|Year : 2017 | Volume
| Issue : 1 | Page : 12-16
Pattern and predictors of outcomes for infective endocarditis in North Kuala Lumpur
Khairul Shafiq Ibrahim1, Johan Rizwal Ismail1, Yusrizal Yusof1, Yazli Yuhana1, Mohd Shahril Ahmad Saman1, N Rizmy Khir1, Chiao Wen Lim1, O Zubin Ibrahim1, Effarezan Abdul Rahman1, Nicholas Chua1, Hafisyatul Aiza Zainal Abidin1, Mohd Kamal Mohd Arshad1, Sazzli Kasim2
1 Department of Cardiology, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
2 Department of Cardiology, Faculty of Medicine, Universiti Teknologi MARA, Selangor; Institute of Pathology, Laboratory and Forensic Medicine I-PPerForM, Universiti Teknologi MARA, Malaysia
|Date of Web Publication||8-Mar-2017|
Dr. Sazzli Kasim
Faculty of Medicine, UiTM, Kampus Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor
Source of Support: None, Conflict of Interest: None
Context: Infective endocarditis (IE) still carries significant mortality and morbidity ever since 1835. Despite improvement in medical technologies, mortality outcome remains unchanged. We sought to analyze the pattern of presentation, treatment, and outcomes predictors for patient presenting to our hospital. This study will explore some of the factors that could be associated with the outcome of a patient diagnosed with IE for a better guidance in management.
Subjects and Methods: This is a retrospective dual center cohort study from North Kuala Lumpur from January 2012 to December 2013. Fifty patients with definite IE based on modified Duke's criteria were recruited into the study. Clinical presentation, risk factors, biochemical markers, echocardiography, and outcome were obtained through chart review, clinic data, and telephone call. Simple logistic regression was utilized for inferential statistic.
Results: A total of 50 patients, 37 (74%) males and 13 (26%) females were included in the study. The mean age was 42 ± 16.4. Most patients (80.39%) were diagnosed within the 1st week of admission. Staphylococcus aureus was the most common pathogen (38%) and the mitral valve was predominantly affected (68%). Complication was common and in-hospital mortality remains high (28%). Nearly 20% of the patients who had surgical intervention survived and discharged alive. Presence of complications predicts poor outcome (odds ratio [OR]: 5.5 P = 0.02), whereas surgical intervention predicts good outcome (OR: 1.56 P = 0.027).
Conclusions: Mortality remains relatively high in patient with IE. Those who presented with complications are at 5.5-fold risk of mortality. Surgical intervention showed an association with good outcome within this cohort.
Keywords: Endocarditis, infective endocarditis, valvular heart disease
|How to cite this article:|
Ibrahim KS, Ismail JR, Yusof Y, Yuhana Y, Ahmad Saman MS, Khir N R, Lim CW, Ibrahim O Z, Rahman EA, Chua N, Zainal Abidin HA, Mohd Arshad MK, Kasim S. Pattern and predictors of outcomes for infective endocarditis in North Kuala Lumpur. Heart India 2017;5:12-6
|How to cite this URL:|
Ibrahim KS, Ismail JR, Yusof Y, Yuhana Y, Ahmad Saman MS, Khir N R, Lim CW, Ibrahim O Z, Rahman EA, Chua N, Zainal Abidin HA, Mohd Arshad MK, Kasim S. Pattern and predictors of outcomes for infective endocarditis in North Kuala Lumpur. Heart India [serial online] 2017 [cited 2018 Apr 26];5:12-6. Available from: http://www.heartindia.net/text.asp?2017/5/1/12/201744
| Introduction|| |
Infective endocarditis (IE) continues to be a major challenge in modern medicine. Despite major advances in both diagnostic and therapeutic procedures, mortality rates have not changed in the past 25 years.,,,,, The current in-hospital mortality for patient with IE is 15%–23%, with a 1-year mortality approaching 40%.,,,,
In developed countries, IE mainly affects aging population with comorbidities. It presents acutely with high rates of Staphylococcus aureus infection and complications such as cardiogenic shock and embolization.,, Global registries tend to under report IE patterns from developing nations and identify patterns pertinent to Western medicine. One study from a low-middle income region highlighted a high incidence of IE in patients with rheumatic heart disease. Published data from upper middle-income countries are lacking. We hereby sought to describe patterns of IE and predictors of outcome from this region.
The main objective was to describe the characteristic of patients admitted with IE from North Kuala Lumpur, an urbanized region of Malaysia.
| Subjects and Methods|| |
All patients admitted to Sungai Buloh Hospital and Selayang Hospital between January 2012 and December 2013 with definite IE according to modified Duke's criteria were included in the study. These two general hospitals have a catchment area of 1.5 million and serve the north of Kuala Lumpur. Patients were identified from the electronic medical record system using keyword search of endocarditis, IE, and subacute bacterial endocarditis. This study received ethical approval from the Institutional Ethics Committee.
The electronic database for patients with clinical diagnosis of IE was retrospectively reviewed. For each patient, the following information was collected: demographics, comorbidities such as diabetes, end-stage renal failure on dialysis, intravenous drug use (IVDU), and HIV infection, clinical presentation, laboratory findings, treatment modality, complications, and outcomes. The definition for IE complications such as severe valve dysfunction, heart failure, septic shock, and embolization are based on contemporary guideline. The type of echocardiography (transthoracic, transesophageal, or both), valve involved, and presence of vegetation were recorded. The valve involved was determined by the presence of vegetation, abscess, and fistula on echocardiogram. Outcomes measures were in-hospital mortality and discharge alive. Good outcome is defined as patient discharged alive and poor outcome is defined as in-hospital mortality.
For descriptive analysis, measurement of mean and standard deviation (SD) was calculated for the numerical data. Frequency and proportion were employed for categorical data. As for inferential statistics, simple logistic regression was utilized in calculating crude odd ratio and the 95% confidence intervals for the predictors with significance value was set at 0.05 (P < 0.05). SPSS for Windows, version 19.0 (IBM Corp., Armonk, NY, USA) was utilized for the analysis. The operational definition of the dependent variable was outcome after completion of medical therapy which were alive (fully resolved or referred for surgical intervention) and death.
| Results|| |
A total of 196,364 hospital admission electronic medical records were screened during the study period. Fifty-four medical records fulfilled the search criteria. Four patients did not fulfill the Duke's criteria for definite IE and were excluded from the study.
In the study group (n = 50), the mean age was 41.5 ± 16.4 SD. The majority were males (74%) and diagnosed with IE within the 1st week of admission to hospital.
The most common predisposing factors were IVDU which occurred in 13 patients, diabetes mellitus in 9, and valvular heart disease in 6 patients. Three patients had colonoscopy done before symptoms of IE. Seventeen out of fifty patients did not have known predisposing factors [Table 1].
Forty-nine out of fifty patients (98%) presented with fever. New murmurs and raised inflammatory markers were clues leading to a diagnosis of IE. None of our patients had immunological manifestation of IE such as Osler's node and Janeway lesions [Table 2].
All patients had at least one set of blood culture taken during hospitalization. Staphylococcus is the predominant microorganism followed by Streptococcus. Microbiological breakdown is given in [Figure 1].
|Figure 1: Causative microorganisms in infective endocarditis. CONS = Coagulase-negative Staphylococcus|
Click here to view
Echocardiography was performed in all patients, and vegetation was identified in all. Nearly 16% of participants had concurrent transthoracic and transesophageal echocardiogram. The mitral valve is most commonly affected (n = 24, 48%). Most cases had single valve lesions (80%), with multiple valve involvement affecting ten patients [Table 3].
Complications of endocarditis in our study include severe valvular regurgitation (32%), shock (18%), systemic embolization other than stroke (12%), and stroke (10%) [Table 4]. Of the fifty patients, 10 (20%) were referred for surgical management. All of the surgically treated endocarditis patients were alive on discharge. In patients who were treated with antibiotics only, 25 (50%) were discharged alive. One patient took self-discharge and was lost to follow-up.
Mortality occurred in 28% of our cohort. Eleven patients died due to complication of IE and three patients died due to hospital-acquired pneumonia. Those cases were not referred for surgical intervention as they were deemed non-suitable. Embolization was the most common complication that was associated with 3.5-fold increase in mortality. Similarly, patient developing shock had a 4-fold increase in mortality.
Presence of complication predicted poor outcome (OR: 5.5. P =0.02). Septic or cardiogenic shock has been shown as strongest predictor for poor outcome, followed by embolization (non-stroke) and stroke [Table 4]. For predictor of good outcome, surgical intervention showed a significant association (OR: 1.56, P = 0.027). Other parameters such as gender, age, clinical presentations, type of organisms, and site of vegetation have no association as predictor of outcome.
| Discussion|| |
We describe the first series of patients with endocarditis from the North Kuala Lumpur region. Most of our patients were young with a third having no risk factors. Overall mortality is high at 29%.
Our findings revealed that most patients within this cohort presented without classical signs of IE. This is consistent with the findings from the International Collaboration on Endocarditis-prospective study (ICE-PCS) in 2009 which showed similar changes in the characteristics of IE. Our study differs from published literature from the period between 1960 and 1980 which documented immunological manifestation in almost 50% of patients with endocarditis.,,,
IVDU is a significant risk factor to contract IE (26%). Similar findings were observed from the East Coast of Malaysia and Hong Kong., This is in contrast to data from ICE-PCS where the majority of IE from developing countries had degenerative valvular heart disease. Another study from India highlighted the younger age of affected patients along with the presence of rheumatic heart disease as risk of contracting IE. Among the IVDU group, S. aureus was most common, and right-sided valves were mainly affected consistent with previous published study. Urbanization may be a factor, contributing to a higher rise of alcohol and drug abuse.
Culture-negative IE made up 32% of our cohort. This is unusually high in comparison to contemporary data which showed a rate of culture-negative IE between 14% and 19%., This trend was last seen in the 1980s. The use of antibiotics before hospital admission might contribute to this occurrence.
Systemic embolization is the most common complication, occurring in up to 50% of patients with endocarditis.,,,, It is associated with high mortality.,, In our study, nine patients had embolization with mortality occurring in 5 (56%).
The indications for surgical intervention in our study include embolic phenomenon, severe acute mitral regurgitation, large vegetation of more than 1 cm, fungal IE, and endocarditis in the presence of congenital heart defect. The survival rate seen in postsurgical patients is consistent with prior studies, emphasizing the need for early intervention when indicated, especially when medical intervention has failed.,,
| Conclusions|| |
In contrast to developed nations, an upper middle-income country such as Malaysia is seeing a high burden of endocarditis arising from IVDU patients. This pattern is different from a low middle-income country where rheumatic heart disease predominates.
Our study highlights the need for further research into disease patterns among different health care and population environment to gain maximum yield from resource allocation.
We acknowledge the potential population bias our study would carry as we sourced patients from tertiary hospitals without cardiac services. We may be missing out on the less complicated IE patterns that are seen in the smaller district and rural regions. We acknowledge the need to have a prospective study to validate our findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cabell CH, Jollis JG, Peterson GE, Corey GR, Anderson DJ, Sexton DJ, et al.
Changing patient characteristics and the effect on mortality in endocarditis. Arch Intern Med 2002;162:90-4.
Pelletier LL Jr., Petersdorf RG. Infective endocarditis: A review of 125 cases from the University of Washington Hospitals, 1963-1972. Medicine (Baltimore) 1977;56:287-313.
Hoen B, Alla F, Selton-Suty C, Béguinot I, Bouvet A, Briançon S, et al
. Changing profile of infective endocarditis: Results of a 1-year survey in France. JAMA 2002;288:75-81.
Delahaye F, Goulet V, Lacassin F, Ecochard R, Selton-Suty C, Hoen B, et al.
Characteristics of infective endocarditis in France in 1991: A 1-year survey. Eur Heart J 1995;16:394-401.
Nissen H, Nielsen PF, Frederiksen M, Helleberg C, Nielsen JS. Native valve infective endocarditis in the general population: A 10-year survey of the clinical picture during the 1980s. Eur Heart J 1992;13:872-7.
Fournier PE, Thuny F, Richet H, Lepidi H, Casalta JP, Arzouni JP, et al.
Comprehensive diagnostic strategy for blood culture-negative endocarditis: A prospective study of 819 new cases. Clin Infect Dis 2010;51:131-40.
Benn M, Hagelskjaer LH, Tvede M. Infective endocarditis, 1984 through 1993: A clinical and microbiological survey. J Intern Med 1997;242:15-22.
Chee QZ, Tan YQ, Ngiam JN, Win MT, Shen X, Choo JN, et al.
The SHARPEN clinical risk score predicts mortality in patients with infective endocarditis: An 11-year study. Int J Cardiol 2015;191:273-6.
Murdoch DR, Corey GR, Hoen B, Miró JM, Fowler VG Jr., Bayer AS, 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 2009;169:463-73.
Selton-Suty C, Célard M, Le Moing V, Doco-Lecompte T, Chirouze C, Iung B, et al.
Preeminence of Staphylococcus aureus
in infective endocarditis: A 1-year population-based survey. Clin Infect Dis 2012;54:1230-9.
Bor DH, Woolhandler S, Nardin R, Brusch J, Himmelstein DU. Infective endocarditis in the U.S 1998-2009: A nationwide study. PLoS One 2013;8:e60033.
Mirabel M, Rattanavong S, Frichitthavong K, Chu V, Kesone P, Thongsith P, et al.
Infective endocarditis in the Lao PDR: Clinical characteristics and outcomes in a developing country. Int J Cardiol 2015;180:270-3.
Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al.
Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): The Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009;30:2369-413.
Rabinovich S, Evans J, Smith IM, January LE. A long-term view of bacterial endocarditis 337 cases 1924 to 1963. Ann Intern Med 1965;63:185-98.
Lerner PI, Weinstein L. Infective endocarditis in the antibiotic era. N Engl J Med 1966;274:199-206.
Venezio FR, Westenfelder GO, Cook FV, Emmerman J, Phair JP. Infective endocarditis in a community hospital. Arch Intern Med 1982;142:789-92.
Wilson LE, Thomas DL, Astemborski J, Freedman TL, Vlahov D. Prospective study of infective endocarditis among injection drug users. J Infect Dis 2002;185:1761-6.
Yousuf RM, How SH, Fauzi AR, Shah A. Infective endocarditis in the East coast of peninsular Malaysia: A two year retrospective survey from Kuantan. JK Pract 2006;13:5-8.
Yiu KH, Siu CW, Lee KL, Fong YT, Chan HW, Lee SW, et al.
Emerging trends of community acquired infective endocarditis. Int J Cardiol 2007;121:119-22.
Jain SR, Prajapati JS, Phasalkar MA, Roy BH, Jayram AA, Shah SR, et al.
Clinical spectrum of infective endocarditis in a tertiary care centre in Western India: A prospective study. Int J Clin Med 2014;2014:177-87.
Sundquist K, Frank G. Urbanization and hospital admission rates for alcohol and drug abuse: A follow-up study of 4.5 million women and men in Sweden. Addiction 2004;99:1298-305.
Hoen B, Selton-Suty C, Lacassin F, Etienne J, Briançon S, Leport C, et al.
Infective endocarditis in patients with negative blood cultures: Analysis of 88 cases from a one-year nationwide survey in France. Clin Infect Dis 1995;20:501-6.
Zamorano J, Sanz J, Almería C, Rodrigo JL, Samedi M, Herrera D, et al.
Differences between endocarditis with true negative blood cultures and those with previous antibiotic treatment. J Heart Valve Dis 2003;12:256-60.
Van Scoy RE. Culture-negative endocarditis. Mayo Clin Proc 1982;57:149-54.
Roy P, Tajik AJ, Giuliani ER, Schattenberg TT, Gau GT, Frye RL. Spectrum of echocardiographic findings in bacterial endocarditis. Circulation 1976;53:474-82.
Lutas EM, Roberts RB, Devereux RB, Prieto LM. Relation between the presence of echocardiographic vegetations and the complication rate in infective endocarditis. Am Heart J 1986;112:107-13.
De Castro S, Magni G, Beni S, Cartoni D, Fiorelli M, Venditti M, et al.
Role of transthoracic and transesophageal echocardiography in predicting embolic events in patients with active infective endocarditis involving native cardiac valves. Am J Cardiol 1997;80:1030-4.
Bayer AS, Bolger AF, Taubert KA, Wilson W, Steckelberg J, Karchmer AW, et al.
Diagnosis and management of infective endocarditis and its complications. Circulation 1998;98:2936-48.
Chu VH, Cabell CH, Benjamin DK Jr., Kuniholm EF, Fowler VG Jr., Engemann J, et al.
Early predictors of in-hospital death in infective endocarditis. Circulation 2004;109:1745-9.
Cabell CH, Pond KK, Peterson GE, Durack DT, Corey GR, Anderson DJ, et al.
The risk of stroke and death in patients with aortic and mitral valve endocarditis. Am Heart J 2001;142:75-80.
Jault F, Gandjbakhch I, Rama A, Nectoux M, Bors V, Vaissier E, et al.
Active native valve endocarditis: Determinants of operative death and late mortality. Ann Thorac Surg 1997;63:1737-41.
Castillo JC, Anguita MP, Ramírez A, Siles JR, Torres F, Mesa D, et al.
Long term outcome of infective endocarditis in patients who were not drug addicts: A 10 year study. Heart 2000;83:525-30.
Remadi JP, Habib G, Nadji G, Brahim A, Thuny F, Casalta JP, et al.
Predictors of death and impact of surgery in Staphylococcus aureus
infective endocarditis. Ann Thorac Surg 2007;83:1295-302.
[Table 1], [Table 2], [Table 3], [Table 4]