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MANAGEMENT OF INFECTIVE ENDOCARDITIS IN TERTIARY CARDIAC CARE HOSPITAL.

Byline: Imran Fazal, Azhar Ali Chaudary, Rehana Khadim, Sohail Aziz, Farhan Tuyyab, Naseer Ahmed Samore and Aysha Siddiqua

ABSTRACT

Objective: To evaluate the management and in-hospital outcomes of the patients of infective endocarditis in tertiary cardiac care hospital.

Study Design: Descriptive cross-sectional study.

Place and Duration of Study: Adult Cardiology Departments of AFIC /NIHD from 1st August 2013 till 31st August 2015.

Material and Methods: Eighty Four patients with infective endocarditis were included in the study using consecutive sampling technique. Infective endocarditis registry by R and D Department was used as a data collection tool.

Results: There were total 84 patients with infective endocarditis, out of which 51.0% (n= 43) were males and 49.0% (n= 41) were females. Mean age was 36.24 +- 15.3 years and mean BMI was found to be 22.68 +- 3.9. Most

patients with infective endocarditis had no heart valve disease 41.6%, followed by patients with rheumatic heart disease 39.2% (n=33). Most prevalent co-morbidity was hypertension 30.6% while most Common symptom of the patients was fever 97.5% (persistent fever 63% and intermittent 34.5%). Vegetations were found in all patients. Blood culture was positive in 51% of patients and the most common organism was streptococcus 72%. Mortality of the infective endocarditis patients was 38% (n=32). Causes of mortality were death after surgery, late Presentation of with Complications, death before surgery, unwillingness for the surgery and death due to other causes. Most common cause of death was late presentations of the patients with complications (19%).

Conclusion: Infective endocarditis is a disease with high mortality. Appropriate provision of healthcare facilities, improved health awareness, early diagnosis of infective endocarditis, use of appropriate antimicrobials and early surgical intervention can improve the outcomes significantly.

Keywords: Infective endocarditis, Rheumatic heart disease, Co-morbidity, Vegetation.

INTRODUCTION

Infective endocarditis is a disease that needs a comprehensive approach for its management, because is not a single disease, but rather may present with very different aspects depending on the first organ involved, the underlying cardiac disease, the microorganism involved, the presence or absence of complications and the patient's characteristics1. Main clinical symptoms might be cardiac, rheumatological, infectious, neurological or other. A very high level of expertise is needed for management of patients with infective endocarditis including cardiologists, cardiac surgeons, microbiologists, neurologists and neurosurgeons. Echocardiography is known to have a major importance in the diagnosis and management of infective endocarditis2.

However, other imaging techniques, including magnetic resonance imaging (MRI), multi-slice computed tomography (MSCT), and nuclear imaging, have also been shown to be useful for diagnosis, follow-up and decision making in patients with infective endocarditis. About half of the patients with infective endocarditis undergo surgery during the hospital course. Early discussion with the surgical team is important and is considered mandatory in all cases of complicated infective endocarditis i.e. endocarditis with heart failure, abscess or embolic or neurological complications3.

The diverse nature and evolving epidemiological profile of infective endocarditis ensure that it remains a diagnostic challenge depending upon the causative organism4. Patients with the highest risk of infective endocarditis can be placed in three categories, patients with a prosthetic valve or with prosthetic material used for cardiac valve repair, patients with previous infective endocarditis and patients with untreated cyanotic congenital heart disease (CHD) and those with CHD who have postoperative palliative shunts, conduits or other prostheses. The clinical history of infective endocarditis is highly variable according to the causative microorganism, the presence or absence of pre-existing cardiac disease, the presence or absence of prosthetic valves or cardiac devices and the mode of presentation. It may present as an acute, rapidly progressive infection, but also as a sub-acute or chronic disease with low-grade fever and non-specific symptoms5.

Patients may present to a variety of specialists who may consider a range of alternative diagnoses. Up to 90% of patients present with fever, often associated with systemic symptoms of chills, poor appetite and weight loss. Heart murmurs are found in up to 85% of patients. Up to 25% of patients have embolic complications at the time of diagnosis6.

Table-1: Presenting complaints and symptoms of the patients with infective endocarditis.

Variables###Valve n (%)###Percentage (%)

Age ( Mean +- S.D)###36.24 +- 15.32 Years

BMI ( Mean +- S.D)###22.68 +- 3.95

Gender

Male###43 (51.0%)###51.0%

Female###41 (49.0%)###49.0%

Underlying Heart Valve Disease

Rheumatic Heart Disease###33 (39.2###39.2%

Infective Endocarditis of Prosthetic Valve###12###14.2%

Congenital Heart Disease###3###3.5%

Atrial Myxoma###1###2.0%

Co-morbidities

Hypertension###39###30.6%

Diabetes###10###10.2%

Stroke###1###2.0%

COPD###5###4.0%

Renal Impairment###7###8.1%

Smoker###14###12.2%

Symptoms:

Fever

Persistent###53###63.0%

Intermittent###29###34.5%

Dyspnea

NYHA Class I###5###5.9%

NYHA Class II###15###22.4%

NYHA Class III###25###29.7%

Weight Loss###67###80.1%

Musculoskeletal pains###59###70.5%

Besides the pathological aspect obtained after valve surgery, in clinical practice the diagnosis of infective endocarditis usually relies on the association between an infective syndrome and recent endocardial involvement. This is the cornerstone of the various criteria proposed to facilitate the difficult diagnosis of this disease Thus, in 2000, the modified Duke criteria were recommended for diagnostic classification.

These criteria are based on clinical, echocardiographic and biological findings, as well as the results of blood cultures and serologies7. This classification has a sensitivity of approximately 80% overall when the criteria are evaluated at the end of patient follow-up in epidemiological studies. However, the modified Duke criteria show a lower diagnostic accuracy for early diagnosis in clinical practice, especially in the case of prosthetic valve endocarditis (PVE) and pacemaker or defibrillator lead infective endocarditis, for which echocardiography is normal or inconclusive in up to 30% of cases8. Successful treatment of IE relies on microbial eradication by antimicrobial drugs. Surgery contributes by removing infected material, draining abscesses and valve repair/ replacement8.

Table-2: Echo findings and blood culture/sensitivity findings of the patients.

Variables###Frequency###Percentage

Echo findings:

Vegetation###84###100%

Abscess###10###11.9%

Perforation###5###5.9%

Para-vavular Leak###9###10.7%

EF

50###34###38.7%

30-50###27###32.6%

< 30###23###28.5%

MR

I###7###8.2%

II###21###24.5%

III###21###24.5%

TR

Mild###5###4.1%

Moderate###5###4.1%

AR

I###9###10.2%

II###9###10.2%

III###16###18.4%

III+IV###10###11.9%

Blood C/S

Positive###43###51.0%

Negative###41###48.9%

Causative Organism

Streptococcus###31###72.0%

Staphylococcus###8###20.0%

E.coli###4###8.0%

MATERIAL AND METHODS

A Retrospective analysis was carried out from 1st August 2013 till 31st August 2015 using infective endocarditis registry by RandD Department. Data was collected in department of Adult Cardiology, AFICand NIHD, Rawalpindi. Consecutive sampling technique was used for recruitment of the patients. All the patients with infective endocarditis were included the study.

Clinical registry of infective endocarditis was used as data collection tool which was developed for demographics of the patients as well as symptoms, clinical characteristics and in hospital short term outcomes of the patient. Formal approval for the study was taken from Institutional Ethical Review Board AFIC and NIHD.

Data was analyzed using SPSS-21 version. Quantitative variables were describes with mean +- S.D while qualitative variables were described with frequency and valid percentages.

RESULTS

There were total 84 patients with infective endocarditis, out of which 51.0% (n= 43) were male and 49.0% (n= 41) were female. Mean age was 36.24 +- 15.3 years and mean BMI of the patients was found to be 22.68 +- 3.9 as shown in table-1.

The underlying heart valve diseases were rheumatic heart disease, infective endocarditis of prosthetic valve, congenital heart disease and atrial myxoma. Most patients with infective endocarditis had no heart valve disease 41.6% (n=35), followed by patients with rheumatic heart disease 39.2% (n=33). Co-morbidities were found to be hypertension, diabetes, stroke, chronic obstructive pulmonary desease (COPD), renal impairment, Smoking history, IV drug usage, Hepatitis C and Tuberculosis, Coarctation of aorta and pregnancy. Most prevalent co-morbidity was hypertension 30.6% (n=39), followed by diabetes 10.2% (n=10). Most Common symptom of the patients was fever (n=82) 97.5% (persistent fever 63% and intermittent 34.5%) and weight loss 80.1% (n=67).

Table-3: Complications and mortality in patients with infective endocarditis.

Variables###Frequency###Percentage

Complications:

Stroke###7###8.3%

Heart Failure###39###46.4%

Renal Failure###26###30.9%

Septic Emboli###6###7.1%

Splenic Abscess###1###1%

Lung Abscess###2###2.3%

Pericardial Effusion###2###2.3%

Aortic Root Abscess###10###11.9%

Perforations###5###5.9%

Arrhythmias###2###2.3%

Peripheral Embolism###1###1%

Mortality###32###38%

Mortality after surgery###5###5.9%

Late Presentation###16###19%

Death before surgery###6###7.1%

Unwilling for surgery###3###3.5%

Death due to other causes###2###2.3%

Most common clinical presentation was vegetation, found in all patients (n=84). Ejection fraction was more than 50 in 38.7% patients, 30-50 in 32.6% patients and <30 in 28.5% of the patients. Blood culture was positive in 51% (n=43) patients and most common organism was streptococcus 72% (n=31), then staphylococcus 20% (n=8) and E.Coli 8% (n=4) as show in table-2.

Complications among patients were found to be stroke, heart failure, renal failure, septic emboli, splenic abscess, lung abscess, pericardial effusion, aortic root abscess, perforations, arrhythmias, peripheral embolism. The most common were heart failure 46.4% (n=39) and renal failure 30.9% (n=26) as shown in table-3.

Mortality of the infective endocarditis patients was 38% (n=32). Causes of mortality were death after surgery, late presentation of with complications, death before surgery, unwillingness for the surgery and death due to other causes. Most common cause of death was late presentations of the patients or due to complications 19% (n=16).

DISCUSSION

Infective endocarditis remains a diagnostic as well as therapeutic challenge and associated with significant mortality especially in our setup due to limited healthcare facilities and delayed diagnosis9. Its clinical manifestations may be muted by the indiscriminate use of antimicrobial agents or by underlying conditions in frail, elderly individuals or immunosuppressed persons. It is not an uncommon disease in our population10. Male predominance, young age and high mortality are the main aspects observed in this study as has been reported elsewhere by researchers of our region10,11. In this study mean age of patients was found to be 36 years with majority of the patients being <40 years, while in Western countries mean age of presentation with infective endocarditis has increased from 58.6 years to 60.8 years, with more than 50% patients above 50 years age12,13.

One possible reason for infective endocarditis being common in younger age group in our population, is the prevalent underlying rheumatic and congenital heart diseases. While improved healthcare facilities and better awareness has led to the decreasing trends in mortality and increasing age of presentation in Western world13.

Infective endocarditis remains common in males as is reported in local and international literature with no racial predilection probably due to socioeconomic bias particularly in our region2. Clinical characteristics and laboratory features in our study are comparable to other reported studies with fever being the most common symptom and vegetations on the valves being commonest finding on echocardiogram8. Mitral valve was predominantly involved with the infective process because of it being most commonly involved in rheumatic heart disease9,14,15.

In this study 48.9% of patients were found to be culture negative, which is quite high percentage consistent with other studies from developing countries8,9,12. Most common reason behind this low positivity of cultures is probably unjustified use of antibiotics in our setup, with significant association was found between previous intake of antibiotics and culture negative endocarditis. The most common organism cultured was streptococcus and staphylococcus being the second most common which is consistent with local and international studies1,6,8,9. Mortality was around 38%, which relatively high considering the international statistics10,13,16. Major reasons behind this high mortality are delayed presentations and late diagnosis leading to complications and multi-organ failure. Mortality after the surgical interventions was 12%, the reflecting role of early surgery in appropriate candidates.

CONCLUSION

Infective endocarditis remains disease of younger age group in our setup, with high mortality due to lack of awareness, delayed presentation and complications and inadequate healthcare facilities especially at the remote areas. Appropriate provision of healthcare facilities, improved health awareness and knowledge about the early diagnosis of infective endocarditis, use of appropriate antimicrobials and early surgical intervention in appropriate candidates can improve the outcomes significantly.

CONFLICT OF INTEREST

This study has no conflict of interest to declare by any author.

REFERENCES

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12. Murdoch DR, Corey GR, Hoen B, Miro JM, Fowler VG Jr, Bayer AS, 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 Mar 9. 169(5):463-73.

13. Bor DH, Woolhandler S, Nardin R, Brusch J, Himmelstein DU. Infective endocarditis in the u.s., 1998-2009: a nationwide study. PLoS One. 2013. 8(3):e60033.

14. Knirsch W, Nadal D. Infective endocarditis in congenital heart disease. Eur J Pediatr 2011;170:1111-1127.

15. Botelho NE, Thuny F, Casalta JP, Richet H, Gouriet F, Collart F et al. Dramatic reduction in infective endocarditis-related mortality with a management-based approach. Arch Intern Med2009;169:1290-1298.

16. Chambers JB, Shanson D, Hall R, Pepper J, Venn G, McGurk M. Antibiot ic prophylaxis of endocarditis: the rest of the world and NICE. J R Soc Med 2011;104:138-140.
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Publication:Pakistan Armed Forces Medical Journal
Date:Apr 30, 2016
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