Infective endocarditis: should diabetic patients be treated more aggressively?

Be Treated More Aggressively? To the Editor: We read with great interest the recent manuscript by Chu et al,1 in which several predictors for in-hospital mortality in patients with infective endocarditis were identified. In that study, the authors found diabetes as an independent predictor for in-hospital mortality and speculated an adverse influence of hyperglycemia on immune function as a possible explanation. In-hospital mortality was 32% and 12% in diabetics and nondiabetics, respectively.1 This finding is clinically important, because there are very few data on the influence of diabetes on the outcome of this disease. Taking into consideration the results from this study, it could be hypothesized that diabetic patients with infective endocarditis should be managed more aggressively than nondiabetics, regardless of other clinical features. We recently published a work focused on the influence of diabetes on the outcome of patients with infective endocarditis, not only during hospitalization but also at long term. As did Chu et al1, we found a higher mortality in diabetics both during hospitalization (35% versus 15%) and at 3 years afterward (54% versus 31%).2 However, in our study, diabetes was not an independent predictor for mortality, either during hospitalization or at long-term. We identified heart failure, renal insufficiency, and anatomic complications during hospitalization, and renal insufficiency and age at long term as independent predictors for mortality. Of note, we found that anatomic complications (eg, abscess or pseudoaneurysm) (15% versus 20%) and valve rupture or perforation (8% versus 17%) were not more frequent in diabetics, indicating that infective endocarditis is not more aggressive in diabetics than in nondiabetics. These findings lead us to believe that among patients with infective endocarditis, the presence of diabetes probably should not lead per se to a more aggressive management (earlier surgical intervention).