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Infective Endocarditis in French West Indies: A 13-Year Observational Study

Elisabeth FernandesDepartment of Infectious Diseases, Medicine B, Hospital of Basse Terre, Guadeloupe, France;

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Claude OliveLaboratory of Bacteriology, University Hospital of Martinique, Fort-de-France, France;
Université des Antilles, EA 4537, Fort-de-France, France;

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Jocelyn InamoDepartment of Cardiology, University Hospital of Martinique, Fort-de-France, France;

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François RoquesDepartment of Thoracic and Cardiovascular Surgery, University Hospital of Martinique, Fort-de-France, France;

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André CabiéUniversité des Antilles, EA 4537, Fort-de-France, France;
INSERM, CIC1424, Cayenne, France;
Department of Infectious Diseases, University Hospital of Martinique, Fort-de-France, France

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Patrick HochedezUniversité des Antilles, EA 4537, Fort-de-France, France;
Department of Infectious Diseases, University Hospital of Martinique, Fort-de-France, France

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We conducted an observational study to describe the characteristics of infective endocarditis (IE) in French West Indies (FWI) and to identify variables associated with in-hospital case fatality. The records of the patients admitted for IE to the University Hospital of Martinique between 2000 and 2012 were collected using an electronic case report form. Only Duke-Li definite cases were considered for this analysis. Variables associated with in-hospital mortality were tested using univariate logistic regression analysis. The analysis included 201 patients (median age 58 years, sex ratio: two males to one female). There was no previously known heart disease in 45.8%, a prosthetic valve in 21.4%, and previously known native valve disease in 32.8% of the cases. Community-acquired IE represented 59.7% of all cases, health-care-associated IE represented 38.3% and injection-drug-use-acquired IE represented 1.5%. Locations of IE were distributed as follows: 42.3% were mitral valve IE, 34.8% were aortic valve IE, and 7% were right-sided IE. Microorganisms recovered from blood cultures included 30.4% streptococci, 28.9% staphylococci, and 5% enterococci. Blood cultures were negative in 20.9% of the cases. Surgical treatment was performed in 53% of the patients. In-hospital case fatality rate was 19%. Advanced age, Staphylococcus aureus IE, and health-care-associated IE were associated with in-hospital case fatality. The epidemiological and microbiological profile of IE in FWI is in between those observed in developed countries and developing countries: patients were younger, blood cultures were more frequently negative, and IE due to group D streptococci and enterococci were less common than in industrialized countries.

INTRODUCTION

Since Osler’s first descriptions in 1885,1 there has been great progress in the diagnosis and therapeutics of infective endocarditis (IE); however, its mortality and morbidity are still high.2,3 With an annual incidence between 30 and 100 cases per million inhabitants depending on the countries,49 IE is an uncommon disease but nonetheless serious, with an in-hospital case fatality rate around 20% and 1-year mortality remains at 30%.35,1013

The epidemiological profile of patients affected with IE has changed within the last decades. In developed countries, health-care-associated IE accounts for 25–30% of contemporary cohorts3,6,9 and patients are older, with an annual incidence reaching 145 cases per million inhabitants when between 70 and 80 years of age.4 There is an increase in degenerative valve disease, in prosthetic valves and in indwelling cardiac devices, and a decrease in rheumatic heart disease.2,3

The incidence of staphylococcal IE increased in industrialized countries, a trend that follows the increase of Staphylococcus aureus risk factors, such as contact with health-care systems, invasive procedures, intravascular device, hemodialysis, diabetes, and injection drug use (IDU).1417 In the same time, oral streptococcal IEs have considerably decreased in industrialized countries.14,18

The annual incidence of IE in France is considered to be around 33 cases per million inhabitants, and the epidemiological and microbiological profile of IE is similar to that in other developed countries.5,6

The epidemiological profile of patients affected with IE changes according to the country’s level of industrialization. Hence, IE-affected patients in developing countries are younger and have higher risk to develop IE upon congenital or rheumatic heart disease; moreover, the incidence of blood culture–negative IE (BCNIE) and mortality are higher.1921

To date, no study has described the current features of IE in French West Indies (FWI). The aim of the present study was to describe the epidemiology, clinical characteristics, and outcome of IE in FWI, and to identify the factors associated with in-hospital mortality.

MATERIALS AND METHODS

Study population and protocol.

This retrospective cohort study was conducted at the University Hospital of Martinique, a large tertiary-care teaching hospital with 1,300 beds, in Martinique, FWI. About 40,000 patients are admitted each year and it includes the only thoracic and cardiovascular surgery department in the FWI.

Patients were included in the study according to the following criteria: 1) definitive diagnosis of IE according to the modified Duke criteria,22 (2) and admission to the University Hospital of Martinique between January 1, 2000 and December 31, 2012.

Patients were excluded from the study if 1) their medical record was not available, or 2) affected by non-IE, or 3) affected by a “possible infective endocarditis” according to the modified Duke criteria.22

A retrospective search was done in the records of the hospital for all cases of IE that were diagnosed during the study period. Clinical data, microbiological data, and echocardiography reports were reviewed and the diagnosis of IE was verified according to the modified Duke criteria. The following information were collected using an electronic case report form: sex, date of birth, place of residence, transfer from or to another facility, history of heart disease, procedures and situations at risk for IE, comorbidities, clinical signs and symptoms, laboratory and imaging examinations, echocardiographic data, microbiological data, medical and surgical treatment, and outcome.

Definition of variables.

A health-care-associated IE was defined as non-nosocomial or nosocomial:

  • A non-nosocomial IE was defined as IE diagnosed within the first 48 hours of hospitalization in a patient exposed to health-care procedures: 1) care with home nurses, 2) hemodialysis or intravenous chemotherapy within the 30 days before the onset of IE, 3) hospitalization in an acute care hospital in the 90 days before the onset of IE, 4) residency in nursing home or long-term care facility, or 5) invasive procedure and surgery within the year prior to infection.

  • A nosocomial IE was defined as IE developing in a patient hospitalized for more than 48 hours before the onset of signs or symptoms consistent with IE.

A community-acquired IE was defined as IE diagnosed upon admission (or within the first 48 hours of hospitalization) in a patient that had not been exposed to care procedures.

The IE was considered as associated to the use of intravenous drugs in IDU patients who were active when IE was diagnosed.

Statistical analysis.

The variables are presented using median with the first and third quartiles for the quantitative variables, and as effectives and frequencies for the qualitative variables. The Fisher’s exact test was used to compare categorical data. The Mann–Whitney test was used to compare continuous data between groups. When appropriate, odds ratio and 95% confidence interval were computed. Groups were compared by the log-rank test. The risk of error of the first kind was 5% (α = 0.05) for all the tests. All statistical analyses were performed using STATA software, version 12 (StataCorp, College Station, TX).

RESULTS

A total of 308 medical records with an IE diagnosis were identified. Eleven patients (3.6%) had a cardiac device infection without associated IE and five patients (1.6%) were affected by non-IE: three Libman–Sacks endocarditis and two marasmic endocarditis. Seventy patients (22.7%) were excluded because IE was invalidated during hospitalization. Twenty-one patients (6.8%) had a possible IE. Finally 201 patients (65.3%) were included with a definite IE according to the modified Duke criteria (Figure 1

Figure 1.
Figure 1.

Flow chart.

Citation: The American Society of Tropical Medicine and Hygiene 97, 1; 10.4269/ajtmh.16-0514

). Five of these 201 patients had two IE episodes, from which only the first one was used for the statistical analysis.

Baseline characteristics and predisposing factors are presented in Table 1

Table 1

Characteristics of infective endocarditis–affected patients

Patients characteristicsNo. of patients (%)
Age ≥ 70 years57 (28.4)
Male gender135 (67.1)
First symptoms diagnosis ≤ 28 days124/185 (67)
Medical history103/199 (52)
 Hypertension54/166 (32.5)
 Overweight (BMI ≥ 25)45/199 (22.6)
 Diabetes mellitus24/124 (19.4)
 Tabagism34/184 (18.5)
 Coronaropathy23/166 (14)
 Obesity (BMI ≥ 30)12/87 (13.8)
 Alcoholism25/198 (12.6)
 Acute rheumatic fever24 (12)
 Chronic kidney disease19 (9.5)
 Malignancy17 (8.46)
 Hemodialysis12/200 (6)
 Immunosuppressive therapy5/192 (2.6)
 HIV infection56/168 (33.3)
Extracardiac predisposing factors26/129 (20.2)
 Invasive procedures within 12 months33 (16.42)
 Dental care within 3 months4/104 (3.8)
 Chronic intravenous access43 (21.4)
 IDU92 (45.8)
Cardiac history66 (32.8)
 Underlying HD13/189 (7)
  Prosthetic valve19 (9.5)
  No previously HD120 (59.7)
  Previously known HD without prosthetic valve77 (38.3)
 Previous IE3 (1.5)
 Intracardiac device (PM or ICD)1 (0.5)
Mode of acquisition107 (53.2)
 Community-acquired IE38 (18.9)
 Health-care-associated IE
 IDU-associated IE
 IE of unknown origin
Outcomes
 Cardiac surgery
 In-hospital death

BMI = body mass index; HD = heart disease; HIV = human immunodeficiency virus; ICD = implantable cardiovertor defebrillator; IDU = intravenous drug use; IE = infective endocarditis; PM = pacemaker. The denominator appears when the data were not available for the 201 patients; it indicates the number of patients for whom the data were available.

. The median age was 58 years (45–71), and 135 patients (67%) were men. The most common underlying conditions were arterial hypertension (103 patients, 52%), overweight (54 patients, 32.5%), and diabetes mellitus (45 patients, 22.6%). The main extracardiac predisposing conditions were recent invasive procedure (56 patients, 33.3%), recent dental care (26 patients, 20.2%), and the presence of long-term intravenous line (33 patients, 16.4%). The median time between first symptoms and diagnosis of IE was 15 days (8–37).

One hundred and nine patients (54.2%) had a previously known heart disease. Community-acquired IE represented 59.7% of all cases, health-care-associated IE represented 38.3% (non-nosocomial [30.8%] and nosocomial [7.5%]) and injection-drug-use-acquired IE represented 1.5% of all cases.

Eighty-eight patients (44%) had been transferred from another hospital, 47 patients from Guadeloupe, 25 patients from another hospital of Martinique, and 16 patients from French Guiana. The comparison between the 138 patients initially hospitalized in Martinique and the 63 patients transferred from Guadeloupe or from French Guiana showed significant differences: 1) transferred patients were younger (53.3 years of age [41.6–65.3]) than patients from Martinique (61.8 years of age [48.3–74]) (P < 0.01), and 2) transferred patients had surgery procedure more frequently: 76% of transferred patients versus 42% of patients from Martinique (P < 0.01).

One hundred and seven patients (53%) had surgery. Median time between diagnosis and surgical treatment was 21 days (9–44). Ninety-five patients (89%) had early surgery (defined as surgery during antibiotic therapy) and 12 patients (11%) had late surgery. Surgical indications for patients who had surgery were 1) heart failure for 81 patients (76%), 2) prevention for embolic risk in 40 patients (37%), 3) ablation of indwelling cardiac device in eight patients (7%), and 4) uncontrolled infection in two patients (2%). In-hospital mortality was 19% with a median delay of 13.5 days (5–31) between diagnosis and death.

Location of IE and echocardiographic data.

One hundred and eighty patients of 195 (92%) had both a transthoracic echocardiography and a transesophageal echocardiography, 10 patients (5%) had had a TTE only, and five patients (3%) had had a TEE only. The most common echographic data found were the presence of vegetations (84%), mobile vegetations (66%), regurgitation (45%), and pulmonary hypertension (31%) (Table 2

Table 2

Location of IE and echocardiographic data

Location of IE and echocardiographic dataNo. of patients (%)
Location of IE
 Native valve IE150 (74.6)
 Prosthetic valve IE39 (19.4)
 Mitral valve85 (42.3)
 Aortic valve70 (34.8)
 Aortic and mitral valves16 (8)
 Tricuspid valve12 (6)
 Pulmonary valve2 (1)
 Bilateral IE4 (2)
 On indwelling cardiac device10 (5)
  Associated with a tricuspid native valve IE2 (1)
  Isolated8 (4)
 Undetermined*4 (2)
Cardiac lesions of IE166/197 (84)
 Vegetation69/166 (35)
  Vegetation < 10 mm49/166 (25)
  Vegetation 10–15 mm48/166 (24)
  Vegetation > 15 mm108/165 (66)
 Mobile vegetation87/194 (45)
 Regurgitation55/180 (31)
 Pulmonary hypertension10/46 (22)
 Prosthesis disinsertion34/195 (17)
 Cardiac abscess31/187 (17)
 Low LVEF55/85 (65)
 Other anomalies (aneurysms, perforations, fistulas)

IE = infective endocarditis; LVEF = left ventricular ejection fraction. The denominator appears when the data were not available for the 201 patients; it indicates the number of patients for whom the data were available.

Nonoperated patients with lack of echocardiographic evidence of endocardial involvement.

). When the first echocardiography was negative, a second TTE/TEE had been done in 97% of the cases. Locations of IE were distributed as follows: 42.3% were mitral valve IE, 34.8% were aortic valve IE, 8% were aortic and mitral valve IE, and 7% were right-sided IE. Left-sided IEs (85.1%) were more frequent than right-sided IEs and mixed IEs. Native valve IEs (74.6%) were more frequent than prosthetic valve IEs (PVIEs) (Table 2). Of 39 PVIEs, 31 IEs were developed on prosthetic valve implanted for more than 1 year and eight on prosthetic valve implanted for less than 1 year. Five of these eight PVIEs were nosocomial with multiresistant microorganisms and three were health-care-associated non-nosocomials.

Causative microorganisms.

One hundred and fifty-nine patients (79%) had positive blood cultures. Gram-positive cocci were predominant (64.3%) with identification of Streptococcus, Staphylococcus, and Enterococcus species in 30.4%, 28.9%, and 5%, respectively (Table 3

Table 3

Microorganisms identified in blood-positive IE patients

MicroorganismsNo. of patients (%)
Streptococci61 (30.3)
 Oral streptococci31 (15.4)
 Group D streptococci12 (5.9)
 Other streptococci*18 (9)
Enterococci10 (5)
Staphylococci58 (28.9)
Staphylococcus aureus46 (22.9)
  Methicillin susceptible42 (20.9)
  Methicillin resistant4 (2)
 Coagulase-negative staphylococci12 (6)
  Methicillin resistant6 (3)
HACEK8 (4)
≥ 2 microorganisms8 (3.9)
Other§14 (7)
No microorganism identified by blood culture42 (20.9)
 Serological identification2 (1.1)
 Heart valve culture7 (3.4)
 No microorganism identified33 (16.4)

IE = infective endocarditis. The denominator appears when the data were not available for the 201 patients; it indicates the number of patients for whom the data were available.

Twelve Streptococcus agalactiae, one Streptococcus spp., and five Streptococcus pneumoniae.

Five Haemophilus parainfluenzae, one Haemophilus aphrophilus, one Aggregatibacter (previously Actinobacillus) actinomycetemcomitans, and one undetermined HACEK group bacteria.

Staphylococcus aureus and Escherichia coli; Klebsiella pneumoniae and Candida albicans; Enterococcus faecalis and E. coli; Streptococcus mutans and Streptococcus mitis; Aeromonas sobria and Streptococcus bovis; S. aureus and Enterococcus faecalis; coagulase-negative Staphylococcus and unidentified hyphae; Enterobacter aerogenes and Pseudomonas aeruginosa.

Five E. coli, one Enterobacter aerogenes, one Pseudomonas aeruginosa, one Acinetobacter, one Moraxella lacunata, two Klebsiella pneumoniae, one Salmonella spp., one Pasteurella, one Corynebacterium spp.

). Blood cultures were negative in 20.9% of the cases, and no microorganism was identified in 16.4% of the cases.

Of the 42 patients (20.9%) with negative blood cultures, 16 (38%) had received antibiotics within 7 days of the blood culture. The recommended serology testing performed in seven patients of the 42 patients with BCNIEs resulted in the identification of a case of IE due to Bartonella henselae and a case of IE due to Coxiella burnetii. Direct examination and surgical sample analysis (valve resection or embolectomy) were required in 90% of the operated patients and allowed identification of seven BCNIEs: one mycotic aneurysm and two valves were positive with gram-positive cocci, one valve was positive with hemolytic group F Streptococcus, one valve with gram-negative bacilli, one valve with coagulase-negative Staphylococcus, and one with Penicillium spp.

Microorganisms found in the community-acquired IE were staphylococci in 23.2% of the cases and oral streptococci in 30.5%, whereas in health-care-associated IE, staphylococci were found in 56.3% of the cases and oral streptococci in 3.1%. In the nosocomial cases of IE, staphylococci were found in 78.6% of the cases, whereas none had oral streptococci. Methicillin-susceptible S. aureus was the microorganism found in the three IDU patients.

Complications.

The main complications identified were heart failure (58.7%), acute renal failure (24%), and metastatic infection (including embolization, metastatic abscess, and mycotic aneurysm) (22.4%) (Table 4

Table 4

Prevalence of complications in patients with IE

ComplicationsNo. of patients (%)
Cardiac complications141 (70)
 Heart failure118 (58.7)
 Others (abscess, perforations, prosthetic dysfunction)23 (11.3)
Extracardiac complications113 (56)
 Acute renal failure48 (24)
 Metastatic infection45 (22.4)
  Stroke29 (14.4)
  Musculoskeletal complications24 (11.9)
  Spondylodiscitis8 (4)

IE = infective endocarditis. The denominator is indicated when the data were not available for the 201 patients, it shows the number of patients for whom the data were available.

).

In-hospital mortality.

Factors associated with in-hospital fatality are presented in Table 5

Table 5

Factors associated with in-hospital mortality among patients with infective endocarditis

VariablesOR (95% CI)P value
Age > 50 years3.84 (1.42–10.38)< 0.01
Arterial hypertension3.61 (1.60–8.13)< 0.01
Immunosuppressive therapy7.09 (2.11–23.79)< 0.01
Cancer3.68 (1.36–9.93)0.01
Chronic kidney disease4.70 (1.91–11.58)< 0.01
Wearer of valve prosthesis (-es)2.69 (1.25–5.83)0.012
Indwelling cardiac device3.72 (1.64–8.42)< 0.01
Hemodialysis3.45 (1.22–9.78)0.019
Invasive procedure within 12 months2.89 (1.31–6.36)< 0.01
Health-care-associated IE (nosocomial and non-nosocomial)4.71 (2.21–10.08)< 0.01
Nosocomial IE3.61 (1.17–11.12)0.025
Community-acquired IE0.21 (0.09–0.45)< 0.01
Heart complications7.74 (2.28–26.21)< 0.01
Neurological signs at the time of diagnosis3.63 (1.36–9.65)0.01
Cerebrovascular accident2.71 (1.14–6.44)0.024
Acute renal failure2.21 (1.04–4.73)0.04
Staphylococcus aureus IE3.45 (1.63–7.29)< 0.01
Enterococcal IE3.38 (1.01–11.29)0.048
Streptococcal IE0.27 (0.1–0.74)0.011
Surgical treatment0.21 (0.09–0.46)< 0.01

CI = confidence interval; IE = infective endocarditis; OR = odds ratio.

. The following variables were associated with a decrease in in-hospital mortality: surgical treatment, community-acquired IE, and streptococcal IE.

DISCUSSION

Despite the medical advances in the diagnosis and treatment of IE, mortality and morbidity remain high. A better understanding of demographic, clinical, therapeutic, and prognostic characteristics of the disease can result in better diagnosis and treatment of patients. Our work represents the largest study conducted in patients with IE in FWI and gives an update of the characteristics of the disease.

Patients with IE in FWI are mainly old men—however, younger than in studies carried out in metropolitan France—mainly without history of valve disease as in the other industrialized countries.3,4,11 Degenerative valve disease and valve prostheses represent the majority of underlying heart diseases in our study. The important portion of patients without underlying heart diseases is probably linked to 1) the decrease in acute rheumatic fever that had an incidence of 19.6/100,000 inhabitants in Martinique aged over 20 years at the beginning of the eighties,23 2) a better prevention among high-risk patients, and also (3) a lack of diagnosis for degenerative valve disease in older patients.

As in other studies, most IEs were located on native valve and the mitral valve was most frequently affected.3,21 The important proportion of health-care-associated IE (38.3%) in our study was also reported in many regions of the world and is linked to the increase in invasive medical care.3,6,14,16

In our study such as in several studies published since 2000,3,6,14,16 S. aureus was the most frequently identified microorganism (22.9%). Although risk factors for S. aureus-associated IE are widespread, Murdoch’s study shows the importance of geographical variations. Indeed S. aureus is the causative bacteria in 31% of the cases while considering the whole cohort reported, but this rate reaches 43% in the United States and only 17% in South America.3 Interestingly in our study, Streptococcus species were more frequently responsible for IE than Staphylococcus species. Furthermore, the proportion of BCNIEs was more frequent, whereas IEs due to group D streptococci or enterococci were less common than in developed countries.3,24 Similar results were found in South America and in Jamaica3,25 which suggests that the epidemiological and microbiological profile of IE in our study is between developing and developed countries’ epidemiological profile.

If the epidemiological conditions are probably similar in Martinique and Guadeloupe, both Caribbean islands, the particular epidemiology of French Guiana must be taken into account, especially in BCNIE. The high number of BCNIEs found in our study (20.9%) is due to several factors: mainly to antibiotic therapies prior to blood culture, but also to a lack of investigations. We observed that serological tests were not systematically reported for patients with BCNIE, and that surgical sample analyses were not systematically required. According to a retrospective study conducted in French Guiana, in 2005, the annual incidence rate of acute Q fever was estimated at 150/100,000 persons.2628 In two seroprevalence studies conducted in Brazil, it appears that Coxiella burnetii seroprevalence was 3.9%, B. henselae seroprevalence was 13.7%, and Bartonella quintana seroprevalence was 12.8% in the Brazilian population.29,30 Frankel and others reported an increase in Q fever in France and the study of Murdoch and others also specified that most cases of Q fever and Bartonella IE came from Europe.3,31

Few bacterial serologies are recommended by the European Society of Cardiology for cases of BCNIE. Given the available epidemiological data about the Amazon region and the lack of seroprevalence study in the FWI, the microbiological analysis of surgical specimens, as well as the serology for Bartonella spp. and Coxiella burnetii, should be systematic in BCNIE cases in our region. Thanks to new techniques in molecular biology, a microbiological diagnosis can be performed in cases of BCNIE and in cases of possible IE.32 However, because of an increasing number of immunocompromised persons, fungal IE or IE with atypical microorganism must be considered. In a recent review on 270 cases of fungal endocarditis, the three main fungi identified were Candida (52%), Aspergillus (24%), and Histoplasma (6%).33 The FWI and French Guiana region is an endemic area for histoplasmosis and, although no endocarditis has been reported to date, this localization has been described in the literature and is a potential etiology of BCNIE.34,35

In-hospital case fatality rate in our study was of 19%, which corresponds to other studies’ results in which in-hospital fatality is around 20%.35,10,11 We have found several factors that were associated with in-hospital fatality, such as age > 50 years, presence of valve prosthesis and implantable cardiovertor defebrillator, IE due to S. aureus, health-care-associated IE, and cardiac complications. These prognostic factors associated with in-hospital fatality in our study are similar to the ones described in the literature.3,7

We have found that streptococcal IE and surgical treatment were associated with decreased in-hospital fatality. Indications and timing for surgical intervention were recently discussed in several articles with conflicting results.10,36,37 Early surgery during antibiotic therapy has been reported as a protective factor for in-hospital mortality in several studies but the appropriate timing of surgery remains controversial.10,3840

The study has several limitations. First, it consisted of a retrospective study with patients lost to follow up and missing data. Moreover, it was based only on the medical reports from the University Hospital of Martinique. There is probably a selection bias with patients initially hospitalized in Martinique on one hand, and patients transferred from French Guiana and Guadeloupe on the other hand. It was indeed found that these two groups were heterogeneous and had different characteristics, with more transferred patients undergoing surgery. Second, there was no systematic serological assessment and an analysis of the surgical specimens for all BCNIEs because there was no standardized diagnostic protocol shared between the different actors during the study period. After the current study, each IE case in FWI and French Guiana is expected to be included in a multicenter cohort study and diagnosis and treatment options are discussed within an “endocarditis team” as recommended by recent guidelines.41

In conclusion, the epidemiological and microbiological profile of IE in FWI is between those observed in developing and developed countries: patients were younger, blood cultures were more frequently negative, and IEs due to group D streptococci and enterococci were less common than in industrialized countries. Treatment of IE in the FWI and French Guiana would beneficiate from implementation of endocarditis team, aiming to improve diagnosis and treatment procedure, adapted to local epidemiological features.

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Author Notes

Address correspondence to Elisabeth Fernandes, Department of Infectious Diseases, Medicine B, Hospital of Basse Terre, Av. Gaston Feuillard, 97110 Basse Terre, Guadeloupe, France. E-mail: fernandes.elisabeth@free.fr

Authors’ addresses: Elisabeth Fernandes, Department of Infectious Diseases, Medicine B, Hospital of Basse Terre, Guadeloupe, France, E-mails: fernandes.elisabeth@free.fr or elisabeth.fernandes@ch-labasseterre.fr. Claude Olive, Laboratory of Bacteriology, University Hospital of Martinique, Fort-de-France, France, E-mail: claude.olive@chu-fortdefrance.fr. Jocelyn Inamo, Department of Cardiology, University Hospital of Martinique, Fort-de-France, France, E-mail: jocelyn.inamo@chu-fortdefrance.fr. François Roques, Department of Thoracic and Cardiovascular Surgery, University Hospital of Martinique, Fort-de-France, France, E-mail: francois.roques@chu-fortdefrance.fr. André Cabié and Patrick Hochedez, Department of Infectious Diseases, University Hospital of Martinique, Fort-de-France, France, E-mails: andre.cabie@chu-fortdefrance.fr and patrick.hochedez@chu-fortdefrance.fr.

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