Halfway between Cure and Care: Suppressive Therapy in Inoperable Infective Endocarditis

Area of Science:

• Cardiology
• Infectious Diseases
• Internal Medicine

Background:

• Infective endocarditis (IE) presents a significant mortality risk, particularly in elderly patients with comorbidities where surgery is often contraindicated.
• Long-term suppressive antimicrobial therapy (SAT) is an emerging strategy to manage IE in high-risk surgical candidates, aiming to reduce relapse and maintain stability.

Purpose of the Study:

• To evaluate the efficacy and safety of long-term suppressive antimicrobial therapy (SAT) in adult patients with infective endocarditis (IE) ineligible for curative surgery.
• To assess outcomes including mortality, infection relapse, and adverse drug events (ADEs) associated with SAT in this patient population.

Main Methods:

• A retrospective, single-center observational study included 34 adult IE patients managed with SAT after initial intravenous treatment from January 2020 to July 2024.
• Patients were selected by a Multidisciplinary Endocarditis Team (MET) due to surgical ineligibility or prior surgical failure.
• Primary outcomes were all-cause mortality and infection relapse; secondary outcomes included SAT characteristics and ADEs.

Main Results:

• The median patient age was 77 years, with a median Charlson Comorbidity Index of 6. Prosthetic valve endocarditis (PVE) was common (70.6%).
• Staphylococci, streptococci, and Enterococcus faecalis were the most frequent pathogens.
• All-cause mortality was 14.7% (5/34), and the relapse rate was 11.8% (4/34), with no relapses after SAT discontinuation by MET decision. ADEs occurred in 17.6% (6/34) without treatment suspension.

Conclusions:

• Long-term suppressive antimicrobial therapy (SAT) is a feasible strategy for non-operable infective endocarditis (IE) patients.
• Careful patient selection and rigorous follow-up are essential to balance the risks of recurrence, drug events, and prolonged antibiotic exposure.