Author + information
- Sadip Pant, MD,
- Abhishek Deshmukh, MD and
- Jawahar L. Mehta, MD, PhD∗ ()
- ↵∗University of Arkansas for Medical Sciences, Division of Cardiovascular Medicine, 4301 West Markham Street, Mail Slot 532, Little Rock, Arkansas 72205-7199
We thank Dr. DeSimone and colleagues for their interest in our paper. In our study, we focused on infective endocarditis (IE) microbiology to Staphylococcus, Streptococcus, gram-negative, and fungal organisms. Our study differs from previous papers from the Nationwide Inpatient Sample database (1,2) in 2 aspects. First, we did include infections from all streptococcal groups (A, B, C, D [enterococcus], G, and unspecified) and did not report viridans group Streptococcus (VGS) separately. Second, previous studies on IE trends in the United States had a very limited follow-up of only 2 years after the guideline publication. Longer follow-up studies are necessary to assess the impact of any “practice changing” guideline because it takes years to note the impact of such change. Similar observations were made in the United Kingdom where a steady incidence of IE was noted for the first 2 years after publication of new guidelines, whereas a 5-year follow-up detected a significant rise (3,4). Our study emphasizes the need for ongoing monitoring of the impact of new guidelines.
Regarding the preliminary data presented at the American College of Cardiology 2014 meeting, our data on VGS were not entirely captured (only ICD9-CM codes 421.0 and 041.00 were used). Furthermore, the VGS IE diagnosis established by DeSimone et al. (2) raises serious concern because the VGS does not carry a unique ICD-9 CM code (unlike staphylococcus, enterococcus, and so forth). This etiology was assumed by including ICD-9 CM code 041.09 or ICD-9 CM code 041.00 (“Streptococcus infection in conditions classified elsewhere and of unspecified site, other Streptococcus”) among patients carrying the diagnosis of IE (2). The accuracy of VGS diagnosis and drawing major conclusions based on nonspecific coding can be erroneous. Feedback from many experts attending the American College of Cardiology 2014 meeting helped us overcome this limitation in our study, resulting in elimination of VGS group. Hence, our conclusion “there has been a significant rise in the incidence of streptococcus IE following 2007 guideline” is statistically sound and the study design valid. Whether the temporal association noted in our study reflects a causal relationship cannot be deduced from our study design. We acknowledged this in the limitation section.
We appreciate the suggestion of DeSimone and colleagues to look at VGS as a specific subgroup. However, as pointed out by Dayer and Thornhill (5), this has to be done in a randomized controlled design to eliminate the inherent limitations of a retrospective database.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
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- Thornhill M.H.,
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