Infective Endocarditis in Special Populations: Epidemiology, Diagnostic Challenges, and Management Strategies

Infective endocarditis (IE) remains a severe cardiovascular infection with persistently high morbidity and mortality despite advances in antimicrobial therapy, imaging, and surgical techniques. Its burden is disproportionately borne by special populations, including patients with prosthetic or transcatheter valves, people who inject drugs, pregnant women, individuals with congenital heart disease, immunocompromised hosts, and critically ill patients. These groups face distinct epidemiological patterns, atypical clinical presentations, and complex management challenges that diverge from native valve disease. We conducted a comprehensive literature review across PubMed/MEDLINE, Web of Science, and Scopus, ultimately including 57 studies addressing epidemiology, diagnostic approaches, surgical management, and outcomes in special populations. Findings highlight increased susceptibility due to prosthetic material, injection practices, immunosuppression, and pregnancy-related physiological changes, as well as diagnostic delays stemming from atypical features or imaging limitations. Management requires balancing infection control with patient-specific risks, including maternal-fetal safety, recurrent infections, or frailty in transplant and ICU patients. Outcomes across groups remain poor, underscoring the need for tailored multidisciplinary strategies. Future directions include refined risk stratification tools, wider adoption of advanced imaging modalities, integration of harm reduction and preventive approaches, and establishment of registries to generate high-quality data in underrepresented populations. By synthesizing current evidence, this review emphasizes the necessity of individualized strategies to improve care and prognosis for vulnerable patients with IE.