Infective endocarditis and solid organ transplantation: Only worse outcomes during initial transplantation hospitalization

Current Views on Infective Endocarditis: Changing Epidemiology, Improving Diagnostic Tools and Centering the Patient for Up-to-Date Management

Infective endocarditis (IE) is a rare but potentially life-threatening disease, sometimes with longstanding sequels among surviving patients. The population at high risk of IE is represented by patients with underlying structural heart disease and/or intravascular prosthetic material. Taking into account the increasing number of intravascular and intracardiac procedures associated with device implantation, the number of patients at risk is growing too. If bacteremia develops, infected vegetation on the native/prosthetic valve or any intracardiac/intravascular device may occur as the final result of invading microorganisms/host immune system interaction. In the case of IE suspicion, all efforts must be focused on the diagnosis as IE can spread to almost any organ in the body. Unfortunately, the diagnosis of IE might be difficult and require a combination of clinical examination, microbiological assessment and echocardiographic evaluation. There is a need of novel microbiological and imaging techniques, especially in cases of blood culture-negative. In the last few years, the management of IE has changed. A multidisciplinary care team, including experts in infectious diseases, cardiology and cardiac surgery, namely, the Endocarditis Team, is highly recommended by the current guidelines.

Infective endocarditis in solid organ transplant: a review

PURPOSE OF REVIEW

Infective endocarditis remains an uncommon disease with significant morbidity and mortality. In the last two decades, progress has been made describing the unique aspects of infective endocarditis in solid organ transplant (SOT) recipients.

RECENT FINDINGS

Incidence of infective endocarditis in SOT is higher when compared with the general population. End-stage organ dysfunction, diabetes mellitus, older age, and prior intravenous lines have been identified as risk factors predisposing to infective endocarditis in SOT. Staphylococci and enterococci represent the most frequently isolated pathogens, whereas fungi are rarely isolated. Median time from transplantation to diagnosis ranges from 33 to 66 months. Nosocomial acquisition and mural endocarditis are more common in SOT recipients with infective endocarditis. Procurement of organs from patients with infective endocarditis might be well tolerated so long as close monitoring and targeted antibiotics are given. Selected patients might benefit from heart transplantation as definitive or salvage therapy for infective endocarditis. Outcomes of infective endocarditis in SOT recipients compared with the general population might be similar; however, patient survival and graft function are reduced when recipients suffer from infective endocarditis.

SUMMARY

Infective endocarditis although rare can affect donors and recipients involved in the SOT process. Recognition of the unique characteristics in the presentation, prevention, medical, and surgical therapy of this disease is essential in order to minimize adverse outcomes.

In-hospital mortality and length of stay among patients with infective endocarditis and solid organ transplant: A study from National Inpatient Sample 2016-2019

Infective endocarditis (IE) is a rare but serious complication following a Solid Organ Transplant (SOT). Due to the lack of sufficient studies, we aimed to compare in-hospital mortality and length of stay (LOS) of patients primarily admitted for IE (index or principal hospitalization) with history of SOT, including the subgroup of heart or lung transplant (HLT), to those without a history of SOT (non-SOT) or HLT (non-HLT). We used the 2016–2019 National Inpatient Sample, the largest all-payer inpatient hospital data from Healthcare Cost and Utilization Project (HCUP), including patients 18 years or older with IE, as a principal diagnosis for hospitalization. From 2016 to 2019, there were 56,330 principal or index hospitalizations for IE. Among them, 0.6 % (n = 327) were SOT recipients, 0.1% (n = 68) were HLT recipients, and 41.4% were females. The mean age was 51.9 ± 19.2 years. Compared to non-SOT controls, SOT recipients were older (mean age 59.3 vs. 51.8 years; P = 0.002) and had higher Charlson-comorbidity-index (CCI) of 3 or more (87.7% vs. 33.2%; p < 0.001). SOT status was not statistically significant for a higher or lower odds of in-hospital mortality (adjusted odds ratio (aOR) 0.7; 95% confidence interval (CI): 0.2, 2.4; p = 0.60) or increased or decreased LOS (coefficient: -0.1, 95% CI: -0.4, 0.1; p = 0.23) among index IE hospitalizations after controlling for age, sex, race, hospital-region, hospital-teaching status, income, insurance status, and CCI. HLT status was also not associated with higher or lower odds of in-hospital mortality (aOR 1.4; 95% CI: 0.2, 13.1; p = 0.77) or increased or decreased LOS (coefficient: -0.1, 95% CI: -0.3, 0.5; p = 0.59). From 2016 to 2019, the rate of index IE hospitalization trends from 37.8 to 41.4 per 100,000 overall hospitalizations (p = 0.001). We found the rate of index IE hospitalizations increasing with time. Among index IE hospitalizations, SOT, including a subgroup of HLT recipients, have similar in-hospital mortality and LOS compared to non-SOT or non-HLT groups. We need a larger sample size to comment on outcomes of IE hospitalizations with the HLT subgroup.