Bartonella quintana endocarditis: A systematic review of individual cases.

INTRODUCTION: Bartonella quintana is a louse-borne bacterium that remains a neglected cause of endocarditis in low-resource settings. Our understanding of risk factors, clinical manifestations and treatment of B. quintana endocarditis are biased by older studies from high-income countries.

METHODS: We searched Pubmed Central, Medline, Scopus, Embase, EBSCO (CABI) Global Health, Web of Science and international trial registers for articles published before March 2023 with terms related to Bartonella quintana endocarditis. We included articles containing case-level information on B. quintana endocarditis and extracted data related to patient demographics, clinical features, diagnostic testing, treatment and outcome.

RESULTS: A total of 975 records were identified, of which 569 duplicates were removed prior to screening. 84 articles were eligible for inclusion, describing a total of 167 cases. Infections were acquired in 40 different countries. 62 cases (37.1%) were acquired in low and middle-income countries (LMICs). Disproportionately more female and pediatric patients were from LMICs. More patients presented with heart failure (n = 70/167 [41.9%]) than fever (n = 65/167 [38.9%]). Mean time from symptom onset to presentation was 5.1 months. 25.7% of cases (n = 43/167) were associated with embolization, most commonly to the spleen and brain. 65.5% of antimicrobial regimens included doxycycline. The vast majority of cases underwent valve replacement surgery (n = 154/167, [98.0%]). Overall case fatality rate was 9.6% (n = 16/167).

CONCLUSION: B. quintana endocarditis has a global distribution, and long delays between symptom onset and presentation frequently occur. Improved clinician education and diagnostic capacity are needed to screen at-risk populations and identify infection before endocarditis develops.