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Infective endocarditis: old problem, new guidelines and still much to learn
  1. John P Erwin1,
  2. Catherine M Otto2
  1. 1Division of Cardiology, Department of Medicine, Texas A&M College of Medicine/Baylor Scott & White Healthcare, Temple, Texas, USA
  2. 2Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
  1. Correspondence to Dr John P Erwin, III, Division of Cardiology, Department of Medicine, Texas A&M College of Medicine/Baylor Scott & White Central, Temple, Texas, 76508 USA; jperwin{at}

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Despite major advances in treating valvular heart disease, the in-hospital mortality (15–20%) and 1-year mortality (≃40%) for infective endocarditis (IE) has not improved even with modern antibiotics and surgical therapy. Further, stroke (17%), embolisation other than stroke (23%), heart failure (HF) (32%) and other complications remain common; therefore, all precautions to help prevent IE should be employed where indicated. In underdeveloped countries, IE is most often associated with rheumatic heart disease. In developed countries, IE is increasingly associated with prosthetic valves and intracardiac devices, with the risk of IE being 50 times higher in patients with a prosthetic valve compared with the general population. Other populations that are at higher risk of IE who might benefit from specific precautions or improved systems of care to prevent infection are intravenous drug users, the elderly and those with diabetes mellitus or with other forms of immunosuppression.

While the need to prevent bacteraemia in these high-risk populations is universally accepted, the efficacy of antibiotic prophylaxis when bacteraemia is likely to occur has been controversial over the years. Most of this controversy stems from the dogma of historical prophylaxis management, the knowledge that endocarditis has very high morbidity/mortality rates, as well as the misperception that antibiotic prophylaxis is harmless. The new AHA/ACC guidelines1 reflect the scarce evidence base for IE prophylaxis. There has been a paucity of data to support historically aggressive prophylaxis measures as evidenced by a Cochrane Review2 concluding that there was no evidence for benefit using penicillin to prevent endocarditis, as well as other data indicating lack of benefit from prophylaxis in non-dental procedures such as endoscopy/cystoscopy. Guidelines from the European Society of Cardiology (ESC) and from the Working Party of the British Society for Antimicrobial Chemotherapy harmonise with the new AHA/ACC recommendations and have been in place for …

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  • Contributors Both authors contributed to this editorial.

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.