Drugs & Aging

, Volume 36, Issue 2, pp 115–124 | Cite as

Infective Endocarditis in the Elderly: Diagnostic and Treatment Options

  • M. P. Ursi
  • E. Durante Mangoni
  • R. Rajani
  • J. Hancock
  • J. B. Chambers
  • B. PrendergastEmail author
Therapy in Practice


Infective endocarditis (IE) is an uncommon, life-threatening systemic disorder with significant morbidity and persistently high mortality. The age of the peak incidence of IE has shifted from 45 years in the 1950s to 70 years at the present time, and elderly people have a five-fold higher risk of IE than the general adult population. Elderly IE patients demonstrate a higher prevalence of coagulase-negative staphylococci, enterococci and Streptococcus bovis, and lower rates of infection by viridans group streptococci. Methicillin resistance is more prevalent in elderly patients as a consequence of increased nosocomial acquisition. The elderly are a vulnerable group in whom diagnosis is often difficult on account of non-specific presenting features and where higher prevalence of comorbidities contributes to adverse outcomes. Treatment of older patients with IE presents specific challenges associated with prolonged antibiotic therapy, and access to surgery may be denied on account of advanced age and attendant comorbidities. This practical review covers all aspects of elderly IE, including clinical and microbiological diagnosis and appropriate diagnostic procedures, initial antibiotic selection, antibiotic prophylaxis, considerations about antibiotic therapy and surgery.


Compliance with Ethical Standards


No funding was received for the preparation of this manuscript.

Conflict of interest

MPU, EDM, RR, JH, JBC and BP declare that they have no conflicts of interest relating to the content of this review.


  1. 1.
    Cahill TJ, Baddour LM, Habib G, et al. Challenges in infective endocarditis. J Am Coll Cardiol. 2017;69:325–44.CrossRefGoogle Scholar
  2. 2.
    Cahill TJ, Prendergast B. Risk of infective endocarditis after left-sided surgical valve replacement. Eur Heart J. 2018;39:586–95.CrossRefGoogle Scholar
  3. 3.
    Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis—prospective cohort study. Arch Intern Med. 2009;169:463–73.CrossRefGoogle Scholar
  4. 4.
    Fowler VG Jr, Sanders LL, Kong LK, et al. Infective endocarditis due to Staphylococcus aureus. Clin Infect Dis. 1999;28:106–14.CrossRefGoogle Scholar
  5. 5.
    Fowler VG, Miro JM, Hoen B, et al. Staphylococcus aureus endocarditis: a consequence of medical progress. JAMA. 2005;293:3012–21.CrossRefGoogle Scholar
  6. 6.
    Chu VH, Woods CW, Miro JM, on behalf of the International Collaboration on Endocarditis Prospective Cohort Study Group, et al. Emergence of coagulase-negative staphylococci as a cause of native valve endocarditis. Clin Infect Dis. 2008;46:232–42.CrossRefGoogle Scholar
  7. 7.
    Chu VH, Miro JM, Hoen B, on behalf of the International Collaboration on Endocarditis-Prospective Cohort Study Group, et al. Coagulase-negative staphylococcal prosthetic valve endocarditis: a contemporary update based on the International Collaboration on Endocarditis: prospective cohort study. Heart. 2009;95:570–6.CrossRefGoogle Scholar
  8. 8.
    Klein RS, Recco RA, Catalano MT, et al. Association of Streptococcus bovis with carcinoma of the colon. N Engl J Med. 1977;297:800–3.CrossRefGoogle Scholar
  9. 9.
    Cahill TJ, Prendergast BD. Infective endocarditis. Lancet. 2016;387:882–93.CrossRefGoogle Scholar
  10. 10.
    Di Salvo G, Thuny F, Rosenberg V, et al. Endocarditis in the elderly: clinical, echocardiographic, and prognostic features. Eur Heart J. 2003;24:1576–83.CrossRefGoogle Scholar
  11. 11.
    Werdan K, Dietz S, Löffler B, et al. Mechanisms of infective endocarditis: pathogen-host interaction and risk states. Nat Rev Cardiol. 2014;11:35–50.CrossRefGoogle Scholar
  12. 12.
    Fernández-Cruz A, Muñoz P, Sandoval C, Spanish Collaboration on Endocarditis (GAMES), et al. Infective endocarditis in patients with cancer: a consequence of invasive procedures or a harbinger of neoplasm? A prospective, multicenter cohort. Medicine. 2017;96:e7913.CrossRefGoogle Scholar
  13. 13.
    Benito N, Miro JM, de Lazzari E, ICE-PCS (International Collaboration on Endocarditis Prospective Cohort Study) Investigators, et al. Health care-associated native valve endocarditis: importance of non-nosocomial acquisition. Ann Intern Med. 2009;150:586–94.CrossRefGoogle Scholar
  14. 14.
    Durante-Mangoni E, Bradley S, Selton-Suty C, et al. Current features of infective endocarditis in elderly patients: results of the International Collaboration on Endocarditis Prospective Cohort Study. Arch Intern Med. 2008;168:2095–103.CrossRefGoogle Scholar
  15. 15.
    Olmos C, Vilacosta I, Fernández-Pérez C, Bernal JL, Ferrera C, García-Arribas D, Pérez-García CN, San Román JA, Maroto L, Macaya C, Elola FJ. The evolving nature of infective endocarditis in Spain: a population-based study (2003 to 2014). J Am Coll Cardiol. 2017;5(70):2795–804.CrossRefGoogle Scholar
  16. 16.
    Habib G, Lancellotti P, Antunes M, et al. 2015 ESC guidelines for the management of infective endocarditis: the task force for the management of infective endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36:3075–128.CrossRefGoogle Scholar
  17. 17.
    Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132:1435–86.CrossRefGoogle Scholar
  18. 18.
    Cahill TJ, Dayer M, Prendergast B, et al. Do patients at risk of infective endocarditis need antibiotics before dental procedures? BMJ. 2017;358:j3942.CrossRefGoogle Scholar
  19. 19.
    Habib G, Derumeaux G, Avierinos JF, et al. Value and limitations of the Duke criteria for the diagnosis of infective endocarditis. J Am Coll Cardiol. 1999;33:2023–9.CrossRefGoogle Scholar
  20. 20.
    Granados U, Fuster D, Pericas J, et al. Diagnostic accuracy of 18F-FDG PET/CT in infective endocarditis and implantable cardiac electronic device infection: a cross-sectional study. Hospital Clinic Endocarditis Study Group. J Nucl Med. 2016;57:1726–32.CrossRefGoogle Scholar
  21. 21.
    Dhawan VK. Infective endocarditis in elderly patients. Curr Infect Dis Rep. 2003;5:285–92.CrossRefGoogle Scholar
  22. 22.
    Remadi JP, Nadji G, Goissen T, et al. Infective endocarditis in elderly patients: clinical characteristics and outcome. Eur J Cardiothorac Surg. 2009;35:123–9.CrossRefGoogle Scholar
  23. 23.
    Chirillo F. It is not how old you are, it is how you are old: need for changes in the management of infective endocarditis in the elderly. Heart. 2017;103:1562–4.CrossRefGoogle Scholar
  24. 24.
    Sandoe JA, Barlow G, Chambers JB, et al. Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint Working Party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE). J Antimicrob Chemother. 2015;70:325–59.CrossRefGoogle Scholar
  25. 25.
    Gould FK, Denning DW, Elliott TSJ, et al. Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. 2012;67:269–89.CrossRefGoogle Scholar
  26. 26.
    Fournier PE, Thuny F, Richet H, et al. Comprehensive diagnostic strategy for blood culture-negative endocarditis: a prospective study of 819 new cases. Clin Infect Dis. 2010;51:131–40.CrossRefGoogle Scholar
  27. 27.
    Daniel WG, Mügge A, Grote J, et al. Comparison of transthoracic and transesophageal echocardiography for detection of abnormalities of prosthetic and bioprosthetic valves in the mitral and aortic positions. Am J Cardiol. 1993;71:210–5.CrossRefGoogle Scholar
  28. 28.
    Habets J, Tanis W, van Herwerden LA, et al. Cardiac computed tomography angiography results in diagnostic and therapeutic change in prosthetic heart valve endocarditis. Int J Cardiovasc Imaging. 2014;30:377–87.CrossRefGoogle Scholar
  29. 29.
    Feuchtner GM, Stolzmann P, Dichtl W, et al. Multislice computed tomography in infective endocarditis: comparison with transesophageal echocardiography and intraoperative findings. J Am Coll Cardiol. 2009;53:436–44.CrossRefGoogle Scholar
  30. 30.
    Saby L, Laas O, Habib G, et al. Positron emission tomography/computed tomography for diagnosis of prosthetic valve endocarditis: increased valvular 18F-fluorodeoxyglucose uptake as a novel major criterion. J Am Coll Cardiol. 2013;61:2374–82.CrossRefGoogle Scholar
  31. 31.
    Pizzi MN, Roque A, Fernández-Hidalgo N, et al. Improving the diagnosis of infective endocarditis in prosthetic valves and intracardiac devices with 18F-fluordeoxyglucose positron emission tomography/computed tomography: initial results at an infective endocarditis referral center. Circulation. 2015;132:1113–26.CrossRefGoogle Scholar
  32. 32.
    Ahmed FZ, James J, Cunnington C, et al. Early diagnosis of cardiac implantable electronic device generator pocket infection using 18F-FDG-PET/CT. Eur Heart J Cardiovasc Imaging. 2015;16:521–30.CrossRefGoogle Scholar
  33. 33.
    Cautela J, Alessandrini S, Cammilleri S, et al. Diagnostic yield of FDG positron-emission tomography/computed tomography in patients with CEID infection: a pilot study. Europace. 2013;15:252–7.CrossRefGoogle Scholar
  34. 34.
    Iversen K, Ihlemann N, Gill SU, et al. Partial oral versus intravenous antibiotic treatment of endocarditis. N Engl J Med. 2018. (Epub ahead of print).Google Scholar
  35. 35.
    Kiefer T, Park L, Tribouilloy C, et al. Association between valvular surgery and mortality among patients with infective endocarditis complicated by heart failure. JAMA. 2011;306:2239–47.CrossRefGoogle Scholar
  36. 36.
    Prendergast BD, Tornos P. Surgery for infective endocarditis: who and when? Circulation. 2010;121:1141–52.CrossRefGoogle Scholar
  37. 37.
    Nagai T, Takase Y, Hamabe A, et al. Observational study of infective endocarditis at a community-based hospital: dominance of elderly patients with comorbidity. Intern Med. 2018;57:301–10.CrossRefGoogle Scholar
  38. 38.
    López J, Revilla A, Vilacosta I, et al. Age-dependent profile of left sided infective endocarditis: a 3-center experience. Circulation. 2010;121:892–7.CrossRefGoogle Scholar
  39. 39.
    Ramírez-Duque N, García-Cabrera E, Ivanova-Georgieva R, et al. Surgical treatment for infective endocarditis in elderly patients. J Infect. 2011;63:131–8.CrossRefGoogle Scholar
  40. 40.
    Rutledge R, Kim BJ, Applebaum RE. Actuarial analysis of the risk of prosthetic valve endocarditis in 1,598 patients with mechanical and bioprosthetic valves. Arch Surg. 1985;120:469–72.CrossRefGoogle Scholar
  41. 41.
    Pérez-Vázquez A, Fariñas MC, García-Palomo JD, et al. Evaluation of the Duke criteria in 93 episodes of prosthetic valve endocarditis: could sensitivity be improved? Arch Intern Med. 2000;160:1185–91.CrossRefGoogle Scholar
  42. 42.
    Amat-Santos IJ, Messika-Zeitoun D, Eltchaninoff H, et al. Infective endocarditis after transcatheter aortic valve implantation: results from a large multicenter registry. Circulation. 2015;131:1566–74.CrossRefGoogle Scholar
  43. 43.
    Regueiro A, Linke A, Latib A, et al. Association between transcatheter aortic valve replacement and subsequent infective endocarditis and in-hospital death. JAMA. 2016;316:1083–92.CrossRefGoogle Scholar
  44. 44.
    Gallouche M, Barone-Rochette G, Pavese P, et al. Incidence and prevention of infective endocarditis and bacteraemia after transcatheter aortic valve implantation in a French university hospital: a retrospective study. J Hosp Infect. 2018;99:94–7.CrossRefGoogle Scholar
  45. 45.
    Olsen NT, DeBacker O, Thyregod HGH, et al. Prosthetic valve endocarditis after transcatheter aortic valve implantation. Circ Cardiovasc Interv. 2015;8:e001939. Scholar
  46. 46.
    Cahill TJ, Chen M, Hayashida K, et al. Transcatheter aortic valve implantation: current status and future perspectives. Eur Heart J. 2018. Scholar
  47. 47.
    Athan E, Chu VH, Tattevin P, ICE-PCS Investigators, et al. Clinical characteristics and outcome of infective endocarditis involving implantable cardiac devices. JAMA. 2012;307:1727–35.CrossRefGoogle Scholar
  48. 48.
    Le KY, Sohail MR, Friedman PA, Mayo Cardiovascular Infections Study Group, et al. Clinical predictors of cardiovascular implantable electronic device-related infective endocarditis. Pacing Clin Electrophysiol. 2011;34:450–9.CrossRefGoogle Scholar
  49. 49.
    Bongiorni MG, Tascini C, Tagliaferri E, et al. Microbiology of cardiac implantable electronic device infections. Europace. 2012;14:1334–9.CrossRefGoogle Scholar
  50. 50.
    Kusumoto FM, Schoenfeld MH, Wilkoff BL, et al. 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017;14:e503–51.CrossRefGoogle Scholar
  51. 51.
    Baddour LM, Epstein AE, Erickson CC, Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular Nursing, Council on Clinical Cardiology;, Interdisciplinary Council on Quality of Care and Outcomes Research, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010;121:458–77.CrossRefGoogle Scholar
  52. 52.
    Fu HX, Huang XM, Zhong LI, et al. Outcomes and complications of lead removal: can we establish a risk stratification schema for a collaborative and effective approach? Pacing Clin Electrophysiol. 2015;38:1439–47.CrossRefGoogle Scholar
  53. 53.
    Durante Mangoni E, Casillo R, et al. High dose daptomycin for cardiac implantable electronic device-related infective endocarditis. Clin Infect Dis. 2012;54:347–54.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Department of CardiologySt Thomas’ HospitalLondonUK
  2. 2.Department of Internal MedicineUniversity of Campania ‘L. Vanvitelli’NaplesItaly

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