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Nel R, Janson J, Esterhuizen T, van der Westhuizen C. The Surgical Outcome of Infective Endocarditis in South Africa over 10 Years: A Retrospective Review. J Clin Med 2024; 13:5226. [PMID: 39274440 PMCID: PMC11395924 DOI: 10.3390/jcm13175226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/27/2024] [Accepted: 08/31/2024] [Indexed: 09/16/2024] Open
Abstract
Objectives: There is a paucity of data on the outcome of left-sided cardiac valve surgery for infective endocarditis in South Africa. It is hypothesized that outcomes may be poorer compared to international standards due to differences in disease burden, timing of surgery, organism prevalence, and co-morbidities. Method: This is a retrospective study of 160 patients with left heart valve endocarditis who underwent cardiac surgery from January 2010 to December 2019. Demographic, operative, and admission-related parameters were assessed to determine their association with all-cause mortality during the early post-operative (<30 days) and late post-operative (>30 days) periods. Results: Early post-operative mortality (<30 days) was 8.8% and late post-operative mortality (>30 days) was 13.1%. Late survival showed 77.5% of the patients were alive with a mean follow-up period of 41 months. Increased age (p = 0.04), critical illness (p < 0.001), and higher urgency of intervention (p < 0.001) were associated with higher early post-operative mortality. Peri-operative organ failure, including cardiac (p = 0.025), renal (p = 0.016), and respiratory failure (p < 0.001), contributed significantly to both early and late mortality. Pre-operative antibiotics for fewer days (p = 0.024), ongoing sepsis (p = 0.022), and para-valvular extension (p = 0.046) were associated with higher early mortality. Conclusions: Infective endocarditis is a common indication for cardiac valve surgery in South Africa. Goal-directed medical management and clinical optimization prior to surgery were crucial to achieving better outcomes. Salvage procedures and critical illness with organ failure prior to surgery were associated with poorer outcomes. Despite unique challenges, cardiac surgery for infective endocarditis at Tygerberg Hospital compares favorably to international standards.
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Affiliation(s)
- Riaan Nel
- Division of Cardiothoracic Surgery, Stellenbosch University and Tygerberg Academic Hospital, Cape Town 7505, South Africa
| | - Jacques Janson
- Division of Cardiothoracic Surgery, Stellenbosch University and Tygerberg Academic Hospital, Cape Town 7505, South Africa
| | - Tonya Esterhuizen
- Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town 7505, South Africa
| | - Clinton van der Westhuizen
- Division of Medical Microbiology, Stellenbosch University and NHLS Tygerberg Academic Hospital, Cape Town 7505, South Africa
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López J, Olmos C, Fernández-Hidalgo N. New developments in infective endocarditis. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:779-787. [PMID: 38763212 DOI: 10.1016/j.rec.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 03/18/2024] [Indexed: 05/21/2024]
Abstract
Infective endocarditis is a continually evolving disease. Present-day patients differ significantly from those treated a few decades ago: they tend to be older and have more comorbidities and health care-related episodes, while new groups of patients have emerged with new types of endocarditis, such as those affecting patients with percutaneous valve prostheses. There have also been changes in diagnostic techniques. Although transthoracic and transesophageal echocardiography are still the most commonly used imaging modalities, other techniques, such as 3-dimensional transesophageal ultrasound, cardiac computed tomography, and nuclear medicine tests (PET/CT and SPECT/CT), are increasingly used for diagnosing both the disease and its complications. In recent years, there have also been significant developments in antibiotic therapy. Currently, several treatment strategies are available to shorten the hospital phase of the disease in selected patients, which can reduce the complications associated with hospitalization, improve the quality of life of patients and their families, and reduce the health care costs of the disease. This review discusses the main recent epidemiological, diagnostic and therapeutic developments in infective endocarditis.
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Affiliation(s)
- Javier López
- Servicio de Cardiología, Hospital Clínico de Valladolid, Valladolid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Carmen Olmos
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain; Facultad de Medicina, Universidad Europea de Madrid, Madrid, Spain
| | - Nuria Fernández-Hidalgo
- Servei de Malalties Infeccioses, Hospital Universitari Vall d'Hebron, Barcelona, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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Boodman C, Gupta N, Nelson CA, van Griensven J. Bartonella quintana Endocarditis: A Systematic Review of Individual Cases. Clin Infect Dis 2024; 78:554-561. [PMID: 37976173 DOI: 10.1093/cid/ciad706] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/30/2023] [Accepted: 11/15/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Bartonella quintana is a louse-borne bacterium that remains a neglected cause of endocarditis in low-resource settings. Our understanding of risk factors, clinical manifestations, and treatment of B. quintana endocarditis are biased by older studies from high-income countries. METHODS We searched Pubmed Central, Medline, Scopus, Embase, EBSCO (CABI) Global Health, Web of Science and international trial registers for articles published before March 2023 with terms related to Bartonella quintana endocarditis. We included articles containing case-level information on B. quintana endocarditis and extracted data related to patient demographics, clinical features, diagnostic testing, treatment, and outcome. RESULTS A total of 975 records were identified, of which 569 duplicates were removed prior to screening. In total, 84 articles were eligible for inclusion, describing a total of 167 cases. Infections were acquired in 40 different countries; 62 cases (37.1%) were acquired in low- and middle-income countries (LMICs). Disproportionately more female and pediatric patients were from LMICs. More patients presented with heart failure (n = 70/167 [41.9%]) than fever (n = 65/167 [38.9%]). Mean time from symptom onset to presentation was 5.1 months. Also, 25.7% of cases (n = 43/167) were associated with embolization, most commonly to the spleen and brain; 65.5% of antimicrobial regimens included doxycycline. The vast majority of cases underwent valve replacement surgery (n = 154/167, [98.0%]). Overall case fatality rate was 9.6% (n = 16/167). CONCLUSIONS B. quintana endocarditis has a global distribution, and long delays between symptom onset and presentation frequently occur. Improved clinician education and diagnostic capacity are needed to screen at-risk populations and identify infection before endocarditis develops.
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Affiliation(s)
- Carl Boodman
- Division of Infectious Diseases, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Unit of HIV and Neglected Tropical Diseases, Institute of Tropical Medicine, Antwerp, Belgium
| | - Nitin Gupta
- Department of Infectious Disease, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Christina A Nelson
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Johan van Griensven
- Unit of HIV and Neglected Tropical Diseases, Institute of Tropical Medicine, Antwerp, Belgium
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Boodman C, Fongwen N, Pecoraro AJ, Mihret A, Abayneh H, Fournier PE, Gupta N, van Griensven J. Hidden Burden of Bartonella quintana on the African Continent: Should the Bacterial Infection Be Considered a Neglected Tropical Disease? Open Forum Infect Dis 2024; 11:ofad672. [PMID: 38370291 PMCID: PMC10873695 DOI: 10.1093/ofid/ofad672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/19/2023] [Indexed: 02/20/2024] Open
Abstract
Bartonella quintana is a louse-borne gram-negative bacillus that remains a poorly characterized cause of bacteremia, fever, and infective endocarditis. Due to the link with pediculosis, B quintana transmission is tied to poverty, conflict, overcrowding, and inadequate water access to maintain personal hygiene. Although these risk factors may be present globally, we argue that a substantial burden of undocumented B quintana infection occurs in Africa due to the high prevalence of these risk factors. Here, we describe the neglected burden of B quintana infection, endocarditis, and vector positivity in Africa and evaluate whether B quintana meets criteria to be considered a neglected tropical disease according to the World Health Organization.
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Affiliation(s)
- Carl Boodman
- Section of Infectious Diseases, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Unit of Neglected Tropical Diseases, Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium
| | - Noah Fongwen
- Diagnostics Access, Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Alfonso J Pecoraro
- Division of Cardiology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Adane Mihret
- Microbiology Department, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Hiwot Abayneh
- Microbiology Department, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Pierre-Edouard Fournier
- French Reference Center for Rickettsioses, Q Fever and Bartonelloses, Institut Hospitalier Universitaire, Marseille, France
| | - Nitin Gupta
- Department of Infectious Diseases, Kasturba Medical College, Manipal, India
| | - Johan van Griensven
- Unit of Neglected Tropical Diseases, Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium
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Pecoraro AJK, Herbst PG, Janson JT, Wagenaar R, Ismail Z, Taljaard JJ, Prozesky HW, Pienaar C, Doubell AF. Early surgery determines prognosis in patients with infective endocarditis: outcome in patients managed by an Endocarditis Team-a prospective cohort study. Cardiovasc Diagn Ther 2022; 12:453-463. [PMID: 36033220 PMCID: PMC9412218 DOI: 10.21037/cdt-21-590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 06/16/2022] [Indexed: 11/24/2022]
Abstract
Background Infective endocarditis (IE) in South Africa is associated with significant morbidity and mortality, despite occurring in younger patients with fewer co-morbidities. Possible contributors include the high rates of blood culture negative endocarditis, high rates of mechanical valve replacement and the lack of inter-disciplinary coordination during management. Methods The Tygerberg Endocarditis Cohort (TEC) study prospectively enrolled patients with IE between November 2019 and April 2021. All patients were managed by an Endocarditis Team with a set protocol for organism detection and a strategy of early surgery limiting the use of prosthetic material. Results Seventy-two consecutive patients with IE were included, with a causative organism identified in 86.1% of patients. The majority of patients had a guideline indication for surgery (n=58; 80.6%). The in-hospital mortality rate was 18%, with a 6-month mortality rate of 25.7%. Surgery was performed in 42 patients (58.3%), with prosthetic valve (PVE) replacement in 32 (76.2%), conventional repair surgery in 8 (19.1%) and mitral valve reconstruction in 2 (4.8%) of patients. Patients who underwent surgery had a significantly lower in-hospital (4.8% vs. 56.3%; P<0.01) and 6-month (4.9% vs. 75.0%; P<0.01) mortality rate as compared with patients with an indication for surgery who did not undergo surgery. Conclusions We have observed a reduction in the 6-month mortality rate in patients with IE following the establishment of an Endocarditis Team, adhering to a set protocol for organism detection and favouring early repair or reconstruction surgery. Patients who underwent surgery had a significantly lower mortality rate than patients with an indication for surgery who did not undergo surgery. Preventable residual mortality was driven by surgical delay.
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Affiliation(s)
- Alfonso J. K. Pecoraro
- Division of Cardiology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Philipus G. Herbst
- Division of Cardiology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Jacques T. Janson
- Division of Cardiothoracic Surgery, Department of Surgery, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Riegardt Wagenaar
- Division of Cardiothoracic Surgery, Department of Surgery, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Zane Ismail
- Division of Cardiothoracic Surgery, Department of Surgery, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Jantjie J. Taljaard
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Hans W. Prozesky
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Colette Pienaar
- Division of Medical Microbiology, Department of Microbiology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
- National Health Laboratory Service, Division of Medical Microbiology, Tygerberg Hospital, Cape Town, South Africa
| | - Anton F. Doubell
- Division of Cardiology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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Zhang X, Jin F, Lu Y, Ni F, Xu Y, Xia W. Clinical Characteristics and Risk Factors for in-Hospital Mortality in 240 Cases of Infective Endocarditis in a Tertiary Hospital in China: A Retrospective Study. Infect Drug Resist 2022; 15:3179-3189. [PMID: 35754785 PMCID: PMC9215907 DOI: 10.2147/idr.s362601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/23/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose This study aimed (i) to investigate the clinical characteristics and risk factors related to in-hospital mortality in patients with infective endocarditis (IE) and (ii) to compare the differences in three age groups. Methods A total of 240 IE cases diagnosed using the modified Duke criteria between January 2016 and December 2019 were included and retrospectively studied. Patients were stratified into three age groups: < 50 y, 50–65 y, and > 65 y. Results The mean age of the patients was 51 ± 14 y, and 154 patients (64.2%) were male. In addition, 136 (56.7%) patients with IE had no previous cardiac disease. Congenital heart disease (CHD, 21.3%) was the most common underlying heart disease, followed by rheumatic heart disease (RHD, 8.8%). Streptococcus was found in 55 (22.9%) patients and was the most common causative pathogen, comprising 52.9% of all positive blood cultures. Echocardiography showed the presence of vegetations in 88.3% of cases and the predominant involvement of the left heart valves. Fever and cardiac murmur were the most frequent presentations, with no significant differences among age groups. Compared with younger patients, elderly patients had a lower operation rate and higher in-hospital mortality. The independent risk factors of in-hospital mortality were age > 65 y, intracranial infection, splenic embolization, cerebral hemorrhage, NYHA class III–IV, and prosthetic valve infection. Conclusion CHD replaces RHD as the most common underlying heart disease in IE patients. Patients without previous cardiac disease are at increased risk of IE. Streptococcus is still the primary causative pathogen of IE. Elderly patients present with more comorbidities and complications, in addition to a more severe prognosis than younger patients. Age older than 65 y, intracranial infection, splenic embolization, cerebral hemorrhage, NYHA class III–IV, and prosthetic valve infection showed poorer in-hospital outcomes.
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Affiliation(s)
- Xiaohui Zhang
- Department of Laboratory Medicine, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, People's Republic of China.,Branch of National Clinical Research Center for Laboratory Medicine, Nanjing, People's Republic of China
| | - Fei Jin
- Department of Laboratory Medicine, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, People's Republic of China.,Branch of National Clinical Research Center for Laboratory Medicine, Nanjing, People's Republic of China
| | - Yanfei Lu
- Department of Laboratory Medicine, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, People's Republic of China.,Branch of National Clinical Research Center for Laboratory Medicine, Nanjing, People's Republic of China
| | - Fang Ni
- Department of Laboratory Medicine, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, People's Republic of China.,Branch of National Clinical Research Center for Laboratory Medicine, Nanjing, People's Republic of China
| | - Yuqiao Xu
- Department of Laboratory Medicine, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, People's Republic of China.,Branch of National Clinical Research Center for Laboratory Medicine, Nanjing, People's Republic of China
| | - Wenying Xia
- Department of Laboratory Medicine, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, People's Republic of China.,Branch of National Clinical Research Center for Laboratory Medicine, Nanjing, People's Republic of China
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Pecoraro AJK, Herbst PG, Pienaar C, Taljaard J, Prozesky H, Janson J, Doubell AF. Modified Duke/European Society of Cardiology 2015 clinical criteria for infective endocarditis: time for an update? Open Heart 2022; 9:e001856. [PMID: 35534094 PMCID: PMC9086646 DOI: 10.1136/openhrt-2021-001856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 04/21/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The diagnosis of infective endocarditis (IE) is based on the modified Duke/European Society of Cardiology (ESC) 2015 clinical criteria. The sensitivity of the criteria is unknown in South Africa, but high rates of blood culture negative endocarditis (BCNIE), coupled with a change in the clinical features of IE, may limit the sensitivity. METHODS The Tygerberg Endocarditis Cohort study prospectively enrolled patients with IE between November 2019 and June 2021. A standardised protocol for organism detection, with management of patients by an Endocarditis Team, was employed. Patients with definite IE by pathological criteria were analysed to determine the sensitivity of the current clinical criteria. RESULTS Eighty consecutive patients with IE were included of which 45 (56.3%) had definite IE by pathological criteria. In patients with definite IE by pathological criteria, 26/45 (57.8%) of patients were classified as definite IE by clinical criteria. BCNIE was present in 25/45 (55.6%) of patients and less than three minor clinical criteria were present in 32/45 (75.6%) of patients. The elevation of Bartonella serology to a major microbiological criterion of the modified Duke/ESC 2015 clinical criteria would increase the sensitivity (57.8% vs 77.8%; p=0.07). CONCLUSION The sensitivity of the modified Duke/ESC 2015 clinical criteria is lower than expected in patients with IE in South Africa, primarily due to the high rates of Bartonella-associated BCNIE. The elevation of Bartonella serology to a major microbiological criterion, similar to the status of Coxiella burnetii in the current criteria, would increase the sensitivity. The majority of patients with definite IE by pathological criteria had less than three minor criteria present.
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Affiliation(s)
- Alfonso Jan Kemp Pecoraro
- Division of Cardiology, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Philipus George Herbst
- Division of Cardiology, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Colette Pienaar
- Division of Medical Microbiology, Department of Pathology, Stellenbusch University Faculty of Medicine and Health Sceinces, Cape Town, Western Cape, South Africa
- National Health Laboratory Service, Johannesburg, Gauteng, South Africa
| | - Jantjie Taljaard
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Hans Prozesky
- Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Jacques Janson
- Division of Cardiothoracic Surgery, Department of Surgery, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Anton Frans Doubell
- Division of Cardiology, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
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