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Original research
Contemporary epidemiology and outcomes in recurrent infective endocarditis
  1. Afonso B Freitas-Ferraz1,
  2. Gabriela Tirado-Conte1,
  3. Isidre Vilacosta1,
  4. Carmen Olmos1,
  5. Carmen Sáez2,
  6. Javier López3,
  7. Cristina Sarriá2,
  8. Carlos Nicolás Pérez-García1,
  9. Daniel García-Arribas1,
  10. Marianela Ciudad2,
  11. Pablo Elpidio García-Granja3,
  12. Raquel Ladrón3,
  13. Carlos Ferrera1,
  14. Salvatore Di Stefano3,
  15. Luis Maroto1,
  16. Manuel Carnero1,
  17. J Alberto San Román3
  1. 1 Servicio de Cardiología, Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), Madrid, Spain
  2. 2 Servicio de Medicina Interna-Infecciosas, Instituto de Investigación Sanitaria del Hospital Universitario de la Princesa, Madrid, Spain
  3. 3 Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), CIBERCV, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
  1. Correspondence to Dr Afonso B Freitas-Ferraz; afonsobff{at}


Objective Recurrent infective endocarditis (IE) is a major complication of patients surviving a first episode of IE. This study sought to analyse the current state of recurrent IE in a large contemporary cohort.

Methods 1335 consecutive episodes of IE were recruited prospectively in three tertiary care centres in Spain between 1996 and 2015. Episodes were categorised into group I (n=1227), first-IE episode and group II (n=108), recurrent IE (8.1%). After excluding six patients, due to lack of relevant data, group II was subdivided into IIa (n=87), reinfection (different microorganism), and IIb (n=15), relapse (same microorganism within 6 months of the initial episode).

Results The cumulative burden and incidence of recurrence was slightly lower in the second decade of the study (2006–2015) (7.17 vs 4.10 events/100 survivors and 7.51% vs 3.82, respectively). Patients with reinfections, compared with group I, were significantly younger, had a higher frequency of HIV infection, were more commonly intravenous drug users (IVDU) and prosthetic valve carriers, had less embolic complications and cardiac surgery, with similar in-hospital mortality. IVDU was found to be an independent predictor of reinfection (HR 3.92, 95% CI 1.86 to 8.28).

In the relapse IE group, prosthetic valve endocarditis (PVE) and periannular complications were more common. Among patients treated medically, those with PVE had a higher relapse incidence (4.82% vs 0.43% in native valve IE, p=0.018). Staphylococcus aureus and PVE were independent predictors of relapse (HR 3.14, 95% CI 1.11 to 8.86 and 3.19, 95% CI 1.13 to 9.00, respectively) and in-hospital-mortality was similar to group I. Three-year all-cause mortality was similar in recurrent episodes compared with single episodes.

Conclusion Recurrent IE remains a frequent late complication. IVDU was associated with a fourfold increase in the risk of reinfection. PVE treated medically and infections caused by S. aureus increased the risk of relapse. In-hospital and long-term mortality was comparable among groups.

  • endocarditis
  • valvular heart disease

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  • ABF-F and GT-C contributed equally.

  • Contributors ABFF, GTC, IV and CO made substantial contributions to the conception and design of the study. ABFF and GTC have drafted the manuscript and analysed the data. IV, CO, CS, JL, CS, CNPG, DGA, MC, PEGG, RL, CF, SDS, LM, MCA and JASR have revised the manuscript for important intellectual content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the local ethics committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.