Multidisciplinary service delivery for the endocarditis patient


Introduction

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.

The endocarditis team–lessons from European experiences

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.

Table 22.1
European studies on multidisciplinary team for infective endocarditis.
Authors, Country Methods, valves Development, structure, and function of MDT Statistically significant outcomes
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:

  • 1.

    1994–diagnosis kit was implemented (systematic serology testing, blood cultures, microbiological and histological analysis of removed valves)

  • 2.

    2002—MDT was fully implemented with a protocol/medical-surgical guide—final decisions were taken in multi-disciplinary way

  • 1.

    Mortality decreased from 18.5% (before) to 8.2% (after).

  • 2.

    Improved compliance for antimicrobial therapy

  • 3.

    Reduction in embolic events, renal failure, multiple organ failure syndromes

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:

  • 1.

    2003–Mandated referral to MDT—cardiology, infectious disease, microbiology, cardiac surgery.

  • 2.

    Particular attention to standardization of blood cultures and echocardiography

  • 1.

    Overall mortality decreased from 28% (before) to 13% (after) [surgical mortality 47%–13%, three-year mortality 34%–16%]

  • 2.

    Less culture negative IE

  • 3.

    Less renal failure

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:

  • Clinical–internal medicine, infectious diseases

  • Microbiological

  • Echocardiography

  • Cardiac surgery involved if duke criteria satisfied

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:

  • Cardiologist

  • Infectious diseases specialist

  • Cardiac surgeon

  • Microbiologist

  • Imaging specialists

  • Intensivist

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:

  • Infectious diseases specialist

  • Cardiologist

  • Cardiac surgeon

  • Echocardiographer

Nonsignificant decrease in in-hospital mortality (pre-MDT 20.3% vs. post-MDT 14.7%)
Significant reduction between pre- versus post-MDT:

  • 1.

    Time to surgery (16.4 days vs. post-MDT 10.3 days)

  • 2.

    Antibiotic days (55.2 vs. 47.2 days)

  • 3.

    Hospital days (40.6 vs. 31.9 days)

  • 4.

    Multi-variate analysis: Post-MDT period was positively associated with survival.

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:

  • Two cardiologists

  • One microbiologist

  • One cardiac imaging specialist

  • One cardiac surgeon

  • Nurse coordinator

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

  • 1.

    Since 1993–Storage of pathogenic strains–experimental endocarditis laboratory

  • 2.

    Since 1994–Weekly meetings on IE

  • MDT main structure:

    • Infectious diseases specialist

    • Microbiologist

    • Specialists in heart valve disease and cardiac imaging

    • Cardiac surgeon

    • Pathologist

    • Specialist in OPAT

No data on outcomes reported
IE , infective endocarditis; NVEs , native valve endocarditis; PVEs , prosthetic valve endocarditis; MDT , multidisciplinary team; OPAT , outpatient parenteral antimicrobial therapy

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 ).

Table 22.2
Criteria for the transfer of patients from hospitals without cardiovascular surgery.
Reprinted with permission from ref. Mestres CA, Paré JC, Miró JM. Organization and functioning of a multidisciplinary team for the diagnosis and treatment of infective endocarditis: a 30-year perspective (1985-2014). Rev Esp Cardiol 2015;68(5):363–368.
  • 1.

    Patients with unstable hemodynamics (inotropic support, mechanical ventilation)

  • 2.

    Severe valvular regurgitation (clinical and echocardiographic criteria)

  • 3.

    Prosthetic endocarditis

  • 4.

    Intracardiac device endocarditis (pacemakers, defibrillators, resynchronizers)

  • 5.

    Extra-valvular complications (abscesses, fistulas)

  • 6.

    Persistent sepsis (positive blood cultures > seven days)

  • 7.

    Stroke

  • 8.

    Recurrent embolism

  • 9.

    Residual large vegetations (>10 mm)

  • 10.

    Aggressive or difficult to treat microorganisms (e.g., Staphylococcus aureus , gram-negative bacilli, fungi, culture-negative endocarditis)

Figure 22.1, Round-table approach in infective endocarditis (IEs) and cardiac implantable electronic device (CIED) infections.

Table 22.3
Quality control of the multidisciplinary working group on infectious endocarditis.
Reprinted with permission from ref. Mestres CA, Paré JC, Miró JM. Organization and functioning of a multidisciplinary team for the diagnosis and treatment of infective endocarditis: a 30-year perspective (1985-2014). Rev Esp Cardiol 2015;68(5):363–368.
Organizational aspects
  • 1.

    Provide response within 24 h to inquiries from other centers, including transfer requests made by telephone or via the internet

  • 2.

    Prospective collection of echocardiographic, microbiological, surgical, and clinical course data in a specialized database

  • 3.

    Weekly meetings with all members of the group

  • 4.

    Prevention of nosocomial endocarditis: Provision of information and education to decrease catheter bacteremia and implantable cardiac device infections

Clinical aspects
  • 1.

    Echocardiography within 48 h of diagnosis of suspected infective endocarditis

  • 2.

    Embolic study within 72 h, especially in the case of fungal endocarditis and staphylococcal endocarditis ( Staphylococcus aureus, Staphylococcus lugdunensis )

  • 3.

    Regular review of the suitability, duration, and toxicity of empirical and definitive antibiotic regimens

Microbiological aspects
  • 1.

    A minimum of two nonsimultaneous blood cultures by direct venipuncture using different veins at the time of suspicion of IE. Control blood cultures at three and seven days

  • 2.

    Real-time communication from the group's microbiologist to the infectious disease specialist if growth is observed in blood cultures of typical pathogens of infective endocarditis (<24 h)

  • 3.

    Staining, cultures, and molecular biology (16 and 18S) of all valvular vegetations, embolic material, and intracardiac devices of patients with suspected infective endocarditis

Surgical aspects
  • 1.

    In less than 24 h, discuss with the surgeon patients with indications for surgery

  • 2.

    Adhere to the time limits recommended in the guidelines for patients with urgent and emergency surgical indication

  • 3.

    Removal of all infected intracardiac devices and review and discuss patients in which this is not done

Scientific-academic issues
  • 1.

    Continuing education inside and outside the group

  • 2.

    Collaboration with local, national, and international study groups

  • 3.

    Communications to congresses; publications in scientific journals; participation in the development of local, national, and international clinical guidelines

General aspects
  • 1.

    Autopsy studies in more than 50% of inpatient deaths

  • 2.

    Clinical, microbiological, and echocardiographic follow-up for a minimum of one year in all patients

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