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Am Fam Physician. 2002;65(6):1208

Before the antibiotic era, infectious endocarditis was uniformly fatal. Even with the advent of antibiotics and modern cardiac care, the five-year mortality rate for endocarditis can be as high as 60 percent. Bishara and associates report on the long-term survival impact of early surgical intervention to remove the infected valve compared with standard antibiotic therapy alone.

The authors performed a retrospective analysis of 252 patients with infectious endocarditis who were seen during a 10-year period at a tertiary-care hospital in Israel. Early surgery meant that the patient underwent replacement of the infected valve before completion of the typical four- to six-week antibiotic regimen. None of the endocarditis patients had a history of injection drug use as the cause of their infection; most infections were related to structural cardiac abnormalities (valvular disease, prosthetic valve, pacemaker). The most common infecting organisms, in order of decreasing frequency, were viridans streptococci, Staphylococcus aureus, coagulase-negative staphylococci and Enterococcus species.

Early surgery (usually within two days of hospital admission) was performed in 17.5 percent of patients, and the remainder received medical therapy alone. Surgery was more commonly performed in patients with S. aureus endocarditis or infected prosthetic valves. Similar to rates in other large studies, the overall mortality rate (51 percent) was substantial. There was no statistically significant difference in early (in-hospital) mortality between surgical and medical groups (11 vs. 18 percent, respectively). Long-term survival was significantly better with early surgery than with medical therapy alone.

After eight years of follow-up, more than 60 percent of surgery patients were alive, compared with less than 35 percent of those receiving medical therapy alone. To account for a possible bias of avoiding surgery in the sickest patients, the authors repeated their analysis, excluding any patient who died within seven days of starting medical therapy, but there was no significant change in the survival advantage of early surgery.

The authors concluded that early surgical intervention is associated with improved long-term survival in patients with infectious endocarditis. Given the limitations of their retrospective analysis, they advocate for a prospective trial comparing surgery with antibiotics alone.

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Copyright © 2002 by the American Academy of Family Physicians.

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