Clinical characteristics and in-hospital outcomes of fungal infective endocarditis: a 21-year tertiary centre cohort study

Background

Fungal infective endocarditis (IE) is an uncommon but life-threatening condition, accounting for 1–3% of all IE cases and associated with substantially higher mortality than bacterial causes. Candida species predominate, followed by Aspergillus, and infection frequently involves prosthetic valves or intracardiac devices. Despite advances in imaging, antifungal therapy and surgical management, reported in-hospital mortality remains high. Contemporary data describing clinical presentation, structural complications and early outcomes remain limited.

Methods

We performed an analysis of prospectively collected data for all episodes of fungal IE managed at a tertiary referral centre in London, UK between 2004 and 2024. Demographic, microbiological and clinical characteristics, valve/device involvement, structural complications, management strategies and in-hospital outcomes were evaluated. Comparisons were performed using Fisher’s exact test.

Results

Twenty-one episodes of fungal endocarditis occurred in 19 patients (median age 58.5 years; 62% [13/21] male), including two relapse episodes; this comprised 1.3% of all IE episodes during the study period. Candida accounted for 62% (13/21) and Aspergillus for 38% (8/21) of cases.

Prosthetic valves were involved in 57% (12/21) and intracardiac devices in 10% (2/21), resulting in combined prosthetic/device involvement in 67% (14/21) of episodes. Native valve infection accounted for 24% (5/21), while one case involved a repaired aortic valve without prosthetic material (5%, 1/21) and one was non-valvular (right atrial mass; 5%, 1/21).

Aortic valve involvement was present in 48% (10/21) of episodes, among which peri-annular or aortic root abscess was documented in 50% (5/10). Cardiac surgery or device extraction was performed in 95% (20/21) of cases.

In-hospital mortality was 19% (4/21) and occurred exclusively in Aspergillus infection (50% [4/8] vs 0% [0/13] in Candida; p=0.012).

Conclusion

In this tertiary centre cohort, fungal infection remained an uncommon cause of IE, accounting for 1.3% of all cases. Episodes predominantly involved prosthetic material or intracardiac devices and required surgical management in nearly all cases. Aortic involvement was frequent and associated with a high rate of peri-annular abscess formation, reflecting the destructive nature of the disease. In-hospital mortality was driven by Aspergillus infection, highlighting the need for prompt recognition and aggressive multidisciplinary management.