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A Consequence of Medical Progress

Vance G. Fowler, Jr, MD, MHS; Jose M. Miro, MD, PhD; Bruno Hoen, MD, PhD; Christopher H. Cabell, MD, MHS; Elias Abrutyn, MD; Ethan Rubinstein, MD, LLb; G. Ralph Corey, MD; Denis Spelman, MD; Suzanne F. Bradley, MD; Bruno Barsic, MD, PhD; Paul A. Pappas, MS; Kevin J. Anstrom, PhD; Dannah Wray, MD; Claudio Q. Fortes, MD; Ignasi Anguera, MD; Eugene Athan, MD; Philip Jones, MD; Jan T. M. van der Meer, MD; Tom S. J. Elliott, PhD, DSc FRCPath; Donald P. Levine, MD; Arnold S. Bayer, MD; for the ICE Investigators

JAMA. 2005;293:3012-3021.

Context  The global significance of infective endocarditis (IE) caused by Staphylococcus aureus is unknown.

Objectives  To document the international emergence of health care–associated S aureus IE and methicillin-resistant S aureus (MRSA) IE and to evaluate regional variation in patients with S aureus IE.

Design, Setting, and Participants  Prospective observational cohort study set in 39 medical centers in 16 countries. Participants were a population of 1779 patients with definite IE as defined by Duke criteria who were enrolled in the International Collaboration on Endocarditis-Prospective Cohort Study from June 2000 to December 2003.

Main Outcome Measure  In-hospital mortality.

Results  S aureus was the most common pathogen among the 1779 cases of definite IE in the International Collaboration on Endocarditis Prospective-Cohort Study (558 patients, 31.4%). Health care–associated infection was the most common form of S aureus IE (218 patients, 39.1%), accounting for 25.9% (Australia/New Zealand) to 54.2% (Brazil) of cases. Most patients with health care–associated S aureus IE (131 patients, 60.1%) acquired the infection outside of the hospital. MRSA IE was more common in the United States (37.2%) and Brazil (37.5%) than in Europe/Middle East (23.7%) and Australia/New Zealand (15.5%, P<.001). Persistent bacteremia was independently associated with MRSA IE (odds ratio, 6.2; 95% confidence interval, 2.9-13.2). Patients in the United States were most likely to be hemodialysis dependent, to have diabetes, to have a presumed intravascular device source, to receive vancomycin, to be infected with MRSA, and to have persistent bacteremia (P<.001 for all comparisons).

Conclusions  S aureus is the leading cause of IE in many regions of the world. Characteristics of patients with S aureus IE vary significantly by region. Further studies are required to determine the causes of regional variation.

Author Affiliations: Duke University Medical Center, Durham, NC (Drs Fowler, Cabell, Corey, Anstrom, and Mr Pappas); Hospital Clinic-IDIBAPS, University of Barcelona, Spain (Dr Miro); Hôpital Saint-Jacques, Besançon, France (Dr Hoen); Drexel University College of Medicine, Philadelphia, Pa (Dr Abrutyn); Tel Aviv University, School of Medicine, Tel Aviv, Israel (Dr Rubinstein); Alfred Hospital, Melbourne, Australia (Dr Spelman); University of Michigan, Ann Arbor (Dr Bradley); University Hospital for Infectious Diseases, Zagreb, Croatia (Dr Barsic); Medical University of South Carolina, Charleston (Dr Wray); Hospital Universitario Clementino Fraga Filho, Rio de Janeiro, Brazil (Dr Fortes); Hospital de Sabadell, Sabadell, Spain (Dr Anguera); Geelong Hospital, Geelong, Australia (Dr Athan); Prince of Wales Hospital, Sydney, Australia (Dr Jones); Academic Medical Center, University of Amsterdam, the Netherlands (Dr van der Meer); Queen Elizabeth Hospital, Birmingham, England (Dr Elliott); Wayne State University, Detroit, Mich (Dr Levine); and Harbor-UCLA Medical Center and the LA Biomedical Research Institute, Los Angeles (Dr Bayer).

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