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Epidemiological, Clinical, and Prognostic Features of Infective Endocarditis: A Retrospective Study with 90 Episodes/Infektif Endokarditin Epidemiyolojik, Klinik ve Prognostik Sonuclari: 90 Atagin Retrospektif Kohortu.

Infective endocarditis (IE) remains a relatively common challenging clinical entity with high rates of mortality. The incidence of IE is 3-7/100 000 worldwide, varying in epidemiology. (1,2) Mortality is approximately 20%, even in high-income countries. (3,4) The cardiac risk factors for IE include rheumatic valvular disease, prosthetic or degenerative valve, and congenital heart diseases, which differ according to several socio-economic indicators. (5) In high-income countries, although the incidence of rheumatic valvular heart disease has decreased, degenerative heart valve disease has increased in parallel to the increased number of patients in the elderly population. On the contrary, the patient population with rheumatic valvular disease is dramatically younger in low-income countries, as it is an ongoing problem. Due to a low socio-economic situation, community-acquired cases are more frequent than healthcare-associated cases, and the pathogenic microorganisms vary over a broader spectrum. (6) Besides epidemiology, the diagnostic methods and treatment modalities of IE have also significantly changed during the last decade. (7,8) Streptococci and staphylococci account for 80% of the etiology. (6) In recent years, staphylococci have increased proportionally due to the increase in healthcare-associated endocarditis.

National studies have reported that acute rheumatic fever (ARF) is the leading cause of valvular disease in Turkey. (9) Although a decrease has been reported during recent years, the incidence of ARF is still as high as 20/100 000, (9-11) which may correlate to the relatively high incidence of IE in Turkey. Intracardiac foreign bodies also constitute a risk factor for IE and are considered to be responsible for 10% of all IE cases. Implant-related IE consists of approximately 6% of the cases in Turkey. (12) Intravenous drug use, which is a very rare cause in our country affecting less than 1% of the cases, is a predisposing factor in 10% of all IE cases in high-income countries. (3,12)

In this study, we aimed to evaluate the epidemiological, clinical, laboratory, echocardiographic, and microbiological characteristics, as well as the treatment outcomes of IE in a tertiary referral center.

Methods

Retrospectively collected data of the patients diagnosed with IE in our institution between 1998 and 2016 were reviewed. Patients older than 18 years with an International Classification of Disease code of any type of IE were included in the study. The study was approved by the local ethics committee. Informed consents for all medical treatments and for collecting and using the data in clinical studies were received from all patients. Patients who did not meet the definitive diagnostic criteria and patients without complete records of clinical follow-up were excluded.

The blood cultures were performed by automated hemoculture systems. Conventional procedures were used for microbiological identification. Antimicrobial susceptibility tests were performed according to the current Clinical and Laboratory Standards Institute criteria. All the samples were examined in the institutional microbiology laboratory.

Modified Duke criteria were used for definitions. Patients with IE were classified as having "acute" endocarditis if the duration between initial symptom and diagnosis was <6 weeks, "subacute" if between 6 weeks and 3 months, and "chronic" if >3 months. An IE episode was defined as "nosocomial healthcare-associated" if positive blood cultures were obtained from a patient hospitalized for more than 48 hours without relevant symptoms and signs on admission. "Non-nosocomial healthcare-associated" IE was defined if at least one of the following criteria was present within 48 hours of the patient's admission: (1) had received intravenous therapy, wound care, specialized nursing care, hemodialysis or intravenous chemotherapy within 30 days prior to the onset of IE, (2) was hospitalized in an acute care hospital for 2 or more days within 90 days before the onset of IE, or (3) resided in a nursing home or long-term care facility before admission. (13) The infection was recorded as "community-acquired" when the symptoms and signs of IE occurred within 48 hours of admission in a patient not fulfilling the criteria for non-nosocomial healthcare-associated infection. Cases with prosthetic valve endocarditis were tiered into 2 groups, as "early" (within 1 year after operation) and "late" (endocarditis >1 year of operation).

Ethical approval was obtained from the scientific Ethics Committee of Istanbul University-Cerrahpasa with the approval number 83045809/604.01/02-405910 dated December 23, 2015.

Statistical analysis

The IBM Statistical Package for the Social Sciences 22.0 (IBM SPSS Corp., Armonk, NY, USA) package program was used for statistical analyses. Continuous variables were expressed as means and ranges, and categorical variables as frequencies and percentages. The association between categorical variables and age was determined with the chi-square test. The association between continuous variables and age was tested by the independent samples t-test. P values < .05 were defined as statistically significant.

Results

There were 114 patients in total who were admitted with an IE diagnosis. Twenty-four patients were excluded because they did not meet the diagnostic criteria and/or were lacking follow-up data. Eighty-six patients with 90 IE episodes were included in the analysis. The mean age was 49.9 [+ or -] 14.3, 56 (65%) patients were male, and 30 (35%) were female. Definite and possible endocarditis were determined in 71 (78.8%) and 19 (21.2%) cases, respectively.

The most common predisposing condition for IE was a prosthetic valve (n = 32, 37.2%), followed by chronic rheumatic heart disease (n = 29, 33.7%) and degenerative valve disease (n = 22, 25.5%). Out of the 29 patients with a rheumatic valve disease, 6 had a definitive history of ARF. Congenital heart disease was significantly higher in patients <50 years old (P = .048), while degenerative valve disease was more common in patients [greater than or equal to] 50 years (P = .004). None of the patients had an implanted cardiac device. The clinical features of the cases are shown in Table 1.

Blood cultures and/or serological tests (1 case of Coxiella burnetii was verified only serologically) were positive in 71 (78.8%) episodes. None of the cases were histopathologically confirmed. Streptococci (27.7%), staphylococci (24.4%), and enterococci (16.6%) were the most common pathogens isolated in the whole cohort group (Table 2). Regarding community-acquired cases, streptococci accounted for 30%, staphylococci for 21.2%, and enterococci for 17.5%. Staphylococci were identified as the major pathogen among the healthcare-associated cases. The relationship between etiological agent, type of valvular diseases, and age were evaluated. Staphylococci (P = .016) and streptococci (P = .035) were found to be significantly associated with prosthetic valve endocarditis. There was no statistically significant relationship between the etiological agents (streptococci, staphylococci, and enterococci; P = .674, P = .701, P = .129) and age.

Echocardiography was performed in all the patients. Vegetations were detected in 79 (88%) cases, periannular abscess was detected in 5 (5.5%) cases, and chordal rupture in 4 (4.4%) cases. The aortic valve was the most frequently involved structure (34.4%), followed by the mitral (24.4%), and the mitral + aortic valve (22.2%). Among all complications, embolic complications (35.5%) were the most common. Echographically documented cardiac vegetations were complicated by peripheral emboli in 31.6%, and heart failure in 22.7% of the patients, and mortality was seen in 15%. One-third of the cases with complications underwent surgical valve replacement. In the echography-negative group, peripheral emboli, heart failure, and mortality rates were 36.3%, 19%, and 9.1%, respectively. In one echography-negative patient with C. burnetii, valvular involvement was detected by PET-CT. This patient died after valve replacement surgery. The distribution of cardiac and systemic complications is presented in Table 3. The overall in-hospital mortality was 15.1% (n = 13). Three of these patients (23%) had chronic renal failure and 7 patients (53.8%) had underlying degenerative heart disease. When the surviving and the deceased patients were compared, the presence of degenerative valve (P = .036) and chronic renal failure (P = .042) were found as the major determinants of mortality. However, the causative agent, patient age (P = .080), clinical course (acute, subacute, or chronic endocarditis) (P = .093), and the location of the vegetation (P = .093) were not found to be statistically associated with survival. Baseline characteristics and complications of the cases in terms of in-hospital mortality are shown in Tables 4 and 5.

Out of 73 cases, 43 (59%) were available for phone surveys during the post-discharge follow-up. The second IE episode was determined in 4 patients with prosthetic valves in the first year, and 2 patients had died due to a cardiac failure. The other 2 recurrent episodes caused by methicillin-sensitive Staphylococcus aureus (MSSA) were medically treated. Five patients died due to other cardiac or non-cardiac conditions. Thirty-four (79%) patients have been followed-up uneventfully, without any sign or symptom of IE or cardiac disease.

Discussion

There has been a slow but prominent shift in the characteristics of IE in high-income countries; from rheumatic valve diseases towards degenerative heart diseases as a major risk factor, from community-acquired cases towards healthcare-associated cases, and from streptococci toward S. aureus in the etiology. Our retrospective study, consisting of 90 cases, has partly verified this epidemiologic trend for Turkey.

IE is usually a disease that affects persons over 60, in high-income countries, whereas it is more common at younger ages in low- and middle-income countries. (4) In a retrospective study from Turkey covering IE cases diagnosed between 1974 and 1999, the mean age was 36 and the rate of underlying rheumatic valve disease was 65%. (14) Recent similar studies have demonstrated an apparent decrease in the proportion of rheumatic valve diseases (46%, 36%, 28%), and an increase in the mean age (between 45 and 51). (9,12,15-17) In our study, the mean age of the patients was 49.9, and the rate of rheumatic heart diseases was 33.7%, compatible with the literature. Congenital heart diseases were found more frequently in patients under 50 years of age, and degenerative and prosthetic heart valve diseases were more common in patients over 50 years of age. Intravenous drug use was a risk factor in only 1 patient (1.1%) with tricuspid valve endocarditis. This result was compatible with the data of similar Turkish patients, (12) and considered to be lower when compared with high-income countries where the rate of IV drug use among IE cases is about 10%. (18) Of 90 cases, acute endocarditis (n = 50, 56%) was the most common clinical form, comprised of 24 native valve, 22 "late" prosthetic, and 4 "early" prosthetic valve endocarditis diagnoses. Staphylococci accounted for 38% of the overall etiology of the whole cohort group, with MSSA being the most common among acute and healthcare-associated cases. These findings were compatible with the results of N'Guyen et al., (19) reporting S. aureus as 32.9% in the etiology of "early diagnosed" (vs. 8.9% among late-diagnosed) cases of IE, and Fowler et al. (20) which also reported S. aureus as the most common organism in each major risk group, including cases with intracardiac devices. Among the 20 episodes of "chronic" endocarditis, the Viridans streptococci were more commonly seen in patients below age 60 (2 episodes were due to Streptococcus bovis) and enterococci were more common in patients above the age 60, compatible with the study of Olmos et al. (21)

Definite etiology was microbiologically demonstrated in 71 (78.8%) episodes in our study, which was similar to the rate (77.8%) reported in another cohort of 325 cases from Turkey, (12) but lower than some high-income countries reporting a rate of 90%. (18) Staphylococcal endocarditis is much more common in most high-income countries due to the proportional increase of degenerative valve diseases and healthcare-associated cases. (18,22) However, despite the similar epidemiological shift, streptococcal endocarditis remains important in Turkey because of the relatively higher prevalence of rheumatic and congenital valve diseases in the community. (9) The etiology did not statistically differ according to the age (below or above 50 years) or cardiac comorbidities (presence or absence of rheumatic and congenital heart diseases); while staphylococci (P = .016) and streptococci (P = .035) were significantly more common in cases with prosthetic valve endocarditis.

In our study, embolic complications were the most common (35.5%), followed by valve insufficiency (28.8%), and heart failure (21.1%). Valve replacement was performed in 31% of the cases and in-hospital mortality was 15.1%. Heart failure has been reported in 42-60% of cases with native (mostly aortic) valve endocarditis in the literature. (23,24) The corresponding statistic was 17.8% (10/56) in our native valve cases, and it was only slightly higher (23.8%) in those patients with aortic valve involvements. In a study by Elbey et al. (16) from Turkey, which included 248 patients, heart failure was the leading cause of all complications, at 35.4%, while overall mortality was 33%. Similarly, in the study by Murdoch et al., (18) the most common complication was heart failure (32.3%), and 48.2% of the patients underwent surgery, while 17.7% mortality was reported. In one of the largest series in our country, the mortality rate was found to be 27.8%, and this situation was explained by the admissions of complicated cases because the hospital was a reference center. (12) The relatively lower rates of cardiac complications and mortality in our study might be due to the early diagnosis and prompt treatment facilities, the younger age of the patients, and lower rates of underlying comorbidities. In the prospective cohort study by Murdoch et al. (18) comprising 2781 patients, acute S. aureus endocarditis was associated with poor prognosis and higher mortality. Similarly, according to the prospective study by N'Guyen et al., (19) which shared the follow-up results of 486 cases that were diagnosed within 1 month, the presence of prosthetic valve and S. aureus in the etiology were associated with a poor prognosis, as well as higher mortality during the hospital stay and within a 1-year follow-up. In our data, mortality was significantly associated with a chronic renal failure (P = .042) and the presence of underlying degenerative valve disease (P = .036). In the study by Netzer et al. (25) evaluating the long-term prognosis of IE, the presence of at least 6 of the symptoms and signs of endocarditis during diagnosis (early diagnosis), absence of heart failure, an age of 55 years and younger, streptococcal etiology, and early surgical intervention were found to be good prognostic indicators. The 10-year survival rate was 50% in the patients. (25) Heart failure was the most common cause of death, and even more rarely, the incidence of a new IE episode was higher than in the general community. (25) In another study conducted by Delahaye et al. (26) which evaluated the long-term prognosis of patients, all-cause mortality in the first year was found to be higher than in the general population, but gradually decreased over time. As expected, the most common cause of mortality was heart failure. Repeated episodes of IE were rare, but more frequent than in the general community.

Of the patients we were able to reach, 36 (83.7%) were alive for an average of 4.27 years (between 6 months and 14 years) and well in general, suggesting a better rate of 10-year survival (50%) in comparison to the recent literature. (25) Having community-acquired native valve endocarditis or being below 55 years of age at the time of diagnosis were the 2 common features that might explain the higher rate of survival.

In conclusion, the current epidemiology and clinical outcomes of IE have been highlighted with this study. Community-acquired native valve endocarditis in patients younger than 55 years and who had lower loads of comorbidities, particularly chronic renal failure, showed better outcomes in short-term and long-term follow-up.

DOI: 10.5152/cjm.2021.21008

Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Ethics Committee of Istanbul University-Cerrahpasa (Date: December 23, 2015, Approval number 83045809/604.01/02-405910).

Informed Consent: Written informed consent was obtained from patientst who participated in this study.

Peer Review: Externally peer-reviewed.

Author Contributions: Concept--A.B.K., I.I.B., M.S.K., F.T., N.S., R.O.; Design--A.B.K., I.I.B., U.Y.S., M.S.K., R.O.; Supervision--R.O., B.M., F.T., A.M., N.S.; Resources--A.B.K., U.Y.S., M.S.K.; Data Collection and/or Processing--A.B.K., I.I.B., U.Y.S., B.M.; Analysis and/or Interpretation--A.B.K., I.I.B., U.Y.S., R.O.; Literature Search--A.B.K., I.I.B.; Writing Manuscript--A.B.K., I.I.B., R.O.; Critical Review--F.T., N.S., B.M., A.M., R.O., M.S.K.; Other--A.B.K, I.I.B., U.Y.S.

Conflict of Interest: The authors have no conflicts of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

Etik Komite Onayi: Bu calisma icin etik komite onayi Istanbul Universitesi-Cerrahpasa'dan (Tarih: 23 Aralik 2015, Onay No: 83045809/604.01/02-405910) alinmistir.

Hasta Onami: Yazili hasta onami bu calismaya katilan hastalardan alinmistir.

Hakem Degerlendirmesi: Dis bagimsiz.

Yazar Katkilari: Fikir--A.B.K., I.I.B., M.S.K., F.T., N.S., R.O.; Tasarim--A.B.K., L.L.B., U.Y.S., M.S.K., R.O.; Denetleme--R.O., B.M., F.T., A.M., N.S.; Kaynaklar--A.B.K., U.Y.S., M.S.K.; Veri Toplanmasi ve/veya Islemesi--A.B.K., I.I.B., U.Y.S., B.M.; Analiz ve/veya Yorum--A.B.K., I.I.B., U.Y.S., R.O.; Literatur Taramasi--A.B.K., I.I.B.; Yaziyi Yazan--A.B.K., I.I.B., R.O.; Elestirel Inceleme--F.T., N.S., B.M., A.M., R.O., M.S.K.; Diger --A.B.K., I.I.B., U.Y.S.

Cikar Catismasi: Yazarlar cikar catismasi bildirmemislerdir.

Finansal Destek: Yazarlar bu calisma icin finansal destek almadiklarini beyan etmislerdir.

References

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(11.) Orun UA, Ceylan O, Bilici M, et al. Acute rheumatic fever in the Central Anatolia Region of Turkey: a 30-year experience in a single center. Eur J Pediatr. 2012;171(2):361-368.

(12.) Simsek-Yavuz S, Sensoy A, Kasikcioglu H, et al. Infective endocarditis in Turkey: aetiology, clinical features, and analysis of risk factors for mortality in 325 cases. Int J Infect Dis. 2015;30:106-114.

(13.) Benito N, Miro JM, de Lazzari E, et al. Health care-associated native valve endocarditis: importance of non-nosocomial acquisition. Ann Intern Med. 2009;150(9):586-594.

(14.) Cetinkaya Y, Akova M, Akalin HE, et al. A retrospective review of 228 episodes of infective endocarditis where rheumatic valvular disease is still common. Int J Antimicrob Agents. 2001;18(1):1-7.

(15.) Sucu M, Davutoglu V, Ozer O, Aksoy M. Epidemiological, clinical and microbiological profile of infective endocarditis in a tertiary hospital in the South-East Anatolia Region. Turk Kardiyol Dern Ars. 2010;38(2):107-111.

(16.) Elbey MA, Akdag S, Kalkan ME, et al. A multicenter study on experience of 13 tertiary hospitals in Turkey in patients with infective endocarditis. Anadolu Kardiyol Derg. 2013;13(6):523-527.

(17.) Leblebicioglu H, Yilmaz H, Tasova Y, et al. Characteristics and analysis of risk factors for mortality in infective endocarditis. Eur J Epidemiol. 2006;21(1):25-31.

(18.) Murdoch DR, Corey GR, Hoen B, et al. Clinical Presentation, Etiology, and Outcome of Infective Endocarditis in the 21st Century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009;169(5):463-473.

(19.) N'Guyen Y, Duval X, Revest M, et al. Time interval between infective endocarditis first symptoms and diagnosis: relationship to infective endocarditis characteristics, microorganisms and prognosis. Ann Med. 2017; 49(2):117-125.

(20.) Fowler VG, Miro JM, Hoen B, et al. Staphylococcus aureus endocarditis: a consequence of medical progress. JAMA. 2005;293(24):3012-3021.

(21.) Olmos C, Vilacosta I, Sarria C, et al. Streptococcus bovis endocarditis: update from a multicenter registry. Am Heart J. 2016;171(1):7-13.

(22.) Vogkou CT, Vlachogiannis NI, Palaiodimos L, Kousoulis AA. The causative agents in infective endocarditis: a systematic review comprising 33,214 cases. Eur J Clin Microbiol Infect Dis. 2016;35(8):1227-1245.

(23.) Nadji G, Rusinaru D, Remadi JP, et al. Heart failure in left sided native valve infective endocarditis: characteristics, prognosis, and results of surgical treatment. Eur J Heart Fail. 2009;11(7):668-675.

(24.) Hasbun R, Vikram HR, Barakat LA, Buenconsejo J, Quagliarello VJ. Complicated left-sided native valve endocarditis in adults: risk classification for mortality. JAMA. 2003;289(15):1933-1940.

(25.) Netzer ROM, Altwegg SC, Zollinger E, et al. Infective endocarditis: determinants of long term outcome. Heart. 2002;88(1):61-66.

(26.) Delahaye F, Ecochard R, de Gevigney G, et al. The long-term prognosis of infective endocarditis. Eur Heart J. 1995;16(supply B):48-53.

Asiye Bahar Kacmaz [1] [ID], Ilker Inanc Balkan [2] [ID], Umit Yasar Sinan [3] [ID], Bilgul Mete [2] [ID], Nese Saltoglu [2] [ID], Fehmi Tabak [2] [ID], Ali Mert [4] [ID], Mehmet Serdar Kucukoglu [3] [ID], Recep Ozturk [5] [ID]

[1] Department of Infectious Diseases and Clinical Microbiology, American Hospital, Istanbul, Turkey

[2] Department of Infectious Diseases and Clinical Microbiology, Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Istanbul, Turkey

[3] Department of Cardiology, Istanbul University-Cerrahpasa, Institute of Cardiology, Istanbul, Turkey

[4] Department of Internal Medicine, Istanbul Medipol University, Faculty of Medicine, Istanbul, Turkey

[5] Department of Infectious Diseases and Clinical Microbiology, Istanbul Medipol University, Faculty of Medicine, Istanbul, Turkey

Received: February 24, 2021 Accepted: April 12, 2021

Corresponding author: Asiye Bahar Kacmaz, Department of Infectious Diseases and Clinical Microbiology, American Hospital, Istanbul, Turkey e-mail: asybaharkacmaz@hotmail.com
Table 1. Epidemiological characteristics, symptoms, and clinical and
laboratory findings of the patients (n = 90)
Characteristics, n (%)               Clinical findings, n (%)
Cardiac risk factors                 Fatigue 90 (100)
  Chronic rheumatic heart disease    Sweating 87 (96.6)
   29 (33.7)
  Prosthetic valve 32 (37.2)         Fever 85 (94.4)
  Degenerative heart valve disease   Anorexia and weight loss 43 (47.7)
   22 (25.5)
  Congenital heart defects           Dyspnea 16 (17.7)
   13 (15.1)
Non-cardiac risk factors             Lumbar and back pain 4 (4.4)
  Dental procedure 9 (10.4)          Laboratory findings
  Diabetes mellitus 8 (9.3)          Cardiac murmur 63 (70)
  Chronic renal failure 6 (6.9)      Hepatomegaly/splenomegaly 24 (26.6)
  Hemodialysis 3 (3.4) 3 (3.4)       Arthralgia 4 (4.4)
  Central venous catheter 2 (2.3)    Roth spot (n = 33) 2 (6) ([dagger])
  Intravenous drug use 1 (1.1)       Osler nodules 1 (1.1)
Epidemiological classification       Cerebrovascular and peripheral
                                     32 (35.5) findings of emboli
  Community-acquired 78 (86.6)       Hematuria (n = 68) 18 (26.4)
                                     ([dagger])
  Healthcare-associated 12 (13.3)    Rheumatoid factor positivity
                                     (n = 29) 9 (31) ([dagger])
    Nosocomial 2 (2.2)               Elevated C-reactive protein
                                     87 (96.6)
    Non-nosocomial 10 (11.1)         Elevated ESR (n = 81) 74 (91.3)
                                     ([dagger])
  Native valve endocarditis
   56 (62.2)
  Prosthetic valve endocarditis
   34 (37.7)
Clinical onset and course
  Acute endocarditis 50 (56)
  Subacute endocarditis 20 (22)
  Chronic endocarditis 20 (22)
([dagger]) Roth spot was investigated in 33, Urinalysis was performed
in 68, RF was investigated in 29, and ESR was detected in 81 episodes.
Abbreviations: PE, Physical examination; ESR, Erythrocyte sedimentation
rate.
Table 2. The distribution of causative agents (n = 90)
Microorganisms                               n (%)
Streptococcus spp.                         25 (27.7)
Viridans group streptococci                20 (22.2)
Streptococcus bovis                         2 (2.2)
Peptostreptococcus anaerobius               2 (2.2)
Lactococcus garvieae                        1 (1.1)
Staphylococcus spp.                        22 (24.4)
Methicillin-sensitive Staphylococcus       10 (11.1)
aureus
Methicillin-resistant coagulase-negative    6 (6.6)
staphylococci
Methicillin-sensitive coagulase-negative    4 (4.4)
staphylococci
Methicillin-resistant S. aureus             1 (1.1)
Kocuria varians                             1 (1.1)
Enterococcus spp.                          15 (16.6)
Brucella spp                                2 (2.2)
Haemophilus parainfluenzae                  1 (1.1)
Escherichia coli                            1 (1.1)
Acinetobacter spp.                          1 (1.1)
Pseudomonas mendocina                       1 (1.1)
Corynebacterium jeikeum                     1 (1.1)
MSSA + VGS + MSCoNS                         1 (1.1)
Coxiella burnetii                           1 (1.1)
Undefined causative agents                 19 (21.1)
* Serology (IgG phase I >1 : 800)
Abbreviations: MSSA, methicillin-sensitive S. aureus; VGS, Viridans
group streptococci; MSCoNS, methicillin-sensitive coagulase-negative
staphylococci.
Table 3. Distribution of systemic and cardiac complications
Systemic Complications                        n (%)
Major arterial emboli                       32 (35.5)
Cerebral complication                       12 (13.3)
Cerebrovascular disease (ischemia/           9 (10)
hemorrhage)
Cerebral artery mycotic aneurysm             2 (2.2)
Cerebral abscess                             1 (1.1)
Splenic infarct                              5 (5.5)
Splenic infarct + superior mesenteric        1 (1.1)
artery embolism
Abdominal aortic mycotic aneurysm            1 (1.1)
Pulmonary emboli                             3 (3.3)
Coronary artery emboli                       1 (1.1)
Janeway lesions                              3 (3.3)
Splinter hemorrhage                          4 (4.4)
Skin rashes                                  1 (1.1)
Septic shock                                 2 (2.2)
Cardiac complications                         n (%)
  New-onset valve regurgitation             26 (28.8)
  ([+ or -] heart failure)
  Mitral regurgitation                       18 (20)
  Aortic regurgitation                       4 (4.4)
  Tricuspid regurgitation                    4 (4.4)
  Advanced heart failure                    19 (21.1)
  ([+ or -] advanced valve regurgitation)
Periannular abscess                          5 (5.5)
Chordal rupture                              4 (4.4)
Table 4. Baseline characteristics of patients with infective
endocarditis in terms of in-hospital mortality
Feature                             Total Cases
                                      (n = 86)       Patients Who
                                   Total Episodes    Died (n = 13)
                                      (n = 90)
Sex
  Male                                   56                8
  Female                                 30                5
Age, years
  >50                                    47               11
 [less than or equal                     39                2
  to] 50
Cardiac predisposing factors
(n = 86 cases)
  Chronic rheumatic heart                29                4
   disease
  Degenerative heart disease             22                7
  Prosthetic heart disease               32                7
  Congenital heart disease               13                1
Non-cardiac predisposing factors
(n = 86 cases)
  Chronic renal failure                   6                3
  Hemodialysis                            3                1
  History of previous                     6                2
   endocarditis
Onset of endocarditis
(n = 90 episodes)
  Acute endocarditis                     50                8
  Subacute endocarditis                  20                1
  Chronic endocarditis                   20                4
Origin of infection acquisition
(n = 90 episodes)
  Community-acquired                     78               11
  Healthcare-associated                  12
    Nosocomial                            2                0
    Non-nosocomial                       10                2
Type of valve involvement
(n = 90 episodes)
  Native valve endocarditis              56                6
  Prosthetic valve endocarditis          34                7
    Late                                 29                6
    Early                                 5                1
Localization of vegetations
(n = 90 episodes)
  Aortic valve                           32                3
  Mitral valve                           22                4
  Aortic and mitral valve                20                4
  Tricuspid valve                         5                0
  Aortic, mitral and tricuspid            1                1
  No defined vegetation                  11                1
Surgical intervention
(n = 90 episodes)
  Surgery applied                        28                3
  No surgery                             62               10
Staphylococcus spp.                      22                4
  MSSA                                   10                2
  MRSA                                    1                1
  MRCoNS                                  6                1
Streptococcus spp.                       25                2
  Viridans streptococcus                 20                1
  Streptococcus bovis                     2                1
Enterococcus spp.                        15                2
  Coxiella burnetii                       1                1
  Undefined causative agents             19                4
Feature
                                   Patients Who
                                     Survived
                                     (n = 73)       P
Sex                                                .761
  Male                                  48
  Female                                25
Age, years                                         .080
  >50                                   36
 [less than or equal                    37
  to] 50
Cardiac predisposing factors
(n = 86 cases)
  Chronic rheumatic heart               25          1
   disease
  Degenerative heart disease            15         .036
  Prosthetic heart disease              25         .147
  Congenital heart disease              12         .681
Non-cardiac predisposing factors
(n = 86 cases)
  Chronic renal failure                  3         .042
  Hemodialysis                           2         .392
  History of previous                    4
   endocarditis
Onset of endocarditis
(n = 90 episodes)                                  .093
  Acute endocarditis                    42
  Subacute endocarditis                 19
  Chronic endocarditis                  16
Origin of infection acquisition                    .683
(n = 90 episodes)
  Community-acquired                    67
  Healthcare-associated
    Nosocomial                           2
    Non-nosocomial                       8
Type of valve involvement                          .226
(n = 90 episodes)
  Native valve endocarditis             50
  Prosthetic valve endocarditis         27
    Late                                23
    Early                                4
Localization of vegetations                        .093
(n = 90 episodes)
  Aortic valve                          28
  Mitral valve                          18
  Aortic and mitral valve               16
  Tricuspid valve                        5
  Aortic, mitral and tricuspid           0
  No defined vegetation                 10
Surgical intervention                              .533
(n = 90 episodes)
  Surgery applied                       25         .728
  No surgery                            52
Staphylococcus spp.                     18
  MSSA                                   8
  MRSA                                   0
  MRCoNS                                 5
Streptococcus spp.                      23         .503
  Viridans streptococcus                19
  Streptococcus bovis                    1
Enterococcus spp.                       13          1
  Coxiella burnetii                      0
  Undefined causative agents            15
Abbreviations: MSSA, methicillin-sensitive Staphylococcus aureus;
MRSA, methicillin-resistant S. aureus; MRCoNS, methicillin-resistant
coagulase-negative staphylococci.
Table 5. Distribution of complications in cases of death and survival
Complications                   Total Episodes   Patients Who Died
                                   (n = 90)           (n = 13)
Peripheral embolism                   17                 1
Splenic infarct                       5                  1
Cerebrovascular complications         12                 3
Ischemia/hemorrhage                   9                  3
Congestive heart failure              19                 11
No complication                       71                 1
Complications                   Patients Who Survived
                                       (n = 73)
Peripheral embolism                       16
Splenic infarct                           4
Cerebrovascular complications             9
Ischemia/hemorrhage                       6
Congestive heart failure                  8
No complication                           70
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Title Annotation:ORIGINAL ARTICLE/OZGUN ARASTIRMA
Author:Kacmaz, Asiye Bahar; Balkan, Ilker Inanc; Sinan, Umit Yasar; Mete, Bilgul; Saltoglu, Nese; Tabak, Fe
Publication:Cerrahpasa Medical Journal
Date:Aug 1, 2021
Words:5023
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