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  • Review Article
  • Published:

Mechanisms of infective endocarditis: pathogen–host interaction and risk states

Nature Reviews Cardiology volume 11, pages 35–50 (2014)Cite this article

Subjects

Key Points

  • Infective endocarditis (IE) is a major challenge for clinicians and a considerable burden for health-care systems

  • In high-income countries over the past 5 decades, patients have been contracting IE at an increasingly old age, and the incidence of health-care-associated staphylococcal IE has risen

  • An improved understanding of the mechanisms of vegetation formation, growth, and embolization will help to combat microbial resistance

  • IE after transfemoral aortic valve implantation in elderly patients can be aggravated by immunosenescence

  • Many factors that increase mortality in patients with IE have been identified, which will help to optimize treatment

  • Mortality risk increases substantially when patients with IE develop septic shock

Abstract

Patients with infective endocarditis (IE) form a heterogeneous group, ranging from those who are successfully treated with no adverse events, to those with severe complications and a high mortality. In this Review, we highlight pathogen–host interactions and the mechanisms underlying various risk factors for patients with IE. A temporal trend in the pattern of IE has been observed in high-income countries within the past 5 decades, with patients contracting IE at an increasingly old age, and a growing incidence of health-care-associated staphylococcal IE. Consequently, prevention strategies should no longer focus on prophylaxis of streptococcal bacteraemia during dental procedures, but instead encourage a more-general approach to reduce the incidence of health-care-associated IE. Much knowledge has been gained about the mechanisms of vegetation formation, growth, and embolization on damaged or inflamed cardiac valves, and on cardiac devices. Improved understanding of these mechanisms will help to combat the increasing problem of antimicrobial resistance. Two mechanisms of IE should increasingly be the focus of future research: the role of immunosenescence in elderly patients with IE, particularly after transcatheter aortic valve implantation, and the mechanisms that trigger septic shock, a condition that leads to a substantial increase in the risk of death in patients with IE.

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Figure 1: Pathogenesis of infective endocarditis.
Figure 2: Mechanisms of infective endocarditis.
Figure 3: Prosthetic aortic valve endocarditis and immunosenescence.
Figure 4: Transition from endocarditis to endocarditis-triggered severe sepsis and septic shock.

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Acknowledgements

B. Löffler was supported by the grant SFB 656/A10.

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  1. Heart Centre of the University Clinics Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, Halle (Saale), D-06120, Germany

    Karl Werdan, Sebastian Dietz, Hasan Bushnaq, Rolf-Edgar Silber & Ursula Müller-Werdan

  2. Institute of Medical Microbiology, University Hospital of Münster, Westphalian Wilhelms-University Münster, Domagkstrasse 10, D-48149, Münster, Germany

    Bettina Löffler, Silke Niemann & Georg Peters

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All the authors researched data for the article, contributed substantially to discussions of its content, and wrote the manuscript. K. Werdan, S. Dietz, and U. Müller-Werdan reviewed/edited the manuscript before submission.

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K. Werdan declared that he is or has been a consultant for: Abbot, Baxter, Bayer, Biotest, Datascope, Novartis, and Servier; he has received honoraria for speaking from: Abbott, Biogen, Biotest, Boehringer Ingelheim, Boston Scientific, Datascope, Maquet, MSD, Novartis, Roche, and Servier; and has received grants or research support from: Bayer, Biotest, Datascope, Novartis, Roche, and Servier. U. Müller-Werdan declares that she has received honoraria for speaking from: Assistenz, Bayer, Berlin Chemie, GbR Salzatal, German Cardiac Society, Klinikum Magdeburg, Medizinische Hochschule Hannover, Roche Diagnostics, Serumwerke Bernburg, Servier, Socreatec Oberursel, Universität Erlangen; and has received grants or research support from: Biotest, Novartis, and Servier. S. Dietz, B. Löffler, S. Niemann, H. Bushnaq, R. E. Silber, and G. Peters declare no competing interests.

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Werdan, K., Dietz, S., Löffler, B. et al. Mechanisms of infective endocarditis: pathogen–host interaction and risk states. Nat Rev Cardiol 11, 35–50 (2014). https://doi.org/10.1038/nrcardio.2013.174

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