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.

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 ).

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

Reprinted with permission from Ref. Kaura A, Byrne J, Fife A, Deshpande R, Baghai M, Gunning M, et al. Inception of the ‘endocarditis team’ is associated with improved survival in patients with infective endocarditis who are managed medically: findings from a before-and-after study. Open Heart. 2017;4(2):e000699.

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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