In-hospital Mortality In Infective Endocarditis Research Articles

Sex-related disparities in the incidence and outcomes of infective endocarditis according to type 2 diabetes mellitus status in Spain, 2016–2020

BackgroundWe performed a study to assess sex-differences in incidence (2016–2020), clinical characteristics, use of therapeutic procedures, and in-hospital outcomes in patients with infective endocarditis (IE) according to T2DM status.MethodsOurs was a retrospective cohort study using data from the Spanish National Hospital Discharge Database. We estimated the incidence of hospitalizations for IE in men and women aged ≥ 40 years with and without T2DM. Propensity score matching (PSM) and multivariable logistic regression were used to compare subgroups according to sex and the presence of T2DM.ResultsFrom 2016 to 2020, IE was coded in 9,958 patients (66.79% men). T2DM was diagnosed in 2,668 (26.79%). The incidence of IE increased significantly from 15.29 cases per 100,000 persons with T2DM in 2016 to 17.69 in 2020 (p < 0.001). However, this increment was significant only among men with T2DM (19.47 cases per 100,000 in 2016 vs. 22.84 in 2020; p = 0.003). The age-adjusted incidence of IE was significantly higher in people with T2DM (both sexes) than in those without T2DM (IRR, 2.86; 95% CI, 2.74–2.99). The incidence of IE was higher in men with T2DM than in women with T2DM (adjusted IRR, 1.85; 95% CI, 1.54–3.31). After PSM, in-hospital mortality (IHM) was higher among T2DM women than matched T2DM men (22.65% vs. 18.0%; p = 0.018).The presence of T2DM was not associated with IHM in men or women.ConclusionsT2DM is associated with a higher incidence of hospitalization for IE. Findings for T2DM patients who had experienced IE differed by sex, with higher incidence rates and lower IHM in men than in women. T2DM was not associated to IHM in IE in men or in women.

Endocarditis: Who Is Particularly at Risk and Why? Ten Years Analysis of Risk Factors for In-hospital Mortality in Infective Endocarditis.

Endocarditis is continuously increasing. Evidence exist that the prognosis is adversely affected by the extent of the disease. We looked at risk factors influencing in-hospital mortality (HM). Between 2010 and 2019, 484 patients, 338 males (69.8%) with mean age of 66.1 years were operated on because of proven endocarditis. In a retrospective study, a risk factor analysis was performed. Overall HM was 30.17%. Significant influencing factors (odds ratios [ORs] or p-value) for HM were: age (p = 0.004), logistic EuroSCORE (p< 0.001), gender (OR = 1.64), dialysis (OR = 2.64), hepatic insufficiency (OR = 2.17), reoperation (OR = 1.77), previously implanted valve (OR = 1.97), periannular abscess (OR = 9.26), sepsis on admission (OR = 12.88), and number of involved valves (OR = 1.96). Development of a sepsis and HM was significantly lower if Streptococcus mitis was the main pathogen in contrast to other bacteria (p< 0.001). Staphylococcus aureus was significantly more often found in patients with a previously implanted prosthesis (p = 0.03) and in recurrent endocarditis (p = 0.02), while it significantly more often showed peripheral septic emboli than the other pathogens (p< 0.001). Endocarditis remains life-threatening. Severe comorbidities adversely affected early outcome, particularly, in presence of periannular abscesses. Patients with suspected endocarditis should be admitted to a specialized heart center as early as possible. Streptococcus mitis appears to be less virulent than S. aureus. Further studies are required to verify these findings.

Nomogram for Predicting In-hospital Mortality in Infective Endocarditis Based on Early Clinical Features and Treatment Options.

AimThe aim of this study was to develop a nomogram based on early clinical features and treatment options for predicting in-hospital mortality in infective endocarditis (IE).MethodsWe retrospectively analyzed the data of 294 patients diagnosed with IE in our hospital from June 01, 2012 to November 24, 2021, determined independent risk factors for in-hospital mortality by univariate and multivariate logistic regression analysis, and established a Nomogram prediction model based on these factors. Finally, the prediction performance of nomogram is evaluated by C-index, bootstrapped-concordance index, and calibration plots.ResultsAge, abnormal leukocyte count, left-sided IE, right-sided IE, and no surgical treatment were independent risk factors for in-hospital mortality in patients with IE, and we used these independent risk factors to construct a nomogram prediction model to predict in-hospital mortality in IE. The C-index of the model was 0.878 (95% CI: 0.824–0.931), and the internal validation of the model by bootstrap validation method showed a prediction accuracy of 0.852 and a bootstrapped-concordance index of 0.53.ConclusionOur nomogram can accurately predict in-hospital mortality in IE patients and can be used for early identification of high-risk IE patients.

Independent risk factors of mortality in streptococcal infective endocarditis

Abstract Background Streptococcal bloodstream infection (BSI) is a common cause of infective endocarditis (IE), yet prognostic factors for mortality are poorly investigated. Purpose To investigate risk factors associated with in-hospital and one-year mortality in streptococcal IE. Methods All patients with a streptococcal BSI, from 2008 to 2017, were included in a regional population-based setup. Based on microbiological identification of phylogenetic relationship, streptococcal species were classified into eight main subgroups: Anginosus, Bovis, Mitis, Mutans, Salivarius, Pyogenic, nutritionally variant streptococci, and S. pneumoniae. Data were crosslinked with nationwide registries for identification of demographics, concomitant hospitalization with IE, medical history, seasonal variation, and socioeconomic status. Patients were followed up until death or a maximum of 365 days after admittance, whichever came first. Using a multivariable adjusted Cox proportional hazard analysis, independent risk factors associated with in-hospital and one-year mortality were identified. Results Among 6,224 patients with a streptococcal BSI, 435 (7.0%) patients with streptococcal IE (mean age 69.0 (SD 14.8), 66% men) were included. The in-hospital mortality in IE patients was 11% (n=48), while the one-year mortality was 23% (n=100). Patients infected with species from the Bovis group had the lowest crude one-year mortality (13%), while patients infected with the Salivarius group had the highest crude mortality (36%). The proportion of deaths among women with IE were significantly higher than among men, both in-hospital (15% versus 9%, p=0.04) and after one year (29% versus 20%, p=0.02). Further, patients dying within one year had a significantly higher prevalence of ischemic heart disease (IHD) (p=0.02), congestive heart failure (CHF) (p&amp;lt;0.0001), cerebral vascular disease (CVD) (p=0.004), cancer (p=0.04), chronic obstructive pulmonary disease (COPD) (p=0.01), and renal disease (p=0.01) than survivors. In the adjusted analysis, age (Hazard Ratio (HR) 1.03, p=0.036) and renal disease (HR 2.46, p=0.045) were associated with higher in-hospital mortality. Furthermore, three independent significant factors associated with one-year mortality were identified; CHF (HR 2.18 [95% confidence interval (CI) 1.30–3.63]), cancer (HR 1.95 [95% CI 1.01–3.77]), and age (HR 1.03 [95% CI 1.01–1.05]) (Figure 1). However, patients infected with species from the Bovis group, had significantly lower risk of death at one-year (HR 0.30 [95% CI 0.10–0.89]) (Figure 1). Conclusion Having a renal disease at the time of IE diagnosis was associated with a higher in-hospital mortality in patients with streptococcal infective endocarditis. Further, congestive heart failure and cancer were associated with a higher one-year mortality, while the Bovis group was associated with a lower one-year mortality. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Zealand University Hospital Roskilde and Helsefonden (20-B-0340) Figure 1. Adjusted risk of one-year mortality

Nomogram based on neutrophil-to-platelet ratio to predict in-hospital mortality in infective endocarditis.

Aim: To develop a nomogram based on neutrophil-to-platelet ratio (NPR) to predict in-hospital mortality in infective endocarditis (IE) patients. Methods: We retrospectively analyzed 294 consecutive patients classified as survivors or nonsurvivors according to hospitalization outcome. Logistic regression analyses were performed to identify independent predictors for in-hospital mortality. A nomogram based on them was established and assessed by receiver operating characteristic (ROC) curve analysis. Results: Admission NPR (odds ratio [OR] = 1.095, 95% CI: 1.037-1.156), positive blood culture (OR = 9.220; 95% CI: 1.478-57.521) and left-sided endocarditis (OR = 5.099; 95% CI: 1.104-23.553) independently predicted in-hospital mortality in IE. The area under the ROC curve for the nomogram based on these predictors was 0.832. Conclusion: The nomogram based on NPR could be used for early risk stratification of IE patients.

Evaluation of Laboratory Predictors for In-Hospital Mortality in Infective Endocarditis and Negative Blood Culture Pattern Characteristics.

Objective: This study aimed to identify possible differences between blood culture-negative and blood culture-positive groups of infective endocarditis (IE), and explore the associations between biological parameters and in-hospital mortality. Methods: This was a retrospective study of patients hospitalized for IE between 2007 and 2017. Epidemiological, clinical and paraclinical characteristics, by blood culture-negative and positive groups, were collected. The best predictors of in-hospital mortality based on the receiver-operating characteristic (ROC) analysis and AUC (area under the curve) results were identified. Results: A total of 126 IE patients were included, 54% with negative blood cultures at admission. Overall, the in-hospital mortality was 28.6%, higher in the blood culture-negative than positive group (17.5% vs. 11.1%, p = 0.207). A significant increase in the Model for End-Stage Liver Disease Excluding International Normalized Ratio (MELD-XI) score was observed in the blood culture-negative group (p = 0.004), but no baseline characteristics differed between the groups. The best laboratory predictors of in-hospital death in the total study group were the neutrophil count (AUC = 0.824), white blood cell count (AUC = 0.724) and MELD-XI score (AUC = 0.700). Conclusion: Classic laboratory parameters, such as the white blood cell count and neutrophil count, were associated with in-hospital mortality in infective endocarditis. In addition, MELD-XI was a good predictor of in-hospital death.

Clinical features and predictive factors of in-hospital mortality in infective endocarditis

Infective endocarditis (IE) is a severe infection with high in-hospital mortality rate. Identification of patients at high risk of death may improve their outcomes. We aim to determine clinical features and predictive factors of intra hospital mortality in patients with IE. Retrospective single-center study including patients with IE admitted during 17 years (1998–2015) in Cardiology B department of Fattouma Bourguiba University Hospital. Diagnosis of IE was made according to the modified Duke classification. A Total of 235 patients were included, 56.3% were male. Mea age was 36 ± 17 years. Forty-three percent of them had previous valvular heart disease. Prosthetic IE occurred in 25.1%. Mitral valve was the most affected by infection. In-hospital mortality rate was 18.3% (43 patients). Dead patients presented significatively more heart failure at admission (53.5% vs. 25.7%, P < 0.001), peripheral embolization (32.6% vs. 5.7%, P = 0.012), major cerebro-vascular events such as hemorrhagic stroke (16.3% vs. 3.7%, P = 0.002), mycotic cerebral aneurysm (14% vs. 4.2%, P = 0.02) and cerebral abcess (7% vs. 0.5%, P = 0.017). In multivaraite analysis, predictive factors of in-hospital death were heart failure at admission (OR = 3.8, 95% CI: 1.8–7.9, P < 0.001), embolic events (OR = 2.28, 95% CI: 1.01–5.2, P = 0.02) and hemorrhagic stroke (OR = 6.06, 95% CI: 1.8–19.5, P = 0.017). IE remains awful disease with high mortality rate. The risk factors of in-hospital death were heart failure, embolic events and hemorrhagic stroke.

Recent trends, clinical characteristics, and outcome of infective endocarditis among intravenous drug users of a tertiary hospital in the east region of Malaysia

Background: Infective endocarditis (IE) is an infection affecting the endocardial lining and contributed to socioeconomic burden due to prolonged admission, invasive procedure, and expensive treatment. The high prevalence of intravenous drug user intravenous drug user (IVDU) shifts the paradigm of the disease, and thus, we aim to determine the clinical characteristics, outcome, and inhospital mortality of IE among IVDU patients. Materials and Methodology: This is a retrospective cohort by analyzing case records for IVDU patients admitted to Hospital Tengku Ampuan Afzan diagnosed with IE from January 2014 until June 2017. Results: A total of 32 patients were included, with a median age of 35 years old (standard deviation: 6.5). Only 56.3% presented with fever, whereas most of them complained of nonspecific symptoms such as reduced exercise tolerance (59.4%) and weight loss (56.3%). Seventy-five percent had concomitant hepatitis C, but only 6.3% of them were HIV positive. Valvular heart disease accounted for 46.9%, while chronic rheumatic heart diseases and previous IE infection accounted for 28.1% and 18.8%, respectively. For microbiological characteristics, Staphylococcus aureus accounted for 62.5%, followed by streptococci (15.4%) and others (2%). The most common valve affected in IVDU was tricuspid valve (62.5%), followed by mitral valve (21.9%) and pulmonary valve (9.4%). Furthermore, mortality was reported at 25%, while severe valvular complications (62.5%) were observed with elevated episodes of emboli (62.5%) and cardiogenic shock (40.6%). Conclusion: Hence, IVDU is an essential predictive factor and is associated with various severe complications and thus warranted for aggressive preventive measurement to reduce the morbidity.

SHARPEN score accurately predict in-hospital mortality in infective endocarditis: a real-world validation study

Abstract Background Infective Endocarditis (IE) has impressive 30-day mortality of up to 30%. Prompt recognition of high-risk patients is required in order to optimize management and outcomes. The SHARPEN score was recently developed to predict intrahospital mortality in patients admitted due to IE, regardless of the need to undergo cardiac surgery. We aimed to evaluate the accuracy of the SHARPEN score to predict in-hospital mortality in comparison to Charlson Comorbidity Index (CCI). Methods Retrospective cohort of all consecutive adult admissions between 2000 and 2016 with diagnosis of definitive IE according to the Modified Duke Criteria. The SHARPEN score was applied comprising: Systolic blood pressure at presentation, Heart failure, Age, Raised creatinine, Pneumonia, Elevated peak CRP and Non-intravenous drug abuser. The CCI was applied to assess comorbidities. Accuracy in predict mortality was estimated with C-statistic. DeLong test was used to compare the areas under the curve (AUC). Survival probabilities were estimated by Kaplan-Meier method and differences between survival curves analyzed using the log-rank test. Multivariate analysis using Poisson Regression with robust variation was performed to determine independent predictors of in-hospital mortality. Results 179 cases of IE were registered (70% male; 55±17 years-old) with an in-hospital mortality of 22%. Cardiac surgery was required in 68 (38%) of the patients. Calculated SHARPEM and CCI scores were 9 (7–11) and 3 (1–6) points respectively. SHARPEN was able to predict in-hospital mortality with an AUC of 0.76 (95% CI 0.7–0.8; p&amp;lt;0.001) and cut-off &amp;gt;10 points (Sen=69%; Sp=71%; PPV=40%; NPV=89%). Mortality was significant higher (40% vs 11%; p&amp;lt;0.001) in patients with SHARPEN &amp;gt;10 points (FIGURE). CCI had a similar AUC of 0.7 (95% CI 0.6 - 0.8; p&amp;lt;0.001) with SHARPEN (p=0.32). However, in a multivariate analysis, SHARPEN score &amp;gt;10 points a stronger predictor related with in-hospital mortality (OR 2.3; 95% CI 1.1 - 4.8; p=0.03) in comparison to CCI &amp;gt;3 points (OR 1.4; 95% CI 0.7–2.8; p=0.3). Conclusion SHARPEN score demonstrated a good accuracy in predict in-hospital mortality independently of other variables, with a high negative predictive value. These findings suggest that SHARPEN score may be useful to stratify high-risk IE patients in a clinical setting. Funding Acknowledgement Type of funding source: None

Infective endocarditis according to type 2 diabetes mellitus status: an observational study in Spain, 2001\u20132015

BackgroundThe main aims of this study were to describe trends and outcomes during admission for infective endocarditis (IE) in people ≥ 40 years old with or without type 2 diabetes distributed in five time-periods (2001–2003; 2004–2006; 2007–2009; 2010–2012 and 2013–2015), using Spanish national hospital discharge data.MethodsWe estimated admission rates by diabetes status. We analyzed comorbidity, therapeutic procedures, and outcomes. We built Poisson regression models to compare the adjusted time-trends in admission rates. Type 2 diabetes cases were matched with controls using propensity score matching (PSM). We tested in-hospital mortality (IHM) in logistic regression analyses.ResultsWe identified 16,626 hospitalizations in patients aged ≥ 40 years for IE in Spain, 2001–2015. The incidence of IE increased significantly from 6.0/100,000 per year to 13.1/100,000 per year (p < 0.001) in the population with type 2 diabetes, and from 3.9/100,000 per year to 5.5/100,000 per year (p < 0.001) in the population without diabetes, over the study period. The adjusted incidence of IE was 2.2-times higher among patients with diabetes than among those without diabetes (IRR = 2.2; 95% CI 2.1–2.3). People with type 2 diabetes less often underwent heart valve surgery than people without diabetes (13.9% vs. 17.3%; p < 0.001). Although IHM decreased significantly in both groups over time, it represented 20.8% of IE cases among diabetes patients and 19.9% among PSM matched controls (p = 0.337). Type 2 diabetes was not associated with a higher IHM in people admitted to the hospital for IE (OR = 1.1; 95% CI 0.9–1.2).ConclusionIncidence rates of IE in Spain, among those with and without T2DM, have increased during the period 2001–2015 with significantly higher incidence rates in the T2DM population. In our population based study and after PSM we found that T2DM was not a predictor of IHM in IE.

Microbiological profile and risk factors for in-hospital mortality of infective endocarditis intertiary care hospitals of south Vietnam

Objectives We aimed to evaluate the microbiological characteristics and risk factors for mortality of infective endocarditis in two tertiary hospitals in Ho Chi Minh City, south Vietnam. Materials and methods A retrospective study of 189 patients (120 men, 69 women; mean age 38±18 years) with the diagnosis of probable or definite infective endocarditis (IE) according to the modified Duke Criteria admitted to The Heart Institute or Tam Duc Hospital between January 2005 and December 2014. Results IE was related to a native valve in 165 patients (87.3%), and prosthetic valve in 24 (12.7 %). Of the 189 patients in our series, the culture positive rate was 70.4 %. The most common isolated pathogens were Streptococci (75.2%), Staphylococci (9.8%) followed by gram negative organism (4.5%). The sensitivity rate of Streptococci to ampicillin, ceftriaxone or vancomycin was 100 %. The rate of methicillin resistant Staphylococcus aureus was 40 %. There was a decrease in penicillin sensitivity for Streptococci over three eras: 2005 ± 2007 (100 %), 2008 ± 2010 (94 %) and 2010 ± 2014 (84 %). The in-hospital mortality rate was 6.9 %. Logistic regression analysis found prosthetic valve and NYHA grade 3 or 4 heart failure and vegetation size of more than 15 mm as strong predictors of in-hospital mortality. Conclusion Streptococcal species were the major pathogen of IE in the recent years with low rates of antimicrobial resistance. Prosthetic valve involvement, moderate or severe heart failure and vegetation size of more than 15 mm were independent predictors for in-hospital mortality in IE.

Risk Factors for In-Hospital Mortality in Infective Endocarditis.

BackgroundInfective endocarditis (IE) is associated with severe complications and high mortality. The assessment of mortality rates and predictors for fatal events is important to identify modifiable factors related to the pattern of treatment, in order to improve outcomes.ObjectivesWe sought to evaluate clinical outcomes of patients with IE and to determine predictors of in-hospital mortality.MethodsRetrospective single-center study including patients with IE admitted during a 10-year period (2006-2015). Data on comorbidities, clinical presentation, microbiology and clinical outcomes during hospitalization were evaluated. Risk factors of in-hospital death were analyzed. A p-value < 0.05 was considered significant.ResultsA total of 134 cases were included (73% males, mean age of 61 ± 16 years-old). Half of them had previous valvular heart disease. Healthcare-associated IE and negative blood-cultures occurred in 22% and prosthetic IE in 25%. The aortic valve was the one most often affected by infection. Staphylococcus aureus was the most commonly isolated microorganism. Forty-four (32.8%) patients underwent cardiac surgery. The in-hospital mortality rate was 31.3% (42 patients). The identified risk factors for in-hospital mortality were Staphylococcus aureus etiology (OR 6.47; 95% CI: 1.07-39.01; p = 0.042), negative blood-cultures (OR 9.14; 95% CI: 1.42-58.77; p = 0.02), evidence of valve obstruction in echocardiography (OR 8.57; 95% CI: 1.11-66.25; p = 0.039), clinical evolution with heart failure (OR 4.98; 95%CI: 1.31-18.92; p = 0.018) or septic shock (OR 20.26; 95% CI: 4.04-101.74; p < 0.001). Cardiac surgery was a protective factor of mortality (OR 0.14; 95% CI 0.03-0.65; p = 0.012).ConclusionThe risk factors for in-hospital mortality were clinical (heart failure, septic shock), evidence of valve obstruction in echocardiography, Staphylococcus aureus etiology or negative blood cultures. Invasive treatment by surgery significantly decreased the mortality risk.

Evaluation of Haematological and Biochemical Markers as Simple Predictors of In-hospital Mortality in Infective Endocarditis

Background: Infective endocarditis (IE) is a serious illness with high morbidity and mortality. There is a need for early recognition of patients at risk of adverse events to guide management decisions and improve outcomes. Recent studies have identified inflammatory biomarkers including C-reactive protein (CRP), neutrophil-to-lymphocyte-ratio (NLR), and platelet-to-lymphocyte ratio (PLR) as prognostic factors in IE. We sought to identify simple laboratory parameters in IE patients as predictors of in-hospital mortality in our centre. Method: This is a single centre retrospective review of all patients diagnosed with definite IE (using Modified Duke Criteria) at St Vincent's Hospital, Melbourne, between January 1999-December 2012. Results: 288 patients were identified, 68.06% males and 31.94% females (mean age, 53.58 years). In-hospital mortality was 20.14% (54/288) and surgical management was 30.9%(89/288). Predictors of in-hospital mortality were higher admission levels of white cell count (WCC), neutrophil count, NLR, CRP and bilirubin [p < 0.001, p = 0.004, p = 0.010, p = 0.017 and p = 0.001 respectively] and lower admission levels of serum albumin and platelet count [p = 0.003 and p = 0.001 respectively]. On stepwise multiple logistic regression analysis, higher white cell and lower platelet counts were identified as independent predictors of in-hospital mortality when adjusted for age, sex, length of stay, and other inflammatory indices [OR 1.1253, p = 0.002 and OR = 0.9944, p = 0.001 respectively]. Conclusion: Our findings suggest that higher white cell and lower platelet counts are independently associated with in-hospital mortality in IE patients. These simple and inexpensive inflammatory indices may be useful for early identification of high-risk IE patients.

Outcomes of infective endocarditis in the current era: Early predictors of a poor prognosis

BackgroundThe early identification of patients at risk of complications of infective endocarditis (IE) using parameters obtained as part of routine practice is essential for guiding clinical decision-making. This study aimed to identify a parameter at hospital admission that predicts the outcome, adding value to other well-known factors of a poor prognosis in IE. MethodsTwo hundred and three patients with IE were included in this study. Clinical evaluation, echocardiography, blood cultures, and routine laboratory tests were performed at hospital admission. The endpoint was in-hospital mortality. ResultsThe mean age of the patients was 48.2±16.6 years; 62% were male and 38% had rheumatic heart disease. During treatment, cardiac surgery was performed in 111 patients (55%), and the overall in-hospital mortality rate was 32%. In the multivariable analysis, the independent predictors of death were age (odds ratio (OR) 1.07, 95% confidence interval (CI) 1.02–1.13), C-reactive protein (CRP) at hospital admission (OR 1.12, 95% CI 1.04–1.21), length of the vegetation at diagnosis (OR 1.15, 95% CI 1.03–1.28), development of heart failure (OR 6.43, 95% CI 2.14–19.33), and embolic events during antimicrobial therapy (OR 12.14, 95% CI 2.11–71.89). ConclusionsAn elevated CRP level at hospital admission and vegetation length at diagnosis were strong predictors of in-hospital mortality in IE, independent of other prognostic parameters, specifically taking into account patient characteristics and complications during therapy.

Microbiological profile and risk factors for in-hospital mortality of infective endocarditis in tertiary care hospitals of south Vietnam.

ObjectivesWe aimed to evaluate the microbiological characteristics and risk factors for mortality of infective endocarditis in two tertiary hospitals in Ho Chi Minh City, south Vietnam.Materials and methodsA retrospective study of 189 patients (120 men, 69 women; mean age 38 ± 18 years) with the diagnosis of probable or definite infective endocarditis (IE) according to the modified Duke Criteria admitted to The Heart Institute or Tam Duc Hospital between January 2005 and December 2014.ResultsIE was related to a native valve in 165 patients (87.3%), and prosthetic valve in 24 (12.7%). Of the 189 patients in our series, the culture positive rate was 70.4%. The most common isolated pathogens were Streptococci (75.2%), Staphylococci (9.8%) followed by gram negative organism (4.5%). The sensitivity rate of Streptococci to ampicillin, ceftriaxone or vancomycin was 100%. The rate of methicillin resistant Staphylococcus aureus was 40%. There was a decrease in penicillin sensitivity for Streptococci over three eras: 2005–2007 (100%), 2008–2010 (94%) and 2010–2014 (84%). The in-hospital mortality rate was 6.9%. Logistic regression analysis found prosthetic valve and NYHA grade 3 or 4 heart failure and vegetation size of more than 15 mm as strong predictors of in-hospital mortality.ConclusionStreptococcal species were the major pathogen of IE in the recent years with low rates of antimicrobial resistance. Prosthetic valve involvement, moderate or severe heart failure and vegetation size of more than 15 mm were independent predictors for in-hospital mortality in IE.

P4541Surgical indications, operative risk and in-hospital mortality in infective endocarditis - is surgery underused?

P4541Surgical indications, operative risk and in-hospital mortality in infective endocarditis - is surgery underused?

The changing landscape of infective endocarditis in the Netherlands.

Despite advances in the diagnosis and treatment of infective endocarditis (IE), the in-hospital mortality of IE has remained unchanged at about 20 %. Subgroups of patients such as those with prosthetic valve IE, IE associated with congenital heart disease or caused by certain microorganisms such as Staphylococcus aureus are at a much higher risk for complications, and may have one-year mortality rates of up to 60 % [1]. These high mortality rates, in combination with the advent of antibiotics, have led to the recommendation of antibiotic prophylaxis in guidelines since the early 1950s. Lately, increasing debate concerning microbacterial resistance due to possible overuse of antibiotics and lack of evidence supporting the use of antibiotic prophylaxis, has led to a change in policy in favour of restriction of antibiotic prophylaxis. The 2008 National Institute of Health and Clinical Excellence (NICE) guideline for IE has been cause for debate, advocating complete cessation of the use of antibiotic prophylaxis altogether. However, up to 20 % of UK physicians admit to prescribing antibiotic prophylaxis in very high-risk groups [2]. The situation in the UK may therefore be rather similar to the Netherlands, where 2008 European Society of Cardiology (ESC) and national guidelines recommend antibiotic prophylaxis use in high-risk patients, during high-risk procedures. In the current issue of the Journal, Krul et al. [3] have shown a gradual increase in the incidence of IE in a large non-academic hospital in the Netherlands. They have started the registry of cases in parallel with the introduction of the new guidelines for the prevention of endocarditis in the Netherlands. The design of the study may have caused under-registration of the occurrence of IE, as only the diagnosis treatment code (DBC) was screened for IE. Patients suffering from multiple disorders in intensive care environments may thus have been missed. Interestingly, the authors show that the increase of IE is mainly due to increase in prosthetic valve endocarditis, thus a population that received antibiotic prophylaxis to prevent IE according to ESC and Dutch guidelines. One could conclude from these figures that the increase in IE incidence is due to a higher prevalence of predisposing factors for IE rather than more restrictive prescription of antibiotic prophylaxis. This is in line with several recent studies. Finally, improving on larger studies with a similar design [4], the authors were able to retrieve the causal microorganism in all IE cases. They show that microorganisms typically found in mucosal infections caused the majority of IE cases. The notion that IE may be caused by bacteria from the mouth was suggested over 100 years ago [5]. Dental procedures have been pointed out as a source for bacteraemia causing IE. However, several large studies compared dental extraction with daily activities such as tooth brushing, and found that brushing teeth can cause bacteraemia in up to 32 % of cases [6]. Their data suggest that bacteraemia due to simple daily activities (including chewing food) may occur hundreds of times more often than bacteraemia due to dental procedures, or other medical procedures. This again calls the use of antibiotic prophylaxis for IE prevention into question. Rather, prevention of longstanding low-grade infection seems prudent. Krul et al. [3] suggest a large-scale registry to further elucidate mechanisms underlying IE increase in the Netherlands. Such efforts have been undertaken in international consortia such as the International Collaboration for Endocarditis. Other successful approaches have employed population-wide entry of all medical records in research databases such as the Rochester Epidemiology Project in Olmsted County, USA. With the recent introduction of mandatory International Classification of Disease (ICD-10) registration of all patients within the Netherlands, a Dutch national registry is possible. While registry of disease will improve disease understanding, prevention of IE could be most effective by education of our patients at risk for IE. Dental hygiene and prevention of caries and parodontitis are an integral part of the Dutch guidelines, and should be discussed with any patients at risk. In addition, patients suffering from alarm symptoms such as ongoing fever despite antibiotic treatment, or symptoms indicative of heart failure or thrombotic events, should seek medical attention. Patient education, and thereby patient empowerment, could be one of the most important tools to improve patient survival in IE.

D-dimer level predicts in-hospital mortality in patients with infective endocarditis: A prospective single-centre study

BackgroundIncreased circulating D-dimer levels have been correlated with adverse outcomes in various clinical conditions. To our knowledge, the association of on-admission D-dimer and in-hospital mortality in infective endocarditis (IE) has not been investigated. We hypothesized that increased on-admission D-dimer levels would correlate with adverse outcomes when prospectively studied in patients with IE. MethodsIn this prospective study, a total of 157 consecutive patients with the definite IE diagnosis met the inclusion criteria and underwent testing for on-admission D-dimer and CRP assays. The outcome measure was in-hospital death from any cause. ResultsIn-hospital mortality occurred in 40 (26%) patients. Increased levels of plasma D-dimer (5.1±1.7 vs 1.9±0.8, p<0.001), CRP [45(13-98) vs 12(5–28), p<0.001] were found in dead patients compared with those survived. In addition to S. aureus infection, increased leukocyte count, end-stage renal disease, LVEF<50%, vegetation size of >10mm, perivalvular abscess, on-admission D-dimer (HR: 1.32; 95% CI: 1.24-1.40; p<0.001) and CRP (HR: 1.18; 95% CI: 1.09-1.36; p=0.001) levels were significantly associated with in-hospital mortality. Furthermore, the sensitivity and specificity of D-dimer ≥4.2mg/L in predicting in-hospital death in IE were 86% and 85%, respectively. Moreover, the sensitivity and specificity of CRP levels ≥13.6mg/L were 72% and 69%, respectively. ConclusionOur findings suggest that on-admission D-dimer level may be a simple, available and valuable biomarker that allows us to identify high-risk IE patients for in-hospital mortality. D-dimer ≥4.2mg/L, CRP ≥13.6mg/L were independently associated with IE related in-hospital death.

Profile of infective endocarditis observed from 2003 - 2010 in a single center in Italy

BackgroundThis study aimed to provide a contemporary picture of the epidemiologic, clinical, microbiologic characteristics and in-hospital outcome of infective endocarditis (IE) observed in a single center in Italy.MethodsWe performed a retrospective study of patients with definite or probable IE observed at the “L. Sacco” Hospital in Milan, Italy, from January 1, 2003 through December 31, 2010.Results189 episodes of IE in 166 patients were included. The mean number of incident IE in the study period was of 1.27 (range 0.59-1.76) cases per 1000 patients admitted. The median age of the cohort was 57 (interquartile range, 43-72) years, 63% were male and 62.5% had native valve IE. Twenty-six percent were active intravenous drug users (IVDU), 29% had a health care-associated IE and 5% chronic rheumatic disease. Twenty-nine percent of the cases occurred in patients affected by chronic liver disease and 19% in HIV positive subjects. Staphylococcus aureus was the most common pathogen (30%), followed by streptococci. The mitral (34%) and aortic (31%) valves were involved most frequently. The following complications were common: stroke (19%), non-stroke embolizations (25%), heart failure (26%) and intracardiac abscess (9%). Surgical treatment was frequently employed (52%) but in hospital mortality remained high (17%). Health care-associated IE and complications were independently associated with an increased risk of in-hospital death, while surgery was associated with decreased mortality.ConclusionS. aureus emerged as the leading causative organism of IE in a University hospital in northern Italy. Our study confirmed the high in-hospital mortality of IE, particularly if health care associated, and the protective role of surgery.

Clinical features of infective endocarditis: Comparison between the 1990s and 2000s

BackgroundThe circumstances surrounding infective endocarditis (IE) are under constant change due to an increase in drug-resistant organisms, a decrease in rheumatic valve disease, progress in surgical treatment, and aging society. The purpose of this study was to compare clinical features of IE between the 1990s and 2000s and to elucidate the determinants of death or clinical event. MethodsAll hospital admission records between January 1990 and December 2009 were retrospectively analyzed. The definition of IE was based on modified Duke criteria. Clinical presentation, blood culture, laboratory results, and echocardiography findings were compared between the 1990s and 2000s. ResultsThere were 112 patients with definite or probable IE according to modified Duke criteria. The most frequent organism causing IE was Streptococcus viridians both in the 1990s and 2000s. The determinants of in-hospital death were hemodialysis and congestive heart failure. The in-hospital mortality of IE was 5.4% in the 1990s and 13.3% in the 2000s. Composite events of in-hospital death and central nervous system disorders were significantly higher in the 2000s compared with the 1990s. ConclusionThe most frequent causative organism of IE was S. viridians, both in the 1990s and 2000s. Independent predictors of in-hospital mortality in IE were hemodialysis and congestive heart failure.