Outcomes and Risk Factors of Septic Shock in Patients With Infective Endocarditis: A Prospective Cohort Study

Abstract

Background Little is known about the characteristics and impact of septic shock (SS) on the outcomes of infective endocarditis (IE). We aimed to investigate the characteristics and outcomes of patients with IE presenting with SS and to compare them to those of IE patients with sepsis (Se) and those with neither Se nor SS (no-Se-SS). Methods Prospective cohort study of 4,864 IE patients from 35 Spanish centers (2008 to 2018). Logistic regression analyses were performed to identify risk factors for SS and mortality. Results SS and Se presented respectively in 597 (12.3%) and 559 (11.5%) patients. Patients with SS were younger and presented significantly higher rates of diabetes, chronic renal and liver disease, transplantation, nosocomial acquisition, S.aureus, IE complications, and in-hospital mortality (62.5%, 37.7% for Se and 18.2% for no-Se-SS,p<.001). S.aureus (OR 1.94, 95%CI 1.34-2.81,p<.001), Gram negative (OR 2.21,95%CI 1.25-3.91,p.006), nosocomial acquisition (OR 1.44,95%CI 1.07-1.94,p.015), persistent bacteremia (OR 1.82, 95%CI 1.24-2.68,p.002), acute renal failure (OR 3.02,95% 2.28-4.01,p<.001), CNS emboli (OR 1.48,1.08-2.01,p.013), and larger vegetation size (OR 1.01,95%CI 1.00-1.02,p.020) were associated with a higher risk of developing SS. Charlson score, heart failure, persistent bacteremia, acute renal failure, mechanical ventilation, worsening of liver disease, S.aureus and receiving aminoglycosides within the first 24h were associated with higher in-hospital mortality, whereas male sex, native valve IE and cardiac surgery were associated with lower mortality. Conclusions SS is frequent and entails dismal prognosis. Early identification of patients at risk of developing SS and early assessment for cardiac surgery appear as key factors to improve outcomes.

Infective Endocarditis: New Challenges in a Classic Disease

“…2,3,7,10,[108][109][110] Of note, sepsis and septic shock are associated with a fourfold increase in the probability of death. [111][112][113] Studies on psychological outcomes in endocarditis survivors have demonstrated-in addition to the possibility of sequelae in the form of heart failure due to valve dysfunction, neurological alterations due to embolic phenomena, or residual osteoarticular lesions after spondylitis or septic arthritis-reductions in the quality of life and the occurrence of posttraumatic stress disorder. 114…”

Endocarditis in the intensive care unit: an update

“…In a US population based-study, complications associated with increased mortality rates were reported in nearly 40% of patients [3 ▪ ]. Likewise, in a large European study, the outcome of IE patients with septic shock was poor, with a 1-year mortality rate approximating two-thirds [4 ▪ ]. Despite these data, few well conducted studies or reviews are dedicated to critically ill IE patients.…”

“…These seminal studies are consistent with clinical findings, as S. aureus is the most common pathogen in patients with IE, followed by Streptococcus and Enterococcus species [2 ▪ ]. Furthermore, in a cohort of ICU patients with IE-related septic shock, S. aureus was the main agent responsible for the infection [4 ▪ ]. A significant increase in Enterococcus -associated IE has been reported consistently over the past decade, likely related to the increased frequency of transcatheter procedures in the elderly, as the femoral microbiota of the elderly has been documented as displaying a higher incidence of enterococcal colonization [1,2 ▪ ,14].…”

“…In a single center retrospective study in non-ICU patients, elevated serum procalcitonin concentrations both at admission and at 48–72 h were associated with in-hospital mortality [16]. Conversely, cardiac surgery is often reported as a protective factor regarding mortality [4 ▪ ,18,19].…”

“…In patients with IE, acute respiratory failure [4 ▪ ], acute kidney injury [3 ▪ ,4 ▪ ,15,16], sepsis [3 ▪ ,17,18], acute heart failure [3 ▪ ,4 ▪ ,18], acute neurological failure [3 ▪ ,16,19], multiorgan failure (as illustrated by high sequential organ failure assessment [SOFA] scores) [19–21], preexisting comorbidities [4 ▪ ,15] and disseminated intravascular coagulopathy are all common causes of ICU admission. All of these are also associated with high rates of mortality [3 ▪ ].…”