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Results of the International Collaboration on Endocarditis Prospective Cohort Study

Emanuele Durante-Mangoni, MD, PhD; Suzanne Bradley, MD; Christine Selton-Suty, MD; Marie-Françoise Tripodi, MD; Bruno Barsic, MD, PhD; Emilio Bouza, MD, PhD; Christopher H. Cabell, MD, MHS; Auristela Isabel de Oliveira Ramos, MD; Vance Fowler Jr, MD, MHS; Bruno Hoen, MD, PhD; Pam Koneçny, MD; Asuncion Moreno, MD; David Murdoch, MD, DTM&H, FRACP, FRCPA, FACTM; Paul Pappas, MS; Daniel J. Sexton, MD; Denis Spelman, MD; Pierre Tattevin, MD; José M. Miró, MD, PhD; Jan T. M. van der Meer, MD, PhD; Riccardo Utili, MD; for the International Collaboration on Endocarditis Prospective Cohort Study Group

Arch Intern Med. 2008;168(19):2095-2103.

Background  Elderly patients are emerging as a population at high risk for infective endocarditis (IE). However, adequately sized prospective studies on the features of IE in elderly patients are lacking.

Methods  In this multinational, prospective, observational cohort study within the International Collaboration on Endocarditis, 2759 consecutive patients were enrolled from June 15, 2000, to December 1, 2005; 1056 patients with IE 65 years or older were compared with 1703 patients younger than 65 years. Risk factors, predisposing conditions, origin, clinical features, course, and outcome of IE were comprehensively analyzed.

Results  Elderly patients reported more frequently a hospitalization or an invasive procedure before IE onset. Diabetes mellitus and genitourinary and gastrointestinal cancer were the major predisposing conditions. Blood culture yield was higher among elderly patients with IE. The leading causative organism was Staphylococcus aureus, with a higher rate of methicillin resistance. Streptococcus bovis and enterococci were also significantly more prevalent. The clinical presentation of elderly patients with IE was remarkable for lower rates of embolism, immune-mediated phenomena, or septic complications. At both echocardiography and surgery, fewer vegetations and more abscesses were found, and the gain in the diagnostic yield of transesophageal echocardiography was significantly larger. Significantly fewer elderly patients underwent cardiac surgery (38.9% vs 53.5%; P < .001). Elderly patients with IE showed a higher rate of in-hospital death (24.9% vs 12.8%; P < .001), and age older than 65 years was an independent predictor of mortality.

Conclusions  In this large prospective study, increasing age emerges as a major determinant of the clinical characteristics of IE. Lower rates of surgical treatment and high mortality are the most prominent features of elderly patients with IE. Efforts should be made to prevent health care–associated acquisition and improve outcomes in this major subgroup of patients with IE.

Author Affiliations: Department of Cardiothoracic and Respiratory Sciences, Università di Napoli II, Naples, Italy (Drs Durante-Mangoni, Tripodi, and Utili); Divisions of Geriatric Medicine and Infectious Diseases, University of Michigan Medical School, Ann Arbor (Dr Bradley); Department of Cardiology, Centre Hôpitalier Universitaire (CHU) Nancy-Brabois, Nancy, France (Dr Selton-Suty); Intensive Care Unit, University Hospital for Infectious Diseases, Zagreb, Croatia (Dr Barsic); Department of Medical Microbiology, Hospital General Universitario Gregorio Marañon, Ciberes, Madrid, Spain (Dr Bouza); Quintiles Transnational, Durham, North Carolina (Dr Cabell); Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil (Dr Ramos); Departments of Medicine, Duke University Medical Center, Durham (Drs Fowler and Sexton), St George Hospital, Sydney, Australia (Dr Koneçny), Hospital Clinic–IDIBAPS (Institut d’Investigacions Biomèdiques August Pi I Sunyer), University of Barcelona, Barcelona, Spain (Drs Moreno and Miró), and University of Otago, Christchurch, New Zealand (Dr Murdoch); Department of Cardiology, Departments of Infectious Diseases, University Medical Center of Besançon, Besançon, France (Dr Hoen), CHU de Rennes, Rennes, France (Dr Tattevin), and University of Amsterdam, Amsterdam, the Netherlands (Dr van der Meer); INC Research, Raleigh, North Carolina (Mr Pappas); and Department of Infectious Disease, Alfred Hospital, Melbourne, Australia (Dr Spelman).

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