International Journal of Cardiology 178 (2015) 31–33
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Characterization and clinical outcome of patients with possible infective endocarditis☆ Carmen Olmos a,⁎, Isidre Vilacosta a, Cristina Sarriá b, Cristina Fernández a, Javier López c, Carlos Ferrera a, David Vivas a, Miguel Hernández b, Cristina Sánchez-Enrique a, Carlos Ortiz c, Luis Maroto a, José Alberto San Román c a b c
Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain Servicio de Medicina Interna-Infecciosas, Instituto de Investigación Sanitaria del Hospital Universitario de la Princesa, Madrid, Spain Instituto de Ciencias del Corazón (ICICOR), Hospital Universitario de Valladolid, Valladolid, Spain
a r t i c l e
i n f o
Article history: Received 26 October 2014 Accepted 27 October 2014 Available online 28 October 2014 Keywords: Infective endocarditis Possible endocarditis Duke criteria Prognosis
Studies specifically focused on patients with possible infective endocarditis (IE) are scarce [1], and the clinical outcome of this group is not well known. The aim of our study was to describe the actual epidemiology, microbiologic profile, and echocardiographic findings of a large cohort of episodes with possible IE, to compare the clinical characteristics and outcome of patients with possible vs. patients with definite IE, and to assess differences between episodes whose major criterion was microbiologic and those with a positive echocardiogram. This study was performed at three tertiary care centers that have been working together with standardized protocols [2], and identical diagnostic and therapeutic criteria since the beginning of the study. The protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the local ethical committees. From 1996 to 2013, 1122 consecutive episodes of IE were prospectively recruited. To ensure consecutive enrolment, all patients who underwent echocardiography to rule out IE were clinically followed until a diagnosis was established. This study only includes patients with a final diagnosis of IE (definite and possible cases). Duke criteria were applied until 2002, and modified Duke criteria thereafter [3,4]. ☆ Financial support: none. ⁎ Corresponding author at: Instituto Cardiovascular, Hospital Clínico de San Carlos, Prof. Martín Lagos s/n, 28040 Madrid, Spain. E-mail address: [email protected] (C. Olmos).
http://dx.doi.org/10.1016/j.ijcard.2014.10.171 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Continuous variables are reported as mean and standard deviation (SD), and compared by a Student's t-test. Categorical variables are expressed as frequency and percentage, and compared with the χ2 test and Fisher's exact test when appropriate. Two multivariable logistic regression analyses were performed to determine the impact of definite endocarditis (vs. possible) in the prognosis of patients with IE. The adjusted odds ratios for each variable were calculated. All tests were two-sided and differences were considered statistically significant at p-values b 0.05. Statistical analysis was performed with PASW Statistics V 17.0 (SPSS Inc., Chicago, IL, USA). Mean age was 64 [SD 22] years, 64.2% were men, communityacquired infections were 68%, and 42% of the episodes were referred from another hospital. Definite IE criteria (Group I) were met in 1029 (91.7%), and 93 episodes (8.3%) had possible IE (Group II). The distribution of episodes with possible IE was as follows: 47 episodes had one major echocardiographic criterion and one or two minor criteria; 37 episodes had one major microbiological criterion and one or two minor criteria; and 9 episodes had three minor criteria. Patients with definite IE were younger. Intravenous drug use was more frequent among definite episodes, and previous endocarditis in those with possible IE. Mean duration of symptoms before diagnosis was similar in both groups (8.5 [SD 28] vs. 7.2 [SD 13] days; p = 0.643). Fever, heart failure, and stroke were similarly present in both groups. New heart murmurs, abnormal skin findings, and septic shock at admission, were more common in Group I (Table 1). Staphylococci were the most frequently isolated microorganisms in both groups, but Staphylococcus aureus predominated in Group I. Positive blood cultures at admission (69.5% vs. 48.4%; p b 0.001), and high-magnitude bacteremia, defined as ≥ 3 positive blood cultures, (54.7% vs. 40.6%; p = 0.007) were more common in definite episodes. Vegetations, periannular complications, and moderate to severe valve insufficiency were more frequent in definite episodes. During hospitalization, acute renal failure, embolisms, and septic shock were more common in definite IE. The need for surgery and inhospital mortality were also higher in Group I. Indications for cardiac surgery in patients with possible IE were: refractory heart failure (n = 10) 43.4%, prevention of recurrent embolisms (n = 2) 8.7%, signs of persistent infection (n = 5) 21.7%, and severe valvular dysfunction (n = 6) 26.1%.
32
C. Olmos et al. / International Journal of Cardiology 178 (2015) 31–33
Table 1 Clinical, microbiologic and echocardiographic characteristics in 1122 episodes of infective endocarditis.
Age (years) Male gender Referred from another hospital Nosocomial acquisition Antibiotic therapy (previous 15 days) Previous endocarditis Comorbidities Diabetes mellitus Chronic renal failure Malignant neoplasia Chronic obstructive pulmonary disease Intravenous drug users Clinical manifestations at admission Fever Heart failure Renal failure New murmur Abnormal skin findings Stroke Septic shock Microbiologic findings Viridans group streptococci Enterococci Staphylococcus aureus Coagulase-negative staphylococci Negative cultures Echocardiographic findings Right-sided endocarditis Vegetation detection Vegetation size (mm) Prosthetic valve endocarditis Moderate–severe valve insufficiency Periannular complications In-hospital evolution Heart failure Embolisms (total) Central nervous system embolisms Acute renal insufficiency Septic shock Cardiac surgery In-hospital mortality
Definite Group I (n = 1029)
Possible Group II (n = 93)
p
62 (16) 664 (64.5%) 454 (44.1%) 332 (32.3%) 317 (36.1%) 75 (7.3%)
69 (13) 56 (60.2%) 17 (18.3%) 26 (28.0%) 36 (42.4%) 13 (14.0%)
0.004 0.403 b0.001 0.650 0.250 0.022
205 (20.1%) 127 (12.4%) 102 (10.0%) 75 (7.4%) 66 (6.5%)
17 (18.3%) 8 (8.6%) 11 (11.8%) 9 (9.7%) 1 (1.1%)
0.678 0.278 0.570 0.417 0.037
684 (71.4%) 394 (38.8%) 185 (18.2%) 444 (44.2%) 92 (9.1%) 137 (13.4%) 64 (6.3%)
59 (63.4%) 36 (38.7%) 12 (13.0%) 19 (20.9%) 3 (3.2%) 6 (6.5%) 1 (1.1%)
0.107 0.984 0.215 b0.001 0.054 0.138 0.040
18 (11.6%) 88 (8.6%) 201 (19.7%) 186 (18.2%) 123 (12.0%)
8 (8.6%) 6 (6.5%) 9 (9.7%) 13 (14.0%) 38 (40.9%)
0.389 0.472 0.018 0.307 b0.001
128 (12.6%) 849 (86.0%) 13 (8) 332 (32.6%) 654 (66.3%) 244 (24.7%)
11 (12.1%) 44 (51.2%) 10 (7) 30 (32.3) 39 (45.3%) 10 (11.6%)
0.507 b0.001 b0.001 0.999 b0.001 0.006
603 (59.9%) 263 (26.1%) 106 (10.5%) 518 (51.3%) 183 (18.3%) 609 (59.6%) 300 (30.4%)
46 (50.5%) 14 (15.6%) 6 (6.7%) 33 (37.1%) 8 (8.9%) 23 (24.7%) 12 (14.1%)
0.083 0.027 0.249 0.010 0.024 b0.001 b0.001
Table 2 Comparison of possible infective endocarditis with one major echocardiographic criterion with those whose major criterion was microbiologic.
Age (years) Male gender Referred from another hospital Nosocomial acquisition In-hospital evolution Heart failure Embolisms (total) Central nervous system embolisms Acute renal insufficiency Atrioventricular block Septic shock Cardiac surgery In-hospital mortality
Echo positive (n = 47)
Micro positive (n = 37)
p
66 (16) 27 (57.4%) 11 (25.0%) 8 (17.0%)
69 (11) 25 (67.6%) 5 (13.5%) 9 (24.3%)
0.826 0.343 0.176 0.557
27 (57.4%) 11 (23.4%) 6 (12.8%) 23 (48.9%) 6 (12.8%) 7 (14.9%) 12 (25.5%) 10 (22.7%)
13 (35.1%) 1 (2.7%) 0 (0.0%) 6 (16.7%) 3 (8.1%) 2 (5.4%) 8 (21.6%) 5 (14.3%)
0.042 0.007 0.032 0.002 0.725 0.287 0.676 0.342
Values are n (%) or mean (standard deviation). Bold values are significant.
by the relatively smaller size of these two cohorts. In any case, in the study of Wallace, the sum of two major criteria compared with any of the other possible combinations was associated with a higher 6month mortality [9]. Several studies addressing IE prognosis emphasized the role of echocardiographic findings in patients' outcome [2, 10]. A lower frequency of infections due to S. aureus, and a lesser magnitude bacteremia along with less echocardiographic lesions possibly explain the better prognosis of patients with possible IE. Our study highlights important differences in in-hospital events among episodes of possible IE. Patients with echocardiographic findings consistent with IE developed more frequently heart failure, central nervous system embolisms, and renal failure than those whose major criterion was microbiologic. Considering all findings together, it seems likely that in IE structural lesions prevail over microbiologic findings with regard to patients' outcome. In addition, it appears reasonable to wonder whether patients with possible IE and one major microbiologic criterion could benefit from a shorter antibiotic scheme or should be managed as the rest of the episodes. Thus, investigations are needed to more accurately characterize possible IE episodes. Possibly, new imaging techniques such as 18F-FDG PET/CT may also help to this task.
Values are n (%) or mean (standard deviation). Bold values are significant.
When comparing possible episodes according to the type of major criterion (i.e., microbiologic vs. echocardiographic), patients with one major echocardiographic criterion were significantly more likely to present a complication with heart failure, peripheral embolisms, central nervous system embolisms, and acute renal failure (Table 2). Finally, two multivariable analyses to determine variables independently associated with in-hospital mortality and poor prognosis (death and need for surgery) were performed. In both analyses, the presence of definite IE criteria was independently associated with inhospital death and poor prognosis (Table 3). Current clinical observations of IE characteristics are based on data from series of patients including mainly or exclusively definite IE cases [5–7]. Nonetheless, with the exception of the small series of Abassade et al. [1], no investigation has specifically been devoted to patients with possible IE. In our cohort, episodes with definite IE had a more virulent microbiological profile than those with possible IE. Accordingly, vegetations, periannular complications and in-hospital complications were more frequent in definite episodes. Interestingly, two previous studies that evaluated predictors of outcome in patients with IE did not find differences in mortality between patients with possible and those with definite IE [8,9]. Discrepancies between these studies and ours could be partially explained
Table 3 Factors independently associated with poor prognosis (death or the need for surgery) and in-hospital mortality. OR (95% CI) Poor prognosis Definite endocarditis (vs. possible) Age N 70 Acute renal insufficiency Periannular complications Heart failure Septic shock Vegetation size N 15
6.16 (2.51–15.13) 1.99 (1.34–2.96) 2.90 (1.94–4.32) 4.60 (2.66–7.95) 3.36 (2.29–4.92) 2.83 (1.49–5.38) 1.99 (1.37–2.91)
In-hospital mortality Definite endocarditis (vs. possible) Acute renal insufficiency Periannular complications Heart failure Septic shock Neurological complications Surgery
3.60 (1.17–11.08) 3.26 (2.17–4.90) 2.08 (1.32–3.28) 4.05 (2.61–6.29) 8.12 (5.09–12.97) 1.75 (0.98–3.13) 0.42 (0.28–0.64)
Factors included in the multivariable analyses: - Poor prognosis (death or surgery): age, septic shock, S. aureus, vegetation detection, heart failure, acute renal failure, periannular complications, stroke, Duke criteria. - In-hospital mortality: age, septic shock, S. aureus, vegetation detection, heart failure, surgery, acute renal failure, vegetation size N 15 mm, periannular complications, stroke and CNS embolisms, Duke criteria.
C. Olmos et al. / International Journal of Cardiology 178 (2015) 31–33
In summary, patients with possible IE have a better prognosis than those who meet definite Duke criteria. Patients with possible IE who fulfill a major microbiologic criterion have the best prognosis. Disclosures The authors report no relationships that could be construed as a conflict of interest. References [1] P. Abassade, C. Ganter, P.-Y. Baudouy, Comparaison entre endocardite “certaine” et endocardite “possible” selon La classification de la Duke University, dans une série de 45 patients, Ann. Cardiol. Angéiol. (Paris) 58 (2009) 272–278. [2] J.A. San Román, J. López, I. Vilacosta, et al., Prognostic stratification of patients with left-sided endocarditis determined at admission, Am. J. Med. 120 (2007) 369 (e1-7).
33
[3] J.S. Li, D.J. Sexton, N. Mick, et al., Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis, Clin. Infect. Dis. 30 (2000) 633–638. [4] D.T. Durack, A.S. Lukes, D.K. Bright, New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service, Am. J. Med. 96 (1994) 200–209. [5] F. Delahaye, F. Alla, I. Béguinot, et al., In-hospital mortality of infective endocarditis: prognostic factors and evolution over an 8-year period, Scand. J. Infect. Dis. 39 (2007) 849–857. [6] D.R. Murdoch, G.R. Corey, B. Hoen, 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. 169 (2009) 463–473. [7] B. Hoen, F. Alla, C. Selton-Suty, et al., Changing profile of infective endocarditis. Results of a 1-year survey in France, JAMA 288 (2002) 75–81. [8] V.H. Chu, Cabell ChH, D.K. Benjamin, et al., Early predictors of in-hospital deaths in infective endocarditis, Circulation 109 (2004) 1745–1749. [9] S.M. Wallace, B.I. Walton, R.K. Kharbanda, R. Hardy, A.P. Wilson, R.H. Swanton, Mortality from infective endocarditis: clinical predictors of outcome, Heart 88 (2002) 53–60. [10] F. Thuny, G. Di Salvo, O. Belliard, et al., Risk of embolism and death in infective endocarditis: prognostic value of echocardiography. A prospective multicenter study, Circulation 112 (2005) 69–75.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Characterization and clinical outcome of patients with possible infective endocarditis☆ Carmen Olmos a,⁎, Isidre Vilacosta a, Cristina Sarriá b, Cristina Fernández a, Javier López c, Carlos Ferrera a, David Vivas a, Miguel Hernández b, Cristina Sánchez-Enrique a, Carlos Ortiz c, Luis Maroto a, José Alberto San Román c a b c
Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain Servicio de Medicina Interna-Infecciosas, Instituto de Investigación Sanitaria del Hospital Universitario de la Princesa, Madrid, Spain Instituto de Ciencias del Corazón (ICICOR), Hospital Universitario de Valladolid, Valladolid, Spain
a r t i c l e
i n f o
Article history: Received 26 October 2014 Accepted 27 October 2014 Available online 28 October 2014 Keywords: Infective endocarditis Possible endocarditis Duke criteria Prognosis
Studies specifically focused on patients with possible infective endocarditis (IE) are scarce [1], and the clinical outcome of this group is not well known. The aim of our study was to describe the actual epidemiology, microbiologic profile, and echocardiographic findings of a large cohort of episodes with possible IE, to compare the clinical characteristics and outcome of patients with possible vs. patients with definite IE, and to assess differences between episodes whose major criterion was microbiologic and those with a positive echocardiogram. This study was performed at three tertiary care centers that have been working together with standardized protocols [2], and identical diagnostic and therapeutic criteria since the beginning of the study. The protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the local ethical committees. From 1996 to 2013, 1122 consecutive episodes of IE were prospectively recruited. To ensure consecutive enrolment, all patients who underwent echocardiography to rule out IE were clinically followed until a diagnosis was established. This study only includes patients with a final diagnosis of IE (definite and possible cases). Duke criteria were applied until 2002, and modified Duke criteria thereafter [3,4]. ☆ Financial support: none. ⁎ Corresponding author at: Instituto Cardiovascular, Hospital Clínico de San Carlos, Prof. Martín Lagos s/n, 28040 Madrid, Spain. E-mail address: [email protected] (C. Olmos).
http://dx.doi.org/10.1016/j.ijcard.2014.10.171 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Continuous variables are reported as mean and standard deviation (SD), and compared by a Student's t-test. Categorical variables are expressed as frequency and percentage, and compared with the χ2 test and Fisher's exact test when appropriate. Two multivariable logistic regression analyses were performed to determine the impact of definite endocarditis (vs. possible) in the prognosis of patients with IE. The adjusted odds ratios for each variable were calculated. All tests were two-sided and differences were considered statistically significant at p-values b 0.05. Statistical analysis was performed with PASW Statistics V 17.0 (SPSS Inc., Chicago, IL, USA). Mean age was 64 [SD 22] years, 64.2% were men, communityacquired infections were 68%, and 42% of the episodes were referred from another hospital. Definite IE criteria (Group I) were met in 1029 (91.7%), and 93 episodes (8.3%) had possible IE (Group II). The distribution of episodes with possible IE was as follows: 47 episodes had one major echocardiographic criterion and one or two minor criteria; 37 episodes had one major microbiological criterion and one or two minor criteria; and 9 episodes had three minor criteria. Patients with definite IE were younger. Intravenous drug use was more frequent among definite episodes, and previous endocarditis in those with possible IE. Mean duration of symptoms before diagnosis was similar in both groups (8.5 [SD 28] vs. 7.2 [SD 13] days; p = 0.643). Fever, heart failure, and stroke were similarly present in both groups. New heart murmurs, abnormal skin findings, and septic shock at admission, were more common in Group I (Table 1). Staphylococci were the most frequently isolated microorganisms in both groups, but Staphylococcus aureus predominated in Group I. Positive blood cultures at admission (69.5% vs. 48.4%; p b 0.001), and high-magnitude bacteremia, defined as ≥ 3 positive blood cultures, (54.7% vs. 40.6%; p = 0.007) were more common in definite episodes. Vegetations, periannular complications, and moderate to severe valve insufficiency were more frequent in definite episodes. During hospitalization, acute renal failure, embolisms, and septic shock were more common in definite IE. The need for surgery and inhospital mortality were also higher in Group I. Indications for cardiac surgery in patients with possible IE were: refractory heart failure (n = 10) 43.4%, prevention of recurrent embolisms (n = 2) 8.7%, signs of persistent infection (n = 5) 21.7%, and severe valvular dysfunction (n = 6) 26.1%.
32
C. Olmos et al. / International Journal of Cardiology 178 (2015) 31–33
Table 1 Clinical, microbiologic and echocardiographic characteristics in 1122 episodes of infective endocarditis.
Age (years) Male gender Referred from another hospital Nosocomial acquisition Antibiotic therapy (previous 15 days) Previous endocarditis Comorbidities Diabetes mellitus Chronic renal failure Malignant neoplasia Chronic obstructive pulmonary disease Intravenous drug users Clinical manifestations at admission Fever Heart failure Renal failure New murmur Abnormal skin findings Stroke Septic shock Microbiologic findings Viridans group streptococci Enterococci Staphylococcus aureus Coagulase-negative staphylococci Negative cultures Echocardiographic findings Right-sided endocarditis Vegetation detection Vegetation size (mm) Prosthetic valve endocarditis Moderate–severe valve insufficiency Periannular complications In-hospital evolution Heart failure Embolisms (total) Central nervous system embolisms Acute renal insufficiency Septic shock Cardiac surgery In-hospital mortality
Definite Group I (n = 1029)
Possible Group II (n = 93)
p
62 (16) 664 (64.5%) 454 (44.1%) 332 (32.3%) 317 (36.1%) 75 (7.3%)
69 (13) 56 (60.2%) 17 (18.3%) 26 (28.0%) 36 (42.4%) 13 (14.0%)
0.004 0.403 b0.001 0.650 0.250 0.022
205 (20.1%) 127 (12.4%) 102 (10.0%) 75 (7.4%) 66 (6.5%)
17 (18.3%) 8 (8.6%) 11 (11.8%) 9 (9.7%) 1 (1.1%)
0.678 0.278 0.570 0.417 0.037
684 (71.4%) 394 (38.8%) 185 (18.2%) 444 (44.2%) 92 (9.1%) 137 (13.4%) 64 (6.3%)
59 (63.4%) 36 (38.7%) 12 (13.0%) 19 (20.9%) 3 (3.2%) 6 (6.5%) 1 (1.1%)
0.107 0.984 0.215 b0.001 0.054 0.138 0.040
18 (11.6%) 88 (8.6%) 201 (19.7%) 186 (18.2%) 123 (12.0%)
8 (8.6%) 6 (6.5%) 9 (9.7%) 13 (14.0%) 38 (40.9%)
0.389 0.472 0.018 0.307 b0.001
128 (12.6%) 849 (86.0%) 13 (8) 332 (32.6%) 654 (66.3%) 244 (24.7%)
11 (12.1%) 44 (51.2%) 10 (7) 30 (32.3) 39 (45.3%) 10 (11.6%)
0.507 b0.001 b0.001 0.999 b0.001 0.006
603 (59.9%) 263 (26.1%) 106 (10.5%) 518 (51.3%) 183 (18.3%) 609 (59.6%) 300 (30.4%)
46 (50.5%) 14 (15.6%) 6 (6.7%) 33 (37.1%) 8 (8.9%) 23 (24.7%) 12 (14.1%)
0.083 0.027 0.249 0.010 0.024 b0.001 b0.001
Table 2 Comparison of possible infective endocarditis with one major echocardiographic criterion with those whose major criterion was microbiologic.
Age (years) Male gender Referred from another hospital Nosocomial acquisition In-hospital evolution Heart failure Embolisms (total) Central nervous system embolisms Acute renal insufficiency Atrioventricular block Septic shock Cardiac surgery In-hospital mortality
Echo positive (n = 47)
Micro positive (n = 37)
p
66 (16) 27 (57.4%) 11 (25.0%) 8 (17.0%)
69 (11) 25 (67.6%) 5 (13.5%) 9 (24.3%)
0.826 0.343 0.176 0.557
27 (57.4%) 11 (23.4%) 6 (12.8%) 23 (48.9%) 6 (12.8%) 7 (14.9%) 12 (25.5%) 10 (22.7%)
13 (35.1%) 1 (2.7%) 0 (0.0%) 6 (16.7%) 3 (8.1%) 2 (5.4%) 8 (21.6%) 5 (14.3%)
0.042 0.007 0.032 0.002 0.725 0.287 0.676 0.342
Values are n (%) or mean (standard deviation). Bold values are significant.
by the relatively smaller size of these two cohorts. In any case, in the study of Wallace, the sum of two major criteria compared with any of the other possible combinations was associated with a higher 6month mortality [9]. Several studies addressing IE prognosis emphasized the role of echocardiographic findings in patients' outcome [2, 10]. A lower frequency of infections due to S. aureus, and a lesser magnitude bacteremia along with less echocardiographic lesions possibly explain the better prognosis of patients with possible IE. Our study highlights important differences in in-hospital events among episodes of possible IE. Patients with echocardiographic findings consistent with IE developed more frequently heart failure, central nervous system embolisms, and renal failure than those whose major criterion was microbiologic. Considering all findings together, it seems likely that in IE structural lesions prevail over microbiologic findings with regard to patients' outcome. In addition, it appears reasonable to wonder whether patients with possible IE and one major microbiologic criterion could benefit from a shorter antibiotic scheme or should be managed as the rest of the episodes. Thus, investigations are needed to more accurately characterize possible IE episodes. Possibly, new imaging techniques such as 18F-FDG PET/CT may also help to this task.
Values are n (%) or mean (standard deviation). Bold values are significant.
When comparing possible episodes according to the type of major criterion (i.e., microbiologic vs. echocardiographic), patients with one major echocardiographic criterion were significantly more likely to present a complication with heart failure, peripheral embolisms, central nervous system embolisms, and acute renal failure (Table 2). Finally, two multivariable analyses to determine variables independently associated with in-hospital mortality and poor prognosis (death and need for surgery) were performed. In both analyses, the presence of definite IE criteria was independently associated with inhospital death and poor prognosis (Table 3). Current clinical observations of IE characteristics are based on data from series of patients including mainly or exclusively definite IE cases [5–7]. Nonetheless, with the exception of the small series of Abassade et al. [1], no investigation has specifically been devoted to patients with possible IE. In our cohort, episodes with definite IE had a more virulent microbiological profile than those with possible IE. Accordingly, vegetations, periannular complications and in-hospital complications were more frequent in definite episodes. Interestingly, two previous studies that evaluated predictors of outcome in patients with IE did not find differences in mortality between patients with possible and those with definite IE [8,9]. Discrepancies between these studies and ours could be partially explained
Table 3 Factors independently associated with poor prognosis (death or the need for surgery) and in-hospital mortality. OR (95% CI) Poor prognosis Definite endocarditis (vs. possible) Age N 70 Acute renal insufficiency Periannular complications Heart failure Septic shock Vegetation size N 15
6.16 (2.51–15.13) 1.99 (1.34–2.96) 2.90 (1.94–4.32) 4.60 (2.66–7.95) 3.36 (2.29–4.92) 2.83 (1.49–5.38) 1.99 (1.37–2.91)
In-hospital mortality Definite endocarditis (vs. possible) Acute renal insufficiency Periannular complications Heart failure Septic shock Neurological complications Surgery
3.60 (1.17–11.08) 3.26 (2.17–4.90) 2.08 (1.32–3.28) 4.05 (2.61–6.29) 8.12 (5.09–12.97) 1.75 (0.98–3.13) 0.42 (0.28–0.64)
Factors included in the multivariable analyses: - Poor prognosis (death or surgery): age, septic shock, S. aureus, vegetation detection, heart failure, acute renal failure, periannular complications, stroke, Duke criteria. - In-hospital mortality: age, septic shock, S. aureus, vegetation detection, heart failure, surgery, acute renal failure, vegetation size N 15 mm, periannular complications, stroke and CNS embolisms, Duke criteria.
C. Olmos et al. / International Journal of Cardiology 178 (2015) 31–33
In summary, patients with possible IE have a better prognosis than those who meet definite Duke criteria. Patients with possible IE who fulfill a major microbiologic criterion have the best prognosis. Disclosures The authors report no relationships that could be construed as a conflict of interest. References [1] P. Abassade, C. Ganter, P.-Y. Baudouy, Comparaison entre endocardite “certaine” et endocardite “possible” selon La classification de la Duke University, dans une série de 45 patients, Ann. Cardiol. Angéiol. (Paris) 58 (2009) 272–278. [2] J.A. San Román, J. López, I. Vilacosta, et al., Prognostic stratification of patients with left-sided endocarditis determined at admission, Am. J. Med. 120 (2007) 369 (e1-7).
33
[3] J.S. Li, D.J. Sexton, N. Mick, et al., Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis, Clin. Infect. Dis. 30 (2000) 633–638. [4] D.T. Durack, A.S. Lukes, D.K. Bright, New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service, Am. J. Med. 96 (1994) 200–209. [5] F. Delahaye, F. Alla, I. Béguinot, et al., In-hospital mortality of infective endocarditis: prognostic factors and evolution over an 8-year period, Scand. J. Infect. Dis. 39 (2007) 849–857. [6] D.R. Murdoch, G.R. Corey, B. Hoen, 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. 169 (2009) 463–473. [7] B. Hoen, F. Alla, C. Selton-Suty, et al., Changing profile of infective endocarditis. Results of a 1-year survey in France, JAMA 288 (2002) 75–81. [8] V.H. Chu, Cabell ChH, D.K. Benjamin, et al., Early predictors of in-hospital deaths in infective endocarditis, Circulation 109 (2004) 1745–1749. [9] S.M. Wallace, B.I. Walton, R.K. Kharbanda, R. Hardy, A.P. Wilson, R.H. Swanton, Mortality from infective endocarditis: clinical predictors of outcome, Heart 88 (2002) 53–60. [10] F. Thuny, G. Di Salvo, O. Belliard, et al., Risk of embolism and death in infective endocarditis: prognostic value of echocardiography. A prospective multicenter study, Circulation 112 (2005) 69–75.
