Author + information
- Daniel C. DeSimone, MD∗ (, )
- Walter R. Wilson, MD and
- Larry M. Baddour, MD
- ↵∗Division of Infectious Diseases, Mayo Clinic, 200 First Street NW, Rochester, Minnesota 55905
We read with great interest the paper by Pant et al. (1) regarding trends in infective endocarditis (IE) incidence using the Nationwide Inpatient Sample (NIS) database to address a nagging question that has rightfully garnered much attention and gravity: have recent changes in IE prophylaxis guidelines for dental procedures in this country and abroad resulted in an increase in IE incidence caused by viridans group streptococci (VGS)? As investigators who have previously used the NIS database (2,3), we pose 2 concerns to Pant et al. First, they unfortunately used ICD-9-CM codes that included enterococcal (04104) and non-VGS (038.2 Streptococcus pneumoniae septicemia, and beta-hemolytic streptococci: 04100 Group A streptococci, 04102 Group B, 04103 Group C, 04105 Group G) IE cases under the category of “streptococcal.” This has major implications as we evaluate the risk, if any, of dental procedures and the subsequent development of IE caused by VGS. In this regard, our findings (2,3) and those of Bor et al. (4), which were both derived from the same database (NIS), did not demonstrate an increase in IE incidence caused by VGS.
Second, the work by Pant et al. was presented at the American College of Cardiology 2014 meeting in a preliminary format (5) and they identified an increase in IE incidence from 2000 to 2011 caused by staphylococci, but reported that there was no increase in IE caused by “VGE” (which we assume was in reference to VGS). Interestingly, there was no designation for “enterococci” in that abstract for the 2014 meeting, or in the current publication (1).
The enterococcal designation is an important one because these organisms are a predominant cause of IE and its prevalence seems to be increasing. For example, an extensive systematic review by Slipczuk et al. (5) of IE over the past 5 decades (up through 2011) demonstrated the prevalence of staphylococcal and enterococcal IE had both increased; in contrast, VGS IE had declined.
The only conclusions that we can derive from the current publication (1) is that there was a key error in the selection of ICD-9-CM codes to define the microbiology of IE and that has likely resulted in a flawed conclusion that “there has been a significant rise in the incidence of streptococcus IE following the 2007 guideline revision.” Therefore, we request that Pant et al. perform a focused analysis of IE caused by VGS to clarify the issue.
These database reviews are critical as guidelines committees struggle to answer one of the most important questions in IE prevention: is antibiotic prophylaxis for certain dental procedures efficacious? This struggle, in large part, is caused by the lack of a randomized controlled clinical trial, as highlighted in an accompanying editorial and has been a plea echoed for decades.
Going forward and until clinical trial data are available, a second plea seems in order. In studies of cardiovascular infections, a cadre of experts from different fields should be included, as done in individual patient management of IE.
Please note: Dr. Baddour has received royalty payments from UpToDate, Inc.; and Editor-in-Chief payments from the Massachusetts Medical Society (NEJM Journal Watch Infectious Diseases). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Pant S.,
- Patel N.J.,
- Deshmukh A.,
- et al.
- DeSimone D.C.,
- Tleyjeh I.M.,
- Correa de Sa D.D.,
- et al.