Summary
Background
Staphylococcus aureus prosthetic valve endocarditis (SAPIE) is a serious disease.
Aims
Our objective was to study the clinical, echocardiographic and prognostic characteristics of left-sided SAPIE, and to compare these characteristics with those of left-sided non- S . aureus prosthetic infective endocarditis (NSAPIE) (i.e. left-sided prosthetic infective endocarditis caused by another germ).
Methods
This was a retrospective analysis of 35 cases of SAPIE among 247 cases of left-sided prosthetic valve endocarditis hospitalized at two university hospitals (Amiens and Marseille, France).
Results
SAPIE accounted for 14.1% of the cases of left-sided prosthetic valve endocarditis. SAPIE complications included heart failure (in 42.8% of cases), acute renal failure (in 51.4%), sepsis (in 51.4%), neurological events (in 31.4%), systemic embolic event (in 34.2%) and abscess (in 60.0%). In-hospital mortality occurred in 48.5% of SAPIE cases compared with 16% of NSAPIE cases. A comparison of the SAPIE and NSAPIE groups showed a significant difference in terms of 4-year survival (31.8 ± 7.3% vs 60.1 ± 4.1%; P = 0.001). Severe sepsis was the only prognostic factor associated with in-hospital mortality (odds ratio 5.7; P = 0.03) and long-term mortality (odds ratio 3.7; P = 0.01) in cases of SAPIE. Sepsis-induced multiple organ dysfunction syndrome was the main cause of in-hospital mortality (70.5%).
Conclusions
SAPIE is a very serious disease, with elevated in-hospital mortality resulting from sepsis-induced multiple organ dysfunction syndrome. Emergency surgery is recommended in these cases, when possible, before the occurrence of complications, especially severe sepsis.
Résumé
Introduction
L’endocardite infectieuse sur prothèse à Staphylococcus aureus (EIPSA) reste une maladie grave.
Objectifs
L’objectif est d’étudier les caractéristiques cliniques, échographiques et pronostiques des EIPSA du cœur gauche et de comparer ces caractéristiques aux autres endocardites sur prothèse.
Méthodes
Il s’agit d’une étude rétrospective analysant les données de 35 EIPSA hospitalisées aux CHU d’Amiens et de Marseille.
Résultats
EIPSA représente 14,1 % des endocardites sur prothèse. EIPSA se complique dans 42,8 % des cas d’insuffisance cardiaque, 51,4 % d’insuffisance rénale aiguë, 51,4 % de sepsis, 31,4 % d’évènement neurologique, 34,2 % d’embolie systémique et 60,0 % d’abcès périannulaires. La mortalité hospitalière est de 48,5 %, plus élevée que celle des EI sur prothèse non liées au S . aureus . La comparaison de survie globale actuarielle à 4 ans montre une différence significative entre le groupe de SAPIE et le groupe des autres endocardites sur prothèse (31,8 ± 7,3 % vs 60,1 ± 4,1 % ; p = 0,001). Le sepsis sévère est le seul facteur pronostique associé à la mortalité hospitalière (OR à 5,7 ; p = 0,03) et à la mortalité à long cours (OR 3,7 ; p = 0,01). La défaillance multiviscérale induite par le sepsis est la principale cause de mortalité hospitalière (70,5 %).
Conclusions
EIPSA est une maladie grave avec une mortalité hospitalière très élevée due dans la majorité des cas à une défaillance multiviscérale induite par le sepsis. Les recommandations européennes conseillent pour ce type d’EI, la réalisation d’une chirurgie urgente sans attendre, si possible, l’apparition des complications.
Background
Infective endocarditis (IE) is a severe disease, with diagnostic difficulties, changing epidemiology in recent decades and high mortality rates. The incidence of IE ranges from 3 to 10 episodes per 100,000 people per year . The epidemiology of IE has changed significantly in recent years, with the advent of new predisposing factors , such as the presence of prosthetic valves or intracardiac materials, haemodialysis, nosocomial infections, immunodeficiency, increased use of injectable treatment and, especially, the aging population with increasing degenerative diseases. These changes have been associated with an increase in infection rates by Staphylococcus aureus . In the past, S . aureus infective endocarditis was infrequent, accounting for 6.9% of IE in 1931 ; these rates have increased steadily from 16% in 1941–1961 to 19–38% currently . Despite the progress in antimicrobial therapy, mortality remains high, especially in cases of prosthetic infection .
The management of prosthetic IE is complicated, especially in cases of left-sided S . aureus prosthetic infective endocarditis (SAPIE). Current guidelines on SAPIE are based on only a few studies , and the indication for surgical treatment is level of proof C. New guidelines from the USA recommend surgery during initial hospitalization for left-sided SAPIE (class IB).
The aims of our work were to determine the clinical and echocardiographic characteristics and prognostic factors of left-sided SAPIE, and to compare these characteristics with those of left-sided non- S . aureus prosthetic infective endocarditis (NSAPIE) (i.e. left-sided prosthetic infective endocarditis caused by another germ).
Methods
Between January 1990 and December 2010, 1254 consecutive patients from two French centres (Amiens and Marseille) with definite IE according to the Duke criteria were referred to our echocardiographic laboratory. All patients were examined by transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE). A total of 247 patients (19.6%) had acute left-sided prosthetic valve IE (mitral and aortic valves), including 35 (14.1%) with blood or valve cultures that were positive for S . aureus ; all 247 patients were included in this study ( Fig. 1 ). In our series, Streptococcus viridans was found in 17.8% of cases ( n = 35), S . aureus in 14.1% ( n = 35), coagulase-negative staphylococci in 10.2% ( n = 25), Streptococcus bovis in 10.1% ( n = 25), Enterococcus foecalis in 17% ( n = 42) and other germs in 4% ( n = 10). The microorganism was not identified in 26.8% of cases ( n = 66). Clinical, biological and echocardiographic data were collected prospectively, whereas follow-up data were obtained retrospectively.
Clinical variables
Age, sex, presence of co-morbidity (history of diabetes, cancer, haematological malignancy, cirrhosis, renal failure, dialysis, heart failure or coronary artery disease) and presence of an intravascular device (venous catheter, pacemaker or dialysis device) were analysed. The Charlson co-morbidity index, taking into account the patient’s age and history, was calculated .
The following acute clinical events present on admission or occurring during hospitalization were recorded: heart failure, neurological event, embolism and severe sepsis. The portal of entry of the infection was investigated. Embolic events were diagnosed based on clinical signs and data derived from a non-invasive procedure (brain, chest and abdomen computed tomography); 74% of patients ( n = 183) had a computed tomography scan. A neurological event was defined as the development of ischaemic stroke with hemiplegia, haemorrhagic stroke, transient ischaemic attack, brain abscess and features of encephalopathy or coma. Severe sepsis was defined as a systemic inflammatory syndrome secondary to an infectious process, leading to organ dysfunction, signs of hypoperfusion or hypotension .
Echocardiography
All patients were systematically assessed by TTE completed by TOE. All echocardiographic studies were performed according to standard techniques and by experienced physicians during the acute phase of IE. Standard definitions were used for vegetations, abscesses and other cardiac infective lesions . All TOE recordings were reviewed by an experienced physician to measure the maximum length of vegetations in various planes. Valvular regurgitation was quantified by Doppler echocardiography using standard methods .
Follow-up
Follow-up data included surgical treatment and death during hospitalization or follow-up. In-hospital mortality was defined as death during the initial hospitalization for IE. Long-term mortality included death during hospitalization and during follow-up. Data on deaths during follow-up were obtained retrospectively. Follow-up was complete in 100% of cases, with a mean follow-up of 25.5 ± 37.7 months.
Statistical analysis
Statistical analyses were performed with SPSS 21.0 software (IBM, Armonk, NY, USA). Quantitative variables are expressed as means ± standard deviations. Comparisons between groups were carried out using Student’s t -test or the χ 2 test. The cumulative probability of survival was estimated using the Kaplan–Meier actuarial method at 1-month intervals, and reported as mean estimated survival ± standard error. The log-rank test was used to determine any significant differences. Multivariable analyses were performed, incorporating, as potential predictors of mortality, variables correlated with mortality on univariate analysis with P -values ≤ 0.10. A multivariable logistic regression model was used for in-hospital mortality and a Cox multivariable model was used for long-term mortality.
Results
Baseline characteristics
Of the 247 patients with left prosthetic IE (155 men/92 women, mean age 65.1 ± 14.2), 15.8% had diabetes and 11.7% had neoplasia, with a mean co-morbidity index of 2.92 ± 2.1 ( Table 1 ). IE involved the aortic prosthesis in 57.4% of cases, the mitral prosthesis in 29.1% of cases and both the mitral and aortic valves in 13.3% of cases. The portal of entry was identified in 46.5% of cases with a homogeneous distribution (12.5% of cutaneous origin, 12.1% of nasopharyngeal origin and 18.6% of digestive origin). The main complications were heart failure (32.7%), acute renal failure (19.0%), severe sepsis (19.4%), neurological events (21.4%), systemic embolism (25.1%) and abscess (41.2%).
| All patients ( n = 247) | SAPIE ( n = 35) | NSAPIE ( n = 212) | P a | |
|---|---|---|---|---|
| Mean age (years) | 65.1 ± 14.2 | 63.9 ± 14.7 | 65.2 ± 14.1 | 0.6 |
| Sex ratio | 155/92 | 25/10 | 130/82 | 0.34 |
| Charlson co-morbidity index | 2.92 ± 2.1 | 2.83 ± 2 | 2.93 ± 2.1 | 0.78 |
| Diabetes | 39 (15.8) | 2 (5.7) | 37 (17.4) | 0.08 |
| Neoplasm | 29 (11.7) | 4 (11.4) | 25 (11.7) | 1 |
| Heart failure | 81 (32.7) | 15 (42.8) | 66 (31.1) | 0.18 |
| Renal failure | 47 (19.0) | 18 (51.4) | 29 (13.6) | 0.0001 |
| Sepsis | 54 (19.4) | 18 (51.4) | 36 (16.9) | 0.0001 |
| Neurological event | 53 (21.4) | 11 (31.4) | 42 (19.8) | 0.12 |
| Systemic embolism | 62 (25.1) | 12 (34.2) | 50 (23.5) | 0.8 |
| Portal of entry | 115 (46.5) | 13 (37.1) | 102 (48.1) | 0.48 |
| Skin | 31 (12.5) | 11 (31.4) | 20 (9.4) | 0.001 |
| Rhinopharynx | 30 (12.1) | 2 (5.7) | 28 (13.2) | 0.27 |
| Digestive | 46 (18.6) | 0 (0) | 46 (21.6) | 0.001 |
| Urological | 8 (3.2) | 0 (0) | 8 (3.7) | 0.6 |
| Type of left valvular endocarditis | 0.57 | |||
| Aortic endocarditis | 142 (57.4) | 22 (62.8) | 120 (56.6) | |
| Mitral endocarditis | 72 (29.1) | 8 (22.8) | 64 (30.1) | |
| Mitral-aortic endocarditis | 33 (13.3) | 5 (14.2) | 28 (13.2) | |
| Length of vegetation (mm) | 8.62 ± 7.8 | 9.5 ± 8.2 | 8.47 ± 6.5 | 0.28 |
| Vegetation > 10 mm | 94 (38.0) | 15 (42.8) | 79 (37.2) | 0.57 |
| Perforation | 16 (6.4) | 3 (8.5) | 13 (6.1) | 0.48 |
| Abscess | 102 (41.2) | 21 (60.0) | 81 (38.2) | 0.025 |
| Early surgery | 136 (55.0) | 15 (42.8) | 121 (56.6) | 0.45 |
| Emergency (< day 1) | 19 (7.6) | 2 (8.5) | 17 (8.0) | |
| Urgent (day 1–day 7) | 41 (16.5) | 4 (11.4) | 37 (17.4) | |
| Elective (> day 7) | 76 (30.7) | 9 (25.7) | 67 (31.6) | |
| In-hospital mortality | 51 (20.6) | 17 (48.5) | 34 (16.0) | 0.0001 |
| Operative mortality | 32 (23.7) | 7 (46.6) | 25 (20.8) | 0.048 |
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