Endocarditis is Alive and Well, Unfortunately (video)

During a recent 2-week tour of duty as the attending physician on one of our busy Internal Medicine services, I saw 3 patients with complicated infective endocarditis. All of these individuals were active or former parenteral street-drug users, a factor that undoubtedly led to their intracardiac infection. I recounted for my housestaff team a quote from one of my attendings in Boston more than 40 years ago who said that with all the new antibiotics coming on the market at that time, the endocarditis of Osler’s era was going to disappear. Indeed, this prophesy was partly true: the chronic form of endocarditis that Osler witnessed at a time before effective antibiotics were available has largely disappeared, although I have seen a few patients with the subacute form of the disease who demonstrated the classic stigmata described by the great physician in his writings.

The current term for the disease is infective endocarditis, although Osler called it “infectious endocarditis or ulcerative endocarditis” in his writings. It does seem to me to make sense to call it infective rather than infectious because the latter term implies that the disease is communicable, which it truly is not. When I was in training more than 40 years ago, we usually referred to the disease as “SBE,” subacute bacterial endocarditis. This term was clearly incorrect because the disease even at that time was usually acute and could be the result of infection by organisms other than bacteria.

What has not changed since the time of Osler, however, is the malignant nature of infective endocarditis. In 1881, in the Archives of Medicine, Osler described the disease as “one of the most formidable of cardiac affections, characterized by a peculiar morbid process on the valves, blood contaminations, constitutional symptoms … and usually associated with multiple emboli.” Osler reported on a number of patients that he had personally cared for, and he was present at their autopsies when they succumbed to infective endocarditis. Included with the descriptions of the patients and their autopsy findings were figures demonstrating the histological structure of the valvular vegetations observed at autopsy. Interestingly, Osler notes that many of his patients also had pneumonia, and he suggests that infective endocarditis may well have developed secondary to the lung infection. He also describes mycotic aneurysms of the aorta in a number of his patients. In some of his writings, Osler describes an acute and highly malignant form of the disease, which is often the clinical picture seen today.

In Osler’s day, essentially all patients with infective endocarditis eventually died from their illness. This is less so today; however, the mortality rate is still substantial. In this month’s issue of The American Journal of Medicine, investigators from the Beth Israel Deaconess Medical Center in Boston review the clinical aspects of 102 patients with drug use-associated infective endocarditis seen there between 2004 and 2014. The overwhelming majority of these patients were between ages 20 and 49 years, and approximately 50% were subsequently readmitted to the hospital, with a number of the patients having multiple readmissions. The mortality rate in this young population of infective endocarditis patients was a frightening 25.5%, with the median age at death being 40.9 years. The median time to death from the initial admission when infective endocarditis was diagnosed was <1 year (305.5 days). In my opinion, Osler would definitely have characterized this illness as “malignant,” which is the term he used when he delivered the Gulstonian Lectures to the Royal College of Physicians in London in March 1885.

Rosenthal et al make another disturbing point in their article: “addiction interventions were suboptimal.” Indeed, although more than 85% of their patients saw social workers during their admission, only 23.7% had addiction consultations, and only 24% were seen by Psychiatry. One wonders why the social workers that saw these patients did not perform in-depth evaluations of these individuals or recommend addiction consultations. However, social service consults on a busy inpatient service are usually short encounters during which addiction therapy may be briefly advised and resources suggested, but given the demands placed on social workers in a busy general hospital, it is very unlikely that an in-depth interview or counseling would occur. Although addiction was mentioned in 55.9% of the discharge summaries, only 7.8% of the patients had a plan for medication-assisted treatment, and naloxone was never prescribed. I have no doubt that the pattern just described is the usual situation for similar patients in US hospitals throughout the country. It is estimated that 7.1 million individuals in the US are afflicted with a substance abuse illness other than alcohol. Because these individuals are at high risk for developing infective endocarditis, it is clear that this is a major public health problem in our country.

The solution to this conundrum is not easy. The so-called “war on drugs” has not been a success, with the number of street-drug users continuing to increase despite all efforts. As physicians, it is unlikely that we will be able to eradicate this illness at any time in the near future. However, we can certainly make greater efforts to enroll these patients in programs that offer at least a chance for them to become street-drug free. The data reported by Rosenthal et al suggest that we are not doing our best for these patients.

As always, I answer all e-mail communications about this editorial on our blog at amjmed.org.

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-Joseph S. Alpert, MD (Editor in Chief, The American Journal of Medicine)

This article originally appeared in the May 2016 issue of The American Journal of Medicine.