Recognition, management and prophylaxis of endocarditis.

Infective endocarditis (IE) remains a disease with high morbidity and mortality. In recent years, a higher frequency of IE has been observed in the elderly, in intravenous drug users and in patients with prosthetic valves. The diverse manifestations of this disease demand a high degree of suspicion from the practitioner, in order to make an early diagnosis. Advances in and increasing use of echocardiography (especially transoesophageal) allow us to identify valvular changes earlier and more precisely. The use of the new Duke's diagnostic criteria, based on clinical manifestations and microbiological and echocardiographic findings, facilitates the diagnosis and categorisation of IE. An increase in staphylococci and other problem pathogens, such as penicillin-resistant streptococci, enterococci resistant to beta-lactams, aminoglycosides and methicillin-resistant staphylococci has been observed. Important changes have also taken place in the management of IE. There is a clear trend towards the use of shorter treatment courses, oral and once-daily regimens and outpatient programmes, all of which aim to reduce costs and provide patients with improved quality of life. Antibiotic prophylaxis for the prevention of IE is still controversial. In the past few years more rational regimens have been used, and indications are now more precise. In spite of all this, however, few cases are prevented and patient compliance to the prophylaxis regimens remains low.