receive surgery even when indicated.8 As expected, non-compliance with guidelines is associated with a worse outcome.20

A multidisciplinary team (MDT) approach is increasingly seen as best practice where decision …