Trends in Infective Endocarditis in California and New York State, 1998-2013

Abstract

Importance: Prophylaxis and treatment guidelines for infective endocarditis have changed substantially over the past decade. In the United States, few population-based studies have explored the contemporary epidemiology and outcomes of endocarditis.

Objective: To quantify trends in the incidence and etiologies of infective endocarditis in the United States.

Design, setting, and participants: Retrospective population epidemiology study of patients hospitalized with a first episode of endocarditis identified from mandatory state databases in California and New York State between January 1, 1998, and December 31, 2013.

Exposure: Infective endocarditis.

Main outcomes and measures: Outcomes were crude and standardized incidence of endocarditis and trends in patient characteristics and disease etiology. Trends in acquisition mode, organism, and mortality were analyzed.

Results: Among 75 829 patients with first episodes of endocarditis (mean [SD] age, 62.3 [18.9] years; 59.1% male), the standardized annual incidence was stable between 7.6 (95% CI, 7.4 to 7.9) and 7.8 (95% CI, 7.6 to 8.0) cases per 100 000 persons (annual percentage change [APC], -0.06%; 95% CI, -0.3% to 0.2%; P = .59). From 1998 through 2013, the proportion of patients with native-valve endocarditis decreased (from 74.5% to 68.4%; APC, -0.7%; 95% CI, -0.9% to -0.5%; P < .001). Prosthetic-valve endocarditis increased (from 12.0% to 13.8%; APC, 1.3%; 95% CI, 0.8% to 1.7%; P < .001), and cardiac device-related endocarditis increased (from 1.3% to 4.1%; APC, 8.8%; 95% CI, 7.8% to 9.9%; P < .001). The proportion of patients with health care-associated nosocomial endocarditis decreased (from 17.7% to 15.3%; APC, -1.0%; 95% CI, -1.4% to -0.7%; P < .001). The proportion of patients with health care-associated nonnosocomial endocarditis increased (from 32.1% to 35.9%; APC, 0.8%; 95% CI, 0.5% to 1.1%; P < .001). The incidence of oral streptococcal endocarditis did not increase (unadjusted: APC, -0.1%; 95% CI, -0.8% to 0.6%; P = .77; adjusted: APC, -1.3%; 95% CI, -1.8% to -0.7%; P < .001). Crude 90-day mortality was unchanged (from 23.9% to 24.2%; APC, -0.3%; 95% CI, -1.0% to 0.4%; P = .44); adjusted risk of 90-day mortality decreased (adjusted hazard ratio per year, 0.982; 95% CI, 0.978 to 0.986; P < .001).

Conclusions and relevance: In California and New York State, the overall standardized incidence of infective endocarditis was stable from 1998 through 2013, with changes in patient characteristics and etiology over this time.

Figure 1.. Standardized Incidence of Infective Endocarditis in California and New York State From 1998 Through 2013

Direct standardization was performed to account for changes in age, sex, and race in the California and New York State census population during the study period, using the population in 1998 as the reference. For all infective endocarditis cases, the annual percentage change was −0.06% (95% CI, −0.3% to 0.2%; P = .59); for oral streptococcal endocarditis cases, the annual percentage change was −1.3% (95% CI, −1.8% to −0.7%; P < .001). P values were calculated using multivariable Poisson regression and were 2-tailed. The shaded regions indicate 95% confidence intervals.

Figure 2.. Five-Year Survival of Patients With Infective Endocarditis, Stratified by Mode of Acquisition, in California and New York State

Patients admitted from 1998 through 2011 were included in the analysis for long-term outcomes.

Figure 3.. Five-Year Survival of Patients With Infective Endocarditis, Stratified by Pathogen, in California and New York State

Patients admitted from 1998 through 2011 were included in the analysis for long-term outcomes. Staphylococcus and Streptococcus each include the entire genus.