Infective Endocarditis Admissions Research Articles

Quantifying infective endocarditis risk in patients with predisposing cardiac conditions.

AimsThere are scant comparative data quantifying the risk of infective endocarditis (IE) and associated mortality in individuals with predisposing cardiac conditions.Methods and resultsEnglish hospital admissions for conditions associated with increased IE risk were followed for 5 years to quantify subsequent IE admissions. The 5-year risk of IE or dying during an IE admission was calculated for each condition and compared with the entire English population as a control. Infective endocarditis incidence in the English population was 36.2/million/year. In comparison, patients with a previous history of IE had the highest risk of recurrence or dying during an IE admission [odds ratio (OR) 266 and 215, respectively]. These risks were also high in patients with prosthetic valves (OR 70 and 62) and previous valve repair (OR 77 and 60). Patients with congenital valve anomalies (currently considered ‘moderate risk’) had similar levels of risk (OR 66 and 57) and risks in other ‘moderate-risk’ conditions were not much lower. Congenital heart conditions (CHCs) repaired with prosthetic material (currently considered ‘high risk’ for 6 months following surgery) had lower risk than all ‘moderate-risk’ conditions—even in the first 6 months. Infective endocarditis risk was also significant in patients with cardiovascular implantable electronic devices.ConclusionThese data confirm the high IE risk of patients with a history of previous IE, valve replacement, or repair. However, IE risk in some ‘moderate-risk’ patients was similar to that of several ‘high-risk’ conditions and higher than repaired CHC. Guidelines for the risk stratification of conditions predisposing to IE may require re-evaluation.

Incidence, predictors and outcomes of infective endocarditis in a contemporary adult congenital heart disease population

BackgroundThe prevalence of congenital heart disease (CHD) in the adult population is steadily increasing. A substrate of prosthetic material and residual lesions, constantly evolving as surgical techniques change over time, predispose these patients to the potentially devastating complication of infective endocarditis (IE). MethodsWe retrospectively reviewed 2935 patients in our adult CHD database for all cases of endocarditis between 1991 and 2016. Incidence, clinical course and predictors of outcomes were analysed. ResultsWe document 74 episodes in 62 patients, with an incidence of 0.9 cases/1000 patient years (py). IE was more common in complex CHD (1.4 cases/1000py) and ventricular septal defects (VSDs) (1.9 cases/1000py). Prosthetic material was involved in 47% and left-sided infection predominated (66%). The incidence in bicuspid aortic valves post aortic valve replacement (AVR) was significantly higher than in unoperated valves, being 1.8 and 1.1 cases/1000 patient years respectively. Streptococcus was the most frequently implicated causative organism (37%). Emboli occurred in 34% of cases with a cerebral predilection. 46% of patients required surgery during the admission for IE, most frequently to replace a severely regurgitant bicuspid aortic valve. Early endocarditis-related mortality was 15%, associated with cerebral emboli and acute renal failure. ConclusionsIn a contemporary adult CHD cohort, those with complex underlying lesions, VSDs or an AVR were at higher risk for IE. Mortality remains substantial and is more likely in patients with cerebral emboli and/or acute renal failure.

Return to the workforce following infective endocarditis—A nationwide cohort study

The ability to return to work after infective endocarditis (IE) holds important socioeconomic consequences for both patients and society, yet data on this issue are sparse. We examined return to the workforce and associated factors in IE patients of working age. Using Danish nationwide registries, we identified 1,065 patients aged 18-60 years with a first-time diagnosis of IE (1996-2013) who were part of the workforce prior to admission and alive at discharge. One year after discharge, 765 (71.8%) patients had returned to the workforce, 130 (12.2%) were on paid sick leave, 76 (7.1%) received disability pension, 23 (2.2%) were on early retirement, 65 (6.1%) had died, and 6 (0.6%) had emigrated. Factors associated with return to the workforce were identified using multivariable logistic regression. Younger age (18-40 vs 56-60 years; odds ratio, 2.85; 95% CI, 1.71-4.76) and higher level of education (higher educational level vs basic school; 5.47, 2.05-14.6) and income (highest quartile vs lowest; 3.17, 1.85-5.46) were associated with return to the workforce. Longer length of hospital stay (>90 vs 14-30 days; 0.16, 0.07-0.38); stroke during IE admission (0.38, 0.21-0.71); and a history of chronic kidney disease (0.29, 0.11-0.75), chronic obstructive pulmonary disease (0.31, 0.13-0.71), and malignancy (0.39, 0.22-0.69) were associated with a lower likelihood of returning to the workforce. Seven of 10 patients who were part of the workforce prior to IE and alive at discharge were part of the workforce 1 year later. Younger age, higher socioeconomic status, and absence of major comorbidities were associated with return to the workforce.

Comparing Sentinel Admission for Infective Endocarditis Among Patients With and Without Injection Drug Use: A Single Center Study

Comparing Sentinel Admission for Infective Endocarditis Among Patients With and Without Injection Drug Use: A Single Center Study

Opiate Injection-associated Infective Endocarditis in the Southeastern United States

BackgroundOpiate pain reliever (OPR) misuse by injection is increasing in the United States. Infective endocarditis (IE), a devastating complication of injection OPR use, has been understudied. MethodsWe conducted a retrospective chart review of IE cases at an academic tertiary care hospital in North Carolina. Hospital admissions from 2009-2014 were screened for cases of definite IE. Subjects reporting injection drug use (IDU) were classified as IDU-IE, and compared to those without reported IDU, classified as No IDU-IE. Rates of IDU-IE and No IDU-IE, patient demographics, microbiologic data and outcomes were compared between the groups. ResultsA total of 127 incident admissions for IE were identified, 48 (37.8%) were classified as IDU-IE and 79 (62.2%) as No IDU-IE. IDU-IE cases increased from 14% of hospitalizations for IE in 2009 to 56% in 2014; reporting of OPR injection increased in 2012 and continued through the study period. IDU-IE subjects were younger (32.6 ± 11.7 versus 54.4 ± 13.1, P < 0.0001), more likely to be single (n = 33 [68.8%] versus n = 23 [29.1%], P < 0.0001) and to reside in rural communities (n = 36 [75.0%] versus n = 25 [31.6%], P < 0.0001) than No IDU-IE subjects. Hospital length of stay (26 days versus 12 days, P < 0.0001) and intensive care unit length of stay (2 days versus 1 day, P = 0.04) were longer for IDU-IE patients and hospital mortality did not differ (10.4% IDU-IE versus 8.9% No IDU-IE, P = 0.77). ConclusionsIDU-IE rates increased over time, and OPR injection use in rural communities appears to be a major contributor. Interventions to reduce IDU-IE and OPR misuse are needed to halt this growing epidemic in at-risk rural communities.

Abstract 18908: Trends in Endocarditis Hospitalizations: Impact of the 2007 American Heart Association Guidelines on Adults With Congenital Heart Disease

Introduction: In 2007, the American Heart Association (AHA) modified the recommendations for infective endocarditis (IE) antibiotic prophylaxis for all but the individuals at the highest risk of acquiring IE. The impact of these guidelines remains unclear, particularly for adults with congenital heart disease (CHD). Our objective was to evaluate the trend in IE hospitalization and mortality before and after implementation of the revised AHA guidelines. Hypothesis: We hypothesized no change in the overall trend in IE hospitalization and mortality, including those adults with CHD, in the period after adoption of the 2007 AHA endocarditis guidelines. Methods: We utilized the Texas Hospital Inpatient Discharge Public Use Data File to identify all patients hospitalized between 2001and 2011 with IE in Texas. We evaluated the trend over time of IE admission and the percentage of those with CHD. We also assessed mortality and need for surgery during the hospital admission. Results: We identified 29, 537 IE cases. There was a steady increase in IE hospitalizations over the 10-year period from 1515 cases in 2001 to 3009 in 2011, comprising an increasing proportion of total IE admissions (0.13% in 2001 to 0.17% in 2011, p for trend &lt;0.0001). Of the patients admitted with IE, 3.3% had CHD. While both IE and percentage with CHD increased overtime, neither had a significant change after the 2007 AHA guidelines (Figure 1). Overall CHD mortality decreased from 14.2% in 2001 to 13.7% in 2011 (p=0.09). Overall mortality for the 10-year period was 14.2% without CHD and 9.1% with CHD (p&lt;0.0001). Adults were three times more likely to undergo surgery if they had CHD (25.4% vs 8.1%; p&lt;0.0001). Conclusions: We found no evidence that the 2007 AHA antibiotic prophylaxis guidelines was associated with a significant change in IE admissions across Texas hospitals, even when accounting for adults with CHD. Overall IE admissions, including those with CHD have continued to increase steadily.

Efficacy of cardioprotective agents in reduction of chemotherapy related cardiotoxicity

Methods: The frequency of infection with specific microorganisms was compared between native valve and device related endocarditis, using infective endocarditis admissions in a New South Wales state wide database between 2000 and 2006. Results: Methicillin resistant Staphylococcus aureus was more significantly associatedwith device related infection (p= 0.008). Culture negative endocarditis was more significantly associated with native valve endocarditis (p= 0.02). Amongst patients with native valve endocarditis, MSSA was more significantly associated with IVDU (0.0002) and strep viridans was significantly associated with community acquired infection. Pathogens Native Valve Endocarditis (%) [N= 1393] Device Related Endocarditis (%) [N= 60] p (Chi sq.) Negative Blood Culture 19.7 6.7 0.02 Methicillin sensitive S. aurues (MSSA) 26.1 33.3 0.2 Methicillin resistant S. aureus (MRSA) 6.3 15.0 0.008 S. epidermidis 5.2 3.3 0.5 Streptococcus viridans 23.8 21.7 0.1 Enterococcus 9.0 6.7 0.5 Pneumococcus 0.9 1.7 0.5

Efficacy of Cardioprotective Agents in Reduction of Chemotherapy Related Cardiotoxicity

Methods: The frequency of infection with specific microorganisms was compared between native valve and device related endocarditis, using infective endocarditis admissions in a New South Wales state wide database between 2000 and 2006. Results: Methicillin resistant Staphylococcus aureus was more significantly associatedwith device related infection (p= 0.008). Culture negative endocarditis was more significantly associated with native valve endocarditis (p= 0.02). Amongst patients with native valve endocarditis, MSSA was more significantly associated with IVDU (0.0002) and strep viridans was significantly associated with community acquired infection. Pathogens Native Valve Endocarditis (%) [N= 1393] Device Related Endocarditis (%) [N= 60] p (Chi sq.) Negative Blood Culture 19.7 6.7 0.02 Methicillin sensitive S. aurues (MSSA) 26.1 33.3 0.2 Methicillin resistant S. aureus (MRSA) 6.3 15.0 0.008 S. epidermidis 5.2 3.3 0.5 Streptococcus viridans 23.8 21.7 0.1 Enterococcus 9.0 6.7 0.5 Pneumococcus 0.9 1.7 0.5

Trends in endocarditis hospitalizations at US children's hospitals: Impact of the 2007 American Heart Association Antibiotic Prophylaxis Guidelines

In 2007, the American Heart Association recommended cessation of antibiotic prophylaxis for infective endocarditis (IE) before dental procedures for all but those at highest risk for adverse outcomes from IE. The impact of these guidelines is unclear. We evaluated IE hospitalizations at US children's hospitals during this period. Children <18 years old hospitalized from 2003 to 2010 with IE at 37 centers in the Pediatric Health Information Systems Database were included. Using Poisson regression, we evaluated the number IE hospitalizations over time (raw and indexed to total hospital admissions). A total of 1157 IE cases were identified; 68% had congenital heart disease (CHD). The raw number of IE cases did not change significantly over time (+1.6% difference post vs pre guidelines, 95% CI -6.4% to +10.3%, P = .7). When the number of IE cases was indexed per 1,000 hospital admissions, there was a significant decline during the time period before the guidelines (annual change: -5.9%, 95% CI -9.9 to -1.8, P = .005) and a similar decline in the post guidelines period such that the difference between the 2 periods was not significant (P = .15). In subgroup analysis, no significant change over time in IE cases (raw or indexed) was found in the CHD subset, those 5 to 18 years old (subgroup most likely receiving dental care), or in cases coded as oral streptococci. We found no evidence that release of new antibiotic prophylaxis guidelines was associated with a significant change in IE admissions across 37 US children's hospitals.

Stroke location, characterization, severity, and outcome in mitral vs aortic valve endocarditis.

To characterize the incidence and clinical features of patients with infective endocarditis (IE) and stroke. The authors reviewed the records of 707 patients diagnosed with definite or possible IE between January 1984 and November 1999. Stroke was confirmed by application of strict definitions and classified by type, pathophysiology, vascular territory, and severity. The authors determined mortality rates for the initial hospitalization and 12 months after admission. Strokes occurred in 68 (9.6%) of 707 patients with IE, 38 (17%) of 218 patients with mitral valve endocarditis (MVE), 14 (9%) of 149 patients with aortic valve endocarditis (AVE), and 16 (5%) of 340 patients with other forms of IE (OR for MVE vs AVE = 2.0, 95% CI 1.1 to 3.9). Among the patients with MVE or AVE and stroke, there were no significant relationships between site of vegetation and length of hospitalization, stroke severity, mortality during the initial hospitalization, or 12-month mortality. Fifty-two percent of patients with stroke and IE died within 1 year of admission. The overall incidence of stroke in patients with IE (9.6%) is lower than previous reports (21 to 39%). Patients with MVE had a greater risk of stroke than patients with AVE. Fifty-two percent of patients died within 1 year of admission for IE.

The febrile parenteral drug user: A prospective study in 121 patients

objective: To determine the most efficient approach to the diagnosis of infective endocarditis (IE) in febrile parenteral drug users (PDUs) and evaluate possible effects of human immunodeficiency virus (HIV) infections or acquired immunodeficiency syndrome (AIDS) on susceptibility to IE and final outcome. design: A prospective study of appropriate patients admitted on 149 random sampling days during a 14-month period and review of past experience with IE, HIV, and AIDS admissions to hospital. setting: An urban university hospital patients: Prospectively, 121 febrile PDUs plus an additional 16 found to have IE on nonsampling days during the study period. Retrospectively, all PDUs with IE from 1985 to 1991 and all patients with HIV infections with or without AIDS from July 1990 through December 1991. measurements: Physical examination, hemograms, urinalysis, blood cultures (plus other body fluids when indicated), echocardiography, laboratory testing for HIV status. main results: Five categories of patients were identified: L Infective endocarditis (n = 16); II. Other infections with bacteremia (n = 21); III. Bacteremia with unidentified source of infection (n = 14); IV. Infections without bacteremia (n = 52); V. Fever of unknown origin (n = 18). Physical findings and standard laboratory testing did not differentiate Group I from any of the other diagnostic categories. Adding additional IE cases from nonstudy days brought the total to 32. Vegetations were found on echocardiography in 94%; blood cultures, available in 30 of 32 instances, were all positive. HIV or AIDS status was not found to alter susceptibility to IE or influence mortality. While hospital admissions for HIV and especially AIDS have continued to increase among PDUs, the number of cases of IE has decreased since 1988 to 1989. conclusions: Based on the high incidence of blood culture positivity and the sensitivity of echocardiography in detecting vegetations in IE, a simple algorithm has been developed for the initial diagnostic management of febrile PDUs admitted with the possible diagnosis of IE. HIV infection, with or without full-blown AIDS, does not appear to affect the incidence or outcome of IE among these patients. Current practices among PDUs may be effecting a decline in IE but not HIV infections.

Risk of infective endocarditis in mitral valve prolapse with and without precordial systolic murmurs

The risk of infective endocarditis (IE) associated with a systolic murmur in patients with mitral valve prolapse (MVP) was investigated in a case-control study. The case group comprised all patients with MVP (n = 19) from a series of 136 consecutive adult admissions for IE. Three matched control subjects were chosen for each case from a series of 144 MVP patients without IE. Seventeen of the 19 cases (89%) had documented evidence of systolic murmurs existing before the IE episode; systolic murmurs were documented in 25 of the 57 control subjects (47%). The data indicate a significant increase in the risk of IE in MVP patients with a systolic murmur (p less than 0.01). The absolute probability of IE developing in a patient with MVP and a murmur was estimated to be approximately 1 in 1,400 per year; this was 35 times greater than the probability in a patient with MVP without a murmur. The results suggest that by restricting prophylaxis to MVP patients with a systolic murmur, cover would be provided for almost 90% of those with MVP in whom IE would be likely to develop.