Infective endocarditis in an Indian setup: Are we entering the 'modern' era?

Comparative analysis of infective endocarditis in hemodialysis versus non-hemodialysis patients in Iran: implications for clinical practice and future research

BACKGROUND

In hemodialysis (HD) patients, there is a larger frequency of mortality and morbidity associated with infective endocarditis (IE) as opposed to the general population. Despite the increased burden of IE in the HD population, optimal strategies for prevention and management still need to be clarified. Elucidating the distinguishing features and outcomes of IE in HD patients is crucial to guide clinical decision-making and improve prognosis in this high-risk group. However, the details of IE characteristics, specifically in HD patients in the Middle East, are limited.

OBJECTIVE

To compare the clinical characteristics and short-term outcomes of IE between HD and non-HD patients.

METHODS

A retrospective analysis was carried out on 139 patients with infective endocarditis who were referred to a tertiary cardiovascular center in Iran from 2006 to 2018. The participants were split into HD (n = 34) and non-HD (n = 105) groups. Data pertaining to demographic characteristics, comorbidities, microbiological findings, occurrence of complications, therapeutic interventions, and mortality rates during hospital stay were gathered.

RESULTS

Diabetes, hypertension, and congestive heart failure were observed more frequently in HD patients. HD patients were more likely than non-HD patients to have involvement of the right valve (41.2% vs. 20.9%), larger vegetation, and extracardiac emboli. In-hospital mortality was 41.2% for HD patients versus 14.3% for non-HD patients. Mortality remained high after valve surgery in HD patients (38.2% vs. 10.5% in non-HD).

CONCLUSION

HD patients exhibited a distinct clinical profile of IE with worse short-term outcomes, including higher mortality.

Streptococcus parasanguinis: An emerging pathogen causing neonatal endocarditis: A case report

Background. The microbial infection of the endocardium, popularly known as Infective Endocarditis (IE), is typically classified on the basis of anatomy, valve nativity and its associated microbiology. As per the associated microbiology, Staphylococcus aureus is the most common microorganism responsible for the cause of IE. Even though, the Streptococcus group accounts for a smaller percentage of IE, however this doesn't give us the liberty of ignoring the high mortality and morbidity associated with this pathogen. Case presentation. We report an unusual case of neonatal sepsis, complicated with endocarditis, caused by penicillin resistant Streptococcus parasanguinis . The neonate however died of the same despite all efforts. The said baby was given birth by a mother with gestational diabetes mellitus.

Conclusion

High index of clinical suspicion and prompt diagnosis are the most important factors of patient management, especially in cases of life threatening neonatal infections. In such conditions a coordinated interdepartmental approach is very much needed.

Changing spectrum of infective endocarditis in India: An 11-year experience from an academic hospital in North India

Objective

Several studies have demonstrated a shift in the spectrum of infective endocarditis (IE) in the developed world. We aimed to investigate whether demographic and microbiologic characteristics of IE have changed in India.

Design

A retrospective analysis of patients with in north India between 2010 and 2020.

Methods

The clinical and laboratory profiles of 199 IE admitted to an academic hospital patients who met the modified Duke criteria for definite IE were analysed.

Results

The mean age was 34 years, and 84% were males. The main predisposing conditions were injection drug use (IDU) (n = 71, 35.7%), congenital heart disease (n = 46, 21.6%), rheumatic heart disease (n = 25, 12.5%), and prosthetic device (n = 19, 9.5%). 17.1% of patients developed IE without identified predispositions. Among 64.3% culture-positive cases, the most prevalent causative pathogens were Staphylococcus aureus (46.1%), viridans streptococci (7.0%), enterococci (6.0%), coagulase-negative staphylococci (5.5%), gram negative bacilli (5.5%), polymicrobial (5.5%), and Candida (1.0%). The tricuspid (30.3%), mitral (25.6%), and aortic (21.6%) valves were the most common sites of infection, and 60.3% had large vegetations (>10 mm). Systemic embolization occurred in 55.3% of patients at presentation. Cardiac surgery was required for 13.1%. In-hospital mortality was 17.1% and was associated with prosthetic devices (p-value, 0.001), baseline leucocytosis (p-value, 0.036) or acute kidney injury (p-value, 0.001), and a microbial etiology of gram negative bacilli or enterococci (p-value, 0.005).

Conclusion

IDU is now the most important predisposition for IE in India, and S. aureus has become the leading cause of native valve endocarditis with or without IDU.

Peripartum native valve endocarditis without underlying risk factors

Infective endocarditis (IE) complicating pregnancy though rare is associated with adverse maternal and fetal outcome. Due to its rarity and varied presentation, literature on IE complicating pregnancy is sparse. We report a case of IE complicating pregnancy caused by methicillin-resistant Staphylococcus aureus (MRSA) in a healthy pregnant lady without any known risk factors. This is the first documented case of IE complicating pregnancy without any underlying risk factors from the Indian subcontinent. This article also briefly outlines the current recommendation regarding management of infective endocarditis caused by MRSA.

Microbiological and Clinicoepidemiological Profile of a Series of Patients with Infective Endocarditis at a Center in Eastern Nepal

Background

The microbiological and clinicoepidemiological profile of infective endocarditis (IE) has undergone significant change over time. The pattern of IE studied at local level provides broader vision in understanding the current scenario of this disease. This study aimed to depict the overall picture of IE and its changing profile by evaluating the microbiological and clinicoepidemiological features in the context of a tertiary care center of eastern Nepal.

Methods

The descriptive study was conducted from September 2017 to August 2018 among IE patients presenting to B. P. Koirala Institute of Health Sciences, Nepal. Detailed history and clinical manifestations of patients were noted. Microorganisms isolated from the blood culture were processed for identification by standard microbiological methods, and susceptibility testings were done. Each patient was assessed daily during hospital stay.

Results

Ten definite and 7 possible endocarditis cases were studied. The mean age was 41.4 ± 15.85 (17–70) years with predominance of male (4.7 : 1). Rheumatic heart disease (41.1%) was the most common underlying heart disease observed followed by injection drug user endocarditis (23.5%). All the cases had native valve endocarditis. Aortic valve was the most common valve involved (35.3%) followed by mitral, tricuspid, and pulmonary valves. Blood culture positivity was 53%. Staphylococcus aureus was the major causative agent responsible for 23.5% of the cases followed by Enterococcus faecium, Enterococcus faecalis, and Pseudomonas aeruginosa. Mortality of 2 cases (11.8%) was associated with S. aureus and P. aeruginosa. Majority of patients developed acute kidney injury (35.3%) and congestive cardiac failure (23.5%).

Conclusion

IE patients in our center exhibited differences from the west in terms of age at presentation and predisposing factors but held similarity in terms of commonly isolated microorganisms. The changing patterns of IE, etiological agents, and their antimicrobial susceptibility observed in this study may be helpful for clinicians in formulating a new empirical antibiotic treatment protocol.

Clinical characteristics and outcome of infective endocarditis among intravenous drug abusers in India

INTRODUCTION

Infective endocarditis (IE) is the most dreaded complication of intravenous drug abuse (IVDA). IVDA is present in significant proportions in India. Since there is scarcity of Indian data on IVDA associated IE, we report a study comparing IVDA to non IVDA associated IE. We compare differences in clinical profile, microbiology, echocardiography and clinical outcome from a tertiary care hospital.

METHODS

A total of 133 patients admitted from 1st January 2017 to 31st December 2019 who met the Modified Duke ''definitive'' criteria for IE were included. Detailed Information was collected regarding demography, clinical data and laboratory investigations. All patients underwent transthoracic echocardiography and trans-esophageal echocardiogram wherever necessary.

RESULTS

Among a total of 133 patients, 54 patients (40.6%) were iv drug abusers. Patients in IVDA-group were younger, mostly males, more likely to have concomitant HCV and HIV infections compared to non IVDA-group. Chronic comorbidities such as DM and CKD were more common in non IVDA-group. Rate of positive blood culture was higher in IVDA-group compared to non IVDA-group (74.1%v/s 32.9%,p < 0.001) with different microbiological profile. Percentage of Methicillin resistant staphylococcus aureus (42.6%v/s17.7%,p = 0.003) and pseudomonas related IE (18.5%v/s2.5%,p = 0.003) was significantly higher among IVDA-group. IVDA-group most commonly had tricuspid valve involvement Whereas mitral and aortic valve were most commonly involved valve in non IVDA-group. Mortality was slightly higher among IVDA-group compared to non IVDA-group, though statistically non-significant. Left sided valve involvement and Congestive heart failure were independent predictors of mortality.

CONCLUSION

IVDA-IE is a significant problem in India. Demographic, microbiological and echocardiographic profile is quite different in IVDA and non IVDA-group. There is urgent need to conduct larger studies.

Infective endocarditis profile, prognostic factors and in-hospital mortality: 6-year trends from a tertiary university center in South America

BACKGROUND

Infective endocarditis (IE) remains an expressive health problem with high morbimortality rates. Despite its importance, epidemiological and microbiological data remain scarce, especially in developing countries.

AIM

This study aims to describe IE epidemiological, clinical, and microbiological profile in a tertiary university center in South America, and to identify in-hospital mortality rate and predictors.

METHODS

An observational, retrospective study of 167 patients, who fulfilled modified Duke's criteria during a six-year enrollment period, from January 2010 to December 2015. The primary outcome was defined as in-hospital mortality analyzed according to treatment received (clinical vs surgical). Multivariate analysis identified mortality predictors.

RESULTS

The median age was 60 years (Q₁ -Q₃ 50-71), and 66% were male. Echocardiogram demonstrated vegetations in 90.4%. An infective agent was identified in 76.6%, being Staphylococcus aureus (19%), Enterococcus (12%), coagulase-negative staphylococci (10%), and Streptococcus viridans (9.6%) the most prevalent. Overall in-hospital mortality was 41.9%, varying from 49.4% to 34.1%, in clinical and surgical patients, respectively (P = .047). On multivariate analysis, diabetes mellitus (odds ratio [OR], 2.5), previous structural heart disease (OR, 3.1), and mitral valve infection (OR, 2.1) were all-cause death predictors. Surgical treatment was the only variable related to a better outcomes (OR, 0.45; 95% Confidence Interval, 0.2-0.9).

CONCLUSION

This study presents IE profile and all-cause mortality in a large patient's cohort, comprising a 6-years' time window, a rare initiative in developing countries. Elderly and male patients predominated, while S. aureus was the main microbiological agent. Patients conservatively treated presented higher mortality than surgically managed ones. Epidemiological studies from developing countries are essential to increase IE understanding.

Inappropriate use of antibiotics in primary care for patients with infective endocarditis

Inappropriate use of antibiotics without blood cultures could delay diagnosis of infective endocarditis (IE). The pattern of use of antibiotics by primary care physicians who were later diagnosed with IE is unclear. A retrospective cohort study of patients with a definite diagnosis of IE at a community teaching hospital in the Kanagawa prefecture was performed over a 12-year period (2006-2017). Of the 145 patients, 38 patients (26%) had initially attended primary care clinics. The mean age was 63 ± 18 years, and 24 patients (63%) were men. Only one patient (3%) was prescribed antibiotics after obtaining blood cultures. Twenty patients (53%) received antibiotics. Fluoroquinolones (50%) and macrolides (25%) were the most antibiotics prescribed. There were no obvious differences in physicians' specialty between the prescriber and non-prescriber groups. Compared to patients without antibiotic prescription, those prescribed antibiotics had delayed admission and higher mortality (10 vs. 14 days and 11% vs. 30%, respectively). In conclusions, about one-quarter of IE patients initially attended primary care clinics. Of them, about half were inappropriately prescribed antibiotics (without blood cultures obtaining). IE patients receiving inappropriate antibiotics potentially have a worse outcome.

Evolving trends in infective endocarditis in a developing country: a consequence of medical progress?

BACKGROUND

Staphylococcus has replaced streptococcus as the most common cause of infective endocarditis (IE) in developed health care systems. The trend in developing countries is less clear.

AIM

To examine the epidemiological trends of infective endocarditis in a developing nation.

METHODS

Single-centre, retrospective study of patients admitted with IE to a tertiary hospital in Malaysia over a 12-year period.

RESULTS

The analysis included 182 patients (n = 153 Duke's definite IE, n = 29 possible IE). The mean age was 51 years. Rheumatic heart disease was present in 42%, while 7.6% were immunocompromised. IE affected native valves in 171 (94%) cases. Health-care associated IE (HCAIE) was recorded in 68 (37.4%). IE admission rates increased from 25/100,000 admissions (2012) to 59/100,000 admissions (2017). At least one major complication on admission was detected in 59 (32.4%) patients. Left-sided IE was more common than right-sided IE [n = 159 (87.4%) vs. n = 18 (9.9%)]. Pathogens identified by blood culture were staphylococcus group [n = 58 (40.8%)], streptococcus group [n = 51 (35.9%)] and Enterococcus species [n = 13 (9.2%)]. staphylococcus infection was highest in the HCAIE group. In-hospital death occurred in 65 (35.7%) patients. In-hospital surgery was performed for 36 (19.8%) patients. At least one complication was documented in 163 (85.7%).

CONCLUSION

Staphylococcus is the new etiologic champion, reflecting the transition of the healthcare system. Streptococcus is still an important culprit organism. The incidence rate of IE appears to be increasing. The rate of patients with underlying rheumatic heart disease is still high.

Clinicomicrobiological spectrum of infective endocarditis - from a tertiary care centre in south India

BACKGROUND AND OBJECTIVES

Infective endocarditis (IE) is a microbial infection of the endothelial surface of the cardiac-valves. Rapid diagnosis, effective treatment and prompt recognition of complications are essential, in order to improve the outcome. We retrospectively reviewed and determined the clinical characteristics, microbiological profile and management strategies of IE cases, changing microbial spectrum of pathogens and outcome in Native Valve Endocarditis (NVE) and Prosthetic Valve Endocarditis (PVE) cases.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 191 patients, clinically diagnosed with IE, based on modified Dukes criteria, from January 2011 to December 2016. Blood cultures received from all these patients were processed, using BacT/Alert system (bioMerieux, Marcy l'Etoile, France).

RESULTS

Sixty eight (68/191) cases were positive for bacterial pathogens. Twenty four (24/191) cases had PVE and 167/191 had NVE. Nineteen cases (19/24, 79.1%) were PVE positive and forty nine (49/167, 29.3%) were NVE positive. Culture negative endocarditis cases were 123/191 (64.39%). The most common pathogen isolated from NVE cases, in our study was Streptococcus mitis, followed by methicillin-resistant coagulase negative staphylococcus (MRCONS) in PVE. The NVE were treated intravenously with a combination of a β-lactam or glycopeptide with an aminoglycoside, for prolonged period of 4-6 weeks, with a successful outcome. The PVE cases were treated with the appropriate antibiotics as per the antibiotic susceptibility report.

CONCLUSION

The high morbidity and mortality rates are associated with IE and hence accurate identification of aetiological agents and appropriate antimicrobial therapy is required.

Infective Endocarditis in Low- and Middle-Income Countries

Infective endocarditis (IE) is a rare, life-threatening disease with a mortality rate of 25% and significant debilitating morbidities. Although much has been reported on contemporary IE in high-income countries, conclusions on the state of IE in low- and middle-income countries (LMICs) are based on studies conducted before the year 2000. Furthermore, unique challenges in the diagnosis and management of IE persist in LMICs. This article reviews IE studies conducted in LMICs documenting clinical experiences from the year 2000 to 2016. Presented are the causes of IE, management of patients with IE, and prevailing challenges in diagnosis and treatment of IE in LMICs.

Epidemiology and the prognosis of healthcare-associated infective endocarditis in China: the significance of non-nosocomial acquisition

Limited research has been conducted on healthcare-associated infective endocarditis (HAIE), although it is of increasing importance. The aim of this study is to compare the epidemiology, clinical characteristics, and prognosis of community-acquired IE (CA-IE) with HAIE and non-nosocomial healthcare-associated IE (NNHCA-IE). A retrospective, consecutive case-series analysis was organized and performed during the 20-year study period in Huashan Hospital, Shanghai, China. A total of 154 patients were enrolled, including 126 (81.8%) who had CA-IE and 28 (18.2%) who had HAIE, among whom 20 (71.4%) had non-nosocomial IE. Patients with HAIE compared to patients with CA-IE had poorer clinical conditions (Charlson comorbidity index ≥2: 35.7% vs. 15.1%, P = 0.012; immunosuppressive therapy: 21.4% vs. 4.0%, P = 0.005), underwent more prosthetic valve replacement (35.7% vs. 7.1%, P <0.001), had less streptococcus infection (16.7% vs. 51.1%, P = 0.007) but more atypical bacterial infection (50.0% vs. 21.1%, P = 0.017) and poorer outcomes (17.9% vs. 4.0%, P = 0.019). It is noteworthy that the results were quite similar between the comparison of patients with NNHCA-IE and those with CA-IE. Overall, in-hospital mortality was 6.5%. The IE acquisition site and low serum albumin levels (odds ratio (OR): 0.8; P = 0.04) were significantly associated with an increased risk of mortality. Nosocomial IE patients had an 8.3-fold and NNHCA-IE patients had 6.5-fold increase in the risk of mortality compared to CA-IE patients. In conclusion, HAIE and NNHCA-IE have important epidemiological and prognostic implications. Because NNHCA-IE usually occurs in patients residing in the community, it is suggested that these patients should be identified and treated by the community primary care clinical staff as early as possible.

Infective endocarditis in the Pacific: clinical characteristics, treatment and long-term outcomes

Introduction

Data on clinical characteristics and outcomes of infective endocarditis (IE) in the Pacific are scarce.

Methods

Retrospective hospital-based study in New Caledonia, a high-income country, on patients aged over 18 years with definite IE according to the modified Duke criteria (2005–2010).

Results

51 patients were included: 31 (60.8%) men; median age of 52.4 years (IQR 33.0–70.0). Left-sided IE accounted for 47 (92.2%) patients: native valve IE in 34 (66.7%) and prosthetic valve IE in 13 (25.5%). The main underlying heart disease included: rheumatic valve disease in 19 (37.3%), degenerative heart valve disease in 12 (23.5%) and congenital heart disease in 6 (11.8%). Significant comorbidities (Charlson's score >3) were observed in 20 (38.7%) patients. Infection was community acquired in 43 (84.3%) patients. Leading pathogens included Staphylococcus aureus in 16 (31.4%) and Streptococcus spp in 15 (29.4%) patients. Complications were noted in 33 patients (64.7%) and 24 (47.1%) were admitted to the intensive care unit. Cardiac surgery was eventually performed in 22 of 40 (55.0%) patients with a theoretical indication. None underwent emergent cardiac surgery (ie, first 24 h); 2 (3.9%) were operated within 7 days; and 20 (39.2%) beyond 7 days. 11 (21.6%) patients died in hospital and 21 (42.9%) were dead after a median follow-up of 28.8 months (IQR 4.6–51.2). Two (3.9%) were lost to follow-up.

Conclusions

In New Caledonia, IE afflicts relatively young patients with rheumatic heart disease, and carries high complication and mortality rates. Access to heart surgery remains relatively limited in this remote archipelago.

Candidial Endocarditis: A Single-Institute Pathological Analysis

Infective endocarditis is increasingly perceived as a byproduct of aggressive medications and/or invasive medical procedures. Some of the organisms are fungi, and in this situation, Candida species account for nearly half of all fungal IE. We report a single-institute pathological experience of 14 cases of candidial endocarditis among surgically excised cardiac tissues and autopsied cases in a 14-year period. Twelve of the 14 cases were seen as healthcare-associated invasive infections, and only five had been diagnosed antemortem. Candidial endocarditis was predominantly right-sided and valvular. The risk factors included underlying heart diseases, central venous catheterization and prolonged antibiotic therapy. Mortality among the autopsied patients was related to septicemia and/or embolic complications.

Failure of early diagnosis of infective endocarditis in Japan--a retrospective descriptive analysis

Infective endocarditis (IE) is a severe disease with high morbidity and mortality, and these can be exacerbated by delay in diagnosis. We investigated IE diagnosis in Japan with the emphasis on the delay in diagnosis and its cause and implications. We conducted a retrospective study on 82 definite IE patients at Kobe University Hospital from April 1, 2008, through March 31, 2013. We reviewed charts of the patients for data such as causative pathogens, prescription of inappropriate antibiotic use prior to the diagnosis, existence of risk factors of IE, previous doctor's subspecialty, or duration until the diagnosis, with the primary outcome of 180-day mortality. We also qualitatively, as well as quantitatively, analyzed those cases with delay in diagnosis, and hypothesized its causes and implications. Eighty-two patients were reviewed for this analysis. The average age was 61 ± 14.5-year-old. Fifty percent of patients had known underlying risk factors for IEs, such as prosthetic heart valve (10), valvular heart disease (21), congenital heart disease (3), or cardiomyopathy (2). The median days until the diagnosis was 14 days (range 2 days to 1 year). Sixty-five percent of patients received inappropriate antibiotic before the diagnosis (53). Forty percent of causative organisms were Staphylococcus aureus (MSSA 20, MRSA 13), 32% were viridans streptococci and Streptococcus bovis, 28% were others or unknown (CNS 5, Corynebacterium 3, Cardiobacterium 1, Candida 1). Subspecialties such as General Internal Medicine (15), and Orthopedics (13) were associated with delay in diagnosis. Ten patients (12%) died during follow up, and 8 of them had been received prior inappropriate antibiotics. Significant delay in the diagnosis of IE was observed in Japan. Inappropriate antibiotics were prescribed frequently and may be associated with poor prognosis. Further improvement for earlier diagnosis of IE is needed.

A Study of Clinical, Microbiological, and Echocardiographic Profile of Patients of Infective Endocarditis

Infective endocarditis, a great masquerader, is a clinical entity which may present with a myriad of manifestations. Its changing epidemiological profile has been studied in the previous decades in both the developed and the developing nations. In this study, we strived to uphold the evolving clinical profile and its outcome from a government tertiary care hospital in Northern India. It was a descriptive, cross-sectional, observational study conducted over two years' period involving 44 patients diagnosed with definite infective endocarditis, according to modified Dukes' criteria. Demographic, clinical, microbiological, and echocardiographic data were analysed. Mean age of patients was 31 years. Rheumatic heart disease with regurgitant lesions was the commonest risk factor. Dyspnea and fever were the predominant symptom, and pallor and heart failure the commonest sign. Cultures were positive in 52% with Staphylococcus, the major isolate. Transesophageal echocardiography fared better than transthoracic one to define the vegetations. Mortality is reported in 4.5%. Prolonged duration of fever, pallor, hematuria, proteinuria, rheumatoid factor positivity, and large vegetations proved to be poor prognostic variables. Culture positive endocarditis, with persistent bacteremia, had higher incidence of acute renal failure. Right sided endocarditis was frequent in congenital lesions or IV drug user, whereas left sided endocarditis mostly presented with atrial fibrillation.