Journal of the American College of Cardiology
Neglecting Enterococci May Lead to a Misinterpretation of the Consequences of Last Changes in Endocarditis Prophylaxis American Heart Association Guidelines
Author + information
- Juan M. Pericas, MD,
- Carlos Falces, MD, PhD,
- Asuncion Moreno, MD, PhD,
- Francesc Marco, MD, PhD,
- Carlos A. Mestres, MD, PhD, FECTS,
- Jose M. Miro, MD, PhD∗ (jmmiro{at}ub.edu) (miro97{at}fundsoriano.es),
- Hospital Clínic Endocarditis Study Group
- ↵∗Infectious Diseases Service, Hospital Clinic, Villarroel, 170, Barcelona 08036, Spain
We read with interest the paper by Pant et al. (1) in a recent issue of the Journal about the 2000 to 2011 trends of infective endocarditis (IE) in the United States. A main conclusion is that the incidence of streptococcal IE significantly rose since 2007, following the restriction of antibiotic prophylaxis of IE in the American Heart Association (AHA) guidelines. Streptococcal IE increased from 24.8% in 2000 to 27% in 2011, with higher incidence in the 2007 to 2011 period (2.22 cases per million population [1.64 to 2.80] vs. 0.85 cases per million population [0.50 to 1.20] in the 2000 to 2007 period) (1). The authors stated that their results contrast with data from Duval et al. (2), who did not report such an increase of streptococcal IE since the guidelines were modified, because short follow-up may preclude detection of this switch in the pattern of streptococcal IE. They also claim that a steady increase in streptococcal IE has also been reported in the United Kingdom since the National Institute for Health and Care Excellence guidelines were changed (3). However, U.K. guidelines not only limited indications for IE prophylaxis, but also completely stopped them in 2008. Hence, comparisons between AHA and National Institute for Health and Care Excellence guidelines should be carefully made.
The major caveat of the contribution by Pant et al. (1), however, is their neglect of enterococci. The authors did not differentiate between enterococcal and other streptococcal IE, pooling all together. Enterococcal IE is a growing entity worldwide, especially in the United States, due to an aging population with numerous comorbidities acquiring the infection in the health care setting (4). Consequently, we suspect that the increase of overall streptococcal IE is not related to rising viridans group IE cases due to failing AHA guidelines, but rather to an increase of enterococcal IE hidden in the work of Pant et al. (1). All physicians must be aware of the “enterococcal menace” and not get distracted with crying wolves.
Footnotes
Please note: Dr. Mestres has served on the clinical events committee of Edwards Lifesciences; and has served on the speakers bureau of On-X Life Technologies. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
