Challenges of Infective Endocarditis in South Africa, a Low- to Middle-Income Country.

Infective endocarditis (IE) remains a complex and life-threatening disease globally, but in low- and middle-income countries (LMICs), the burden is amplified by a confluence of socio-economic disparities, high rates of rheumatic heart disease (RHD), limited local data and systemic healthcare limitations. In South Africa, a representative LMIC, patients with IE are typically younger and often present with advanced disease. This is attributed to delayed diagnosis, limited access to echocardiography, and a high prevalence of blood culture-negative infective endocarditis (BCNIE), which complicates microbiological confirmation and treatment selection compared to patients in high-income countries. Rheumatic heart disease continues to be a dominant predisposing factor, and the burden of long term anticoagulation following valve replacement contributes to recurrent complications. In addition, there has been a shift in epidemiological profile with Staphylococcus aureus predominating. Although international data support oral step-down therapy and early surgical intervention in selected patients, the implementation of these strategies in South Africa and other LMICs are constrained by diagnostic limitations, insufficient surgical infrastructure and health care worker hesitance to implement protocols validated in Western countries. Despite these barriers, growing evidence supports the need for locally adapted guidelines, including screening at primary care level, multidisciplinary endocarditis teams, and prospective local research to evaluate the safety and feasibility of simplified treatment protocols. The ultimate goal should be the development of resource-sensitive interventions with broader applicability across similar settings worldwide, ultimately aiming to reduce the global clinical and economic burden of IE.