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Infective endocarditis (IE) is a morbid disease that requires meticulous clinical assessment and risk stratification in the early stages of illness [ ]. Outcomes are impacted by multiple factors: patient characteristics, virulence of the infecting microorganism, severity of illness at presentation; including presence or absence of heart failure, embolic manifestations, the presence of cardiogenic and or septic shock, timing of presentation, diagnostic and therapeutic delays, and the indications for and timing of surgery. Mortality at 30 days ranges from 10% to 50% and many patients need surgical interventions [ ]. Duke criteria was designed for research purposes but offers diagnostic guidance on the probability of native valve endocarditis (NVE). Not all those with definite IE satisfy this criteria, however [ ]. Moreover, the criteria are less sensitive in the setting of prosthetic valve endocarditis (PVE), where emerging cardiac imaging studies other than echocardiography have been found to be increasingly useful in recent years [ ].
The general prevalence of IE in the community is low, and not all health-care settings have the necessary expertise to care for patients with IE. A single provider may be unable to treat a patient who may have simultaneous cardiac, neurological, rheumatological, infectious, and metabolic derangements, in the absence of expert consultation [ ]. Current guidelines promote a multidisciplinary team approach for enhancing the clinical care of IE [ ]. While recommendations offer general principles to guide decision making, the real-life clinical scenarios are often more complex and need careful and continuous evaluation of individual cases [ ]. Additionally, there exists skepticism arising from differences in expert opinions between guidelines of various societies, and the quality of evidence cited by those guidelines [e.g., >50% of the American Heart Association (AHA) IE guidelines endorsed by the Infectious Diseases Society of America were level C in quality] and require adaptation to individual clinical scenarios, rather than dogmatic adherence [ , ].
A multidisciplinary team (MDT) approach improves adherence to the general principles in IE guidelines, reduces local practice variations and delays in care, and allows for appropriate individualization of care [ , ]. In this chapter, we will discuss multidisciplinary service delivery in the management of IE and provide an overview of published literature specifically describing the structure and functions of multidisciplinary teams published in the medical literature, including our center's experience in the development and practice of such a team.
Early success of a team approach to the management of valvular heart disease was understandably applied to IE [ ]. Multiple studies from Europe have shown that a dedicated endocarditis MDT improves outcomes and mortality [ , ]. Table 22.1 summarizes key publications that describe the components of their MDTs and their impact on outcomes, leading to their inclusion into IE guidelines.
Authors, Country | Methods, valves | Development, structure, and function of MDT | Statistically significant outcomes |
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Botelho Nevers et al., France [ ] | Observational before (1991–2001, N = 173)—after (2002–06, N = 160) study Type of valve: Both NVE and PVE cases included Duke criteria: Only definite IE |
Standardized diagnostic and therapeutic protocol:
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Chirillo et al. Italy (ref [ ]) | Observational before (1996–2002, N = 102) and after (2003–09, N = 190) study. Type of valve: Only NVE Duke criteria: Only definite IE |
Standardized diagnostic and therapeutic model:
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Carrasco-chinchilla F et al., Spain (ref [ ]) | Prospective cohort study (2008–11, N = 72) compared to historical cohort (1996–2007, N = 155) Type of valve: NVE and PVE but only left-sided IE Duke criteria: Definite or possible |
Since 2008–Alerta multidisciplinaria en endocarditis infecciosa (AMULTEI) [multidisciplinary alert strategy in infective endocarditis] MDT structure:
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Early surgery was more frequently performed Incidence of shock was significantly lower during hospitalization Mortality was lower while in-hospital and during first month of follow-up. |
Camou et al. France (ref [ ]) | Retrospective observational–descriptive study on the results of 4.5 years of activity of their MDT (2013–17) Type of valve: NVE and PVE Duke criteria: Definite or possible IE |
Since 2010–a weekly regional endocarditis multidisciplinary meeting aimed at diagnostic confirmation, therapeutic strategy, and prospective follow-up of patients MDT structure:
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Did not evaluate pre-MDT period, hence no conclusions could be made. Nonsignificant difference in mortality between community acquired and hospital acquired IE (9% vs. 14%) |
Ruch et al. France (ref [ ]) | Observational pre-(retrospective, Jan 2012–Dec 2016) and post- MDT (Jan–Dec 2017) implementation. Type of valve: NVE and PVE Duke criteria: Only definite IE |
Since 2012–Centralized database called “registre des endocardites infectieuses” collected medical, paramedical, therapeutic decisions for all patients with diagnosis of IE. MDT structure:
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Nonsignificant decrease in in-hospital mortality (pre-MDT 20.3% vs. post-MDT 14.7%) Significant reduction between pre- versus post-MDT:
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Issa N et al., France [ ] | Prospective observational study (Jan 2013–Mar 2016, N = 357 patients) Type of valve: NVE and PVE Duke criteria: Definite or possible |
Since 2010—MDT weekly meetings | |
Kaura et al. UK [ ] | Observational before (Aug 2009–Jun 2012) and after (Jul 2012–Apr 2015) study | Since 2012–MDT was implemented. Initial evaluation by cardiologist for suspected cases, followed by TTE/TEE and later referred to MDT if clinical suspicion is high. MDT structure:
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Reduction in time to IE specific antibiotic therapy (4 ± 4 days to 2.5 ± 3.5 days) and time to surgery (7.8 ± 7.3 days vs. 5.3 ± 4.2 days) Improved survival from 42.9% to 66.7% |
Mestres et al. Spain (ref [ ]) | An editorial describing a 30-year perspective and experience on the structure of MDT (1985–2014) | Since 1979–Working group on IE–database creation, cardiovascular tissue bank, collaboration with infectious diseases, cardiology and cardiac surgery
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No data on outcomes reported |
Within the structure of the MDT, a high level of expertise is necessary for optimizing outcomes, and consultations from cardiology, cardiothoracic surgery, and infectious diseases are required for all cases [ , ]. The structure and function of such an MDT should be determined by the size of the health care setting, availability of subspecialty services, other resources, effective communication strategies, and support from leadership [ , , ]. If such subspecialty services are unavailable, then it is important to identify referral centers that provide multidisciplinary care for IE and develop a system to effectively transfer care to them during the acute phase of diagnosis and treatment. Mestres CA et al. provide in their editorial a comprehensive overview of their 30 year experience with multidisciplinary service delivery for IE in Spain and reporting criteria used for transfer in their setting ( Table 22.2 ) [ ]. The role of the hospitalist/internal medicine physician should not be undermined as they often hold primary responsibility for the care of patients with IE. Ancillary services such as oral maxillofacial surgery, radiology, neurology, behavioral therapy, orthopedic/spine surgery services, etc., also play significant roles in the management of endocarditis patients. A round table approach ( Fig. 22.1 ) with good team dynamics, clearly defined roles, an interactive and unified participation, and seamless communication between team members at regular meetings is essential for success [ , , , ]. During these discussions, preidentified quality control measures should be reviewed regularly to assess for opportunities to improve care delivery ( Table 22.3 ).
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