Clinical profile and outcome of recurrent infective endocarditis

Abstract

AimsPurpose of this study is to compare the clinical course and outcome of patients with recurrent versus first-episode infective endocarditis (IE).MethodsPatients with recurrent and first-episode IE enrolled in the EUROpean ENDOcarditis (EURO-ENDO) registry including 156 centres were identified and compared using propensity score matching. Recurrent IE was classified as relapse when IE occurred ≤6 months after a previous episode or reinfection when IE occurred >6 months after the prior episode.Results3106 patients were enrolled: 2839 (91.4%) patients with first-episode IE (mean age 59.4 (±18.1); 68.3% male) and 267 (8.6%) patients with recurrent IE (mean age 58.1 (±17.7); 74.9% male). Among patients with recurrent IE, 13.2% were intravenous drug users (IVDUs), 66.4% had a repaired or replaced valve with the tricuspid valve being more frequently involved compared with patients with first-episode IE (20.3% vs 14.1%; p=0.012). In patients with a first episode of IE, the aortic valve was more frequently involved (45.6% vs 39.5%; p=0.061). Recurrent relapse and reinfection were 20.6% and 79.4%, respectively.Staphylococcus aureuswas the microorganism most frequently observed in both groups (p=0.207). There were no differences in in-hospital and post-hospitalisation mortality between recurrent and first-episode IE. In patients with recurrent IE, in-hospital mortality was higher in IVDU patients. Independent predictors of poorer in-hospital and 1-year outcome, including the occurrence of cardiogenic and septic shock, valvular disease severity and failure to undertake surgery when indicated, were similar for recurrent and first-episode IE.ConclusionsIn-hospital and 1-year mortality was similar in patients with recurrent and first-episode IE who shared similar predictors of poor outcome.

Infective Endocarditis in an Intravenous Drug User Leading to Myocardial Rupture and Hemopericardium

“…A validated risk score can be calculated to predict the mortality risk at 6 months, considering host factors, disease factors, and complications ( 10 ). The risk of complications is higher in individuals with comorbidities and lifestyle factors ( 3 , 8 , 11 ), such as the history of intravenous drug use described in the decedent above. While valvular vegetations are often described in association with IE ( 1 , 3 - 5 , 8 , 11 ), other parts of the heart can be affected such as the coronary arteries, myocardium, chordae tendineae, and pericardium ( 4 ).…”

“…It is unclear if the decedent had been experiencing complications from her prior presentation of IE, as she had signed out against medical advice likely before completing treatment. Untreated or incompletely treated, the risk of complications from IE is even greater ( 8 , 10 ).…”

“…Clinically, the ability to effectively treat IE is largely dependent on the identification of the causative organism(s) on blood culture ( 3 , 6 - 8 , 15 ). Empiric broad-spectrum antibiotics are given initially, but the course is modified based on the result of blood culture, which may take several hours.…”

“…Specifically, in individuals with a history of intravenous drug use, there is an association with negative social determinants of health, access to health care and adherence to treatment. There is a higher rate of antimicrobial-resistant organisms in cases of IE in this demographic such as methicillin-resistant Staphylococcus aureus , as well as higher rates of IE recurrence and associated morbidity ( 8 ). There is also a higher incidence of complications during treatment for IE such as pulmonary emboli, increased size of valvular vegetations, and sepsis ( 3 , 8 ).…”

“…There is a higher rate of antimicrobial-resistant organisms in cases of IE in this demographic such as methicillin-resistant Staphylococcus aureus , as well as higher rates of IE recurrence and associated morbidity ( 8 ). There is also a higher incidence of complications during treatment for IE such as pulmonary emboli, increased size of valvular vegetations, and sepsis ( 3 , 8 ). Outpatient therapeutic options are limited, as there is a risk of inappropriate use of central lines and peripherally inserted central catheters (PICC), and oral antibiotics alone are contraindicated in complicated or prolonged cases of IE ( 9 ).…”