Active infective endocarditis observed in an Indian hospital 1981–1991

doi:10.1016/0002-9149(92)90299-E

The American Journal of Cardiology

Volume 70, Issue 18, 1 December 1992, Pages 1453-1458

https://doi.org/10.1016/0002-9149(92)90299-E Get rights and content

Abstract

Clinical data from 186 patients (133 males and 53 females) with 190 episodes of infective endocarditis (IE) occurring between January 1981 and July 1991 were studied retrospectively at a large referral hospital in Northern India with the intention of highlighting certain essential differences from those reported in the West. The mean age was much lower (25 ± SD 12 years, range 2 to 75 years). Rheumatic heart disease was the most frequent underlying heart lesion accounting for 79 patients (42%). This was followed by congenital heart disease in 62 (33%) and normal valve endocarditis in 17 (9%). Twenty-four patients had either aortic regurgitation (n = 15) or mitral regurgitation (n = 9) of uncertain etiology. Prosthetic valve infection and mitral valve prolapse were present in only 2 patients each. A definite predisposing factor could be identified in only 28 patients (15%). Postabortal sepsis and sepsis related to childbirth accounted for 6 and 5 cases, respectively. Only 1 patient had history of intravenous drug abuse. Two-dimensional echocardiography showed vegetations in 121 patients (64%). Blood cultures were positive in only 87 (47%), with a total of 90 microbial isolates. Commonest infecting organisms were staphylococci (37 cases) and streptococci (34 cases). Except for a significantly higher number of patients with neurologic complications in the culture-negative group, there were no differences between patients with culture-positive and culture-negative IE. Of the 190 episodes of IE, the patients had received antibiotics before admission in 110 (58%) instances. A significantly greater number of culture-negative patients had received antibiotics than did culture-positive patients (87 vs 23, p < 0.001). Overall in-hospital mortality was 25%. There was a significantly higher number of neurologic complications in patients who died than in those who recovered (38 vs 14%, p < 0.01). It is concluded that the spectrum of patients with IE that is seen is quite different from that seen in the West. Control of rheumatic fever on a national level, maintaining aseptic techniques during procedures related to childbirth including prophylactic antibiotics, and wider availability of sophisticated surgical techniques would go a long way in improving the outlook in these patients.

References (34)

CZ Naggar et al.
Infective endocarditis — a challenging disease
Med Clin North Am
(1986)
DS McKinsey et al.
Underlying cardiac lesions in adults with infective endocarditis: the challenging spectrum
Am J Med
(1987)
SM Awadallah et al.
The changing pattern of infective endocarditis in childhood
Am J Cardiol
(1991)
A Grover et al.
Profile of right sided endocarditis: an Indian experience
Int J Cardiol
(1991)
FA Dressler et al.
Infective endocarditis in opiate addicts: analysis of 80 cases studied at necropsy
Am J Cardiol
(1989)
JT O'Brien et al.
Infective endocarditis and echocardiography
Am Heart J
(1984)
JY Jung et al.
The case for early surgical treatment of left sided primary infective endocarditis. A collective review
J Thorac Cardiovasc Surg
(1975)
MR Griffin et al.
Infective endocarditis: Olmsted County, Minnesota, 1950 through 1981
JAMA
(1985)
R Bayliss et al.
The microbiology and pathogenesis of infective endocarditis
Br Heart J
(1983)
CF Von Reyn et al.
Infective endocarditis — an analysis based on strict case definitions
Ann Intern Med
(1981)

JD Skehan et al.

Infective endocarditis — incidence and mortality in the North East Thames region

Br Heart J

(1988)

L Gordis

The virtual disappearance of rheumatic fever in the United States: lessons in the rise and fall of disease

Circulation

(1985)

RH Schwartz et al.

Incidence of acute rheumatic fever — a suburban community hospital experience during the 1970's

Clin Pediatr (Phila)

(1983)

MA Land et al.

Acute rheumatic fever — a vanishing disease in suburbia

JAMA

(1983)

Community prevention and control of cardiovascular disease: report of a WHO expert committee

WHO Tech Rep Series no. 732

(1986)

Rheumatic fever and rheumatic heart disease: report of a WHO study group

WHO Tech Rep Series no. 764

(1988)

JA Stewart et al.

Echocardiographic documentation of vegetative lesions in infective endocarditis: clinical implications

Circulation

(1980)

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The polymicrobial group was more likely to have infections from S. aureus, CoNS, Candida, GNB, and enterococci. The relative contributions of GNB and fungi showed no significant variation over time.15–22 P. aeruginosa remained next common to S. aureus in IUD-IE.
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A retrospective analysis of patients with in north India between 2010 and 2020.
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The mean age was 34 years, and 84% were males. The main predisposing conditions were injection drug use (IDU) (n = 71, 35.7%), congenital heart disease (n = 46, 21.6%), rheumatic heart disease (n = 25, 12.5%), and prosthetic device (n = 19, 9.5%). 17.1% of patients developed IE without identified predispositions. Among 64.3% culture-positive cases, the most prevalent causative pathogens were Staphylococcus aureus (46.1%), viridans streptococci (7.0%), enterococci (6.0%), coagulase-negative staphylococci (5.5%), gram negative bacilli (5.5%), polymicrobial (5.5%), and Candida (1.0%). The tricuspid (30.3%), mitral (25.6%), and aortic (21.6%) valves were the most common sites of infection, and 60.3% had large vegetations (>10 mm). Systemic embolization occurred in 55.3% of patients at presentation. Cardiac surgery was required for 13.1%. In-hospital mortality was 17.1% and was associated with prosthetic devices (p-value, 0.001), baseline leucocytosis (p-value, 0.036) or acute kidney injury (p-value, 0.001), and a microbial etiology of gram negative bacilli or enterococci (p-value, 0.005).
IDU is now the most important predisposition for IE in India, and S. aureus has become the leading cause of native valve endocarditis with or without IDU.
Clinical characteristics and outcome of infective endocarditis among intravenous drug abusers in India
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RHD accounted for only 9.0% of cases in total population and 13.9% among non IVDA group. This is in contrast to Indian studies which attribute majority of cases (40–70%) to RHD.12–14 This is likely because of declining incidence of RHD in our country.16–18
Infective endocarditis (IE) is the most dreaded complication of intravenous drug abuse (IVDA). IVDA is present in significant proportions in India. Since there is scarcity of Indian data on IVDA associated IE, we report a study comparing IVDA to non IVDA associated IE. We compare differences in clinical profile, microbiology, echocardiography and clinical outcome from a tertiary care hospital.
A total of 133 patients admitted from 1st January 2017 to 31st December 2019 who met the Modified Duke ‘‘definitive’’ criteria for IE were included. Detailed Information was collected regarding demography, clinical data and laboratory investigations. All patients underwent transthoracic echocardiography and trans-esophageal echocardiogram wherever necessary.
Among a total of 133 patients, 54 patients (40.6%) were iv drug abusers. Patients in IVDA-group were younger, mostly males, more likely to have concomitant HCV and HIV infections compared to non IVDA-group. Chronic comorbidities such as DM and CKD were more common in non IVDA-group. Rate of positive blood culture was higher in IVDA-group compared to non IVDA-group (74.1%v/s 32.9%,p < 0.001) with different microbiological profile. Percentage of Methicillin resistant staphylococcus aureus (42.6%v/s17.7%,p = 0.003) and pseudomonas related IE (18.5%v/s2.5%,p = 0.003) was significantly higher among IVDA-group. IVDA-group most commonly had tricuspid valve involvement Whereas mitral and aortic valve were most commonly involved valve in non IVDA-group. Mortality was slightly higher among IVDA-group compared to non IVDA-group, though statistically non-significant. Left sided valve involvement and Congestive heart failure were independent predictors of mortality.
IVDA-IE is a significant problem in India. Demographic, microbiological and echocardiographic profile is quite different in IVDA and non IVDA-group. There is urgent need to conduct larger studies.
CSI position statement on management of heart failure in India
2018, Indian Heart Journal
Global and regional burden of infective endocarditis, 1990-2010: A systematic review of the literature
2014, Global Heart
Infective endocarditis (IE) is a life-threatening disease associated with serious complications. The GBD 2010 (Global Burden of Disease, Injuries, and Risk Factors) study IE expert group conducted a systematic review of IE epidemiology literature to inform estimates of the burden on IE in 21 world regions in 1990 and 2010. The disease model of IE for the GBD 2010 study included IE death and 2 sequelae: stroke and valve surgery. Several medical and science databases were searched for IE epidemiology studies in GBD high-, low-, and middle-income regions published between 1980 and 2008. The epidemiologic parameters of interest were IE incidence, proportions of IE patients who developed stroke or underwent valve surgery, and case fatality. Literature searches yielded 1,975 unique papers, of which 115 published in 10 languages were included in the systematic review. Eligible studies were population-based (17%), multicenter hospital-based (11%), and single-center hospital-based studies (71%). Population-based studies were reported from only 6 world regions. Data were missing or sparse in many low- and middle-income regions. The crude incidence of IE ranged between 1.5 and 11.6 cases per 100,000 people and was reported from 10 countries. The overall mean proportion of IE patients that developed stroke was 0.158 ± 0.091, and the mean proportion of patients that underwent valve surgery was 0.324 ± 0.188. The mean case fatality risk was 0.211 ± 0.104. A systematic review for the GBD 2010 study provided IE epidemiology estimates for many world regions, but highlighted the lack of information about IE in low- and middle-income regions. More complete knowledge of the global burden of IE will require improved IE surveillance in all world regions.
Infective Endocarditis and Rheumatic Heart Disease in the North of Australia
2012, Heart Lung and Circulation
Citation Excerpt :
RHD was associated with a far greater risk of IE. This association between RHD and increased risk of IE is well documented in the developing world [10,19,20] but is no longer seen in many higher income countries [9]. In the latter context, RHD-associated IE has become less important as the prevalence of RHD has reduced [21] and rates of IDU have risen [22].
To prevent infective endocarditis (IE), Australian guidelines recommend providing prophylactic antibiotics to Indigenous patients with rheumatic heart disease (RHD) prior to procedures which may cause bacteremia. In northern Australia RHD remains prevalent. We aimed to determine whether RHD is associated with an increased risk of IE, which risk factors are associated with IE, and the incidence and aetiology of IE.
A retrospective review of IE patients who fulfilled modified Duke criteria at two tertiary centres in northern Australia.
89 patients were reviewed. The rate of IE was 6.5/100,000 person-years. IE was more common in people with RHD (relative risk (RR) 58), Indigenous Australians (RR 2.0) and men (RR 1.7). RHD-associated IE was not confined to Indigenous Australians with 42% being non-Indigenous. The commonest risk factors for IE were intracardiac prosthetic material, injecting drug use and previous IE. One in five patients died.
In northern Australia the principle risk factor for IE is not RHD. Whilst RHD increased the risk of IE it was not restricted to Indigenous Australians. Current Australian recommendations of providing prophylactic antibiotics to Indigenous patients with RHD prior to procedures which may cause bacteremia may need to be broadened to include non-Indigenous patients.
Prospective study of infective endocarditis from a developing country
2011, American Heart Journal
Citation Excerpt :
In our study, RHD accounted for 29.8% of the cases. Previous studies have quoted figures between 42% and 76%.4,5,8,10,11 Mitral valve prolapse accounted for a minority of cases.
There has been a considerable change in the profile of infective endocarditis (IE) worldwide. However, prospective studies of IE from developing countries are rare.
The aim of this study was to evaluate predisposing factors, clinical presentation, echocardiography, microbiology, in-hospital course, and outcomes of patients with definite IE.
This was a prospective observational study of consecutive cases of definite IE as per the modified Duke criteria.
Between 2004 and 2006, a total of 104 cases of definite IE were identified. The mean age was 23.5 years (interquartile range, 9-38 years), with a male preponderance (2.5:1). Congenital heart disease accounted for 39.4% cases of IE, followed by native valve disease (29.8%), prosthetic valve disease (20%), and normal valves (7.7%). Echocardiography was diagnostic in 96.7% of the patients. Positive cultures were obtained in only 41% of the cases, with staphylococci and streptococci being the most common organisms. Seventy-three percent of the cases had at least 1 major complication. Only 15% of the cases underwent surgery for IE. The in-hospital mortality was 26%. On multivariate analysis, an underlying heart disease other than native valve disease and septic shock were independent predictors of mortality.
The mean age of IE in India is significantly lower than that in the West. Unlike previous reports, congenital heart disease is the major predisposing factor. Culture positivity rates and surgery for IE are unacceptably low. In conclusion, IE in India is associated with a very high morbidity and mortality.

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Active infective endocarditis observed in an Indian hospital 1981–1991

Abstract

Med Clin North Am

Am J Med

Am J Cardiol

Int J Cardiol

Am J Cardiol

Am Heart J

J Thorac Cardiovasc Surg

Infective endocarditis: Olmsted County, Minnesota, 1950 through 1981

JAMA

The microbiology and pathogenesis of infective endocarditis

Br Heart J

Infective endocarditis — an analysis based on strict case definitions

Ann Intern Med

Infective endocarditis — incidence and mortality in the North East Thames region

Br Heart J

The virtual disappearance of rheumatic fever in the United States: lessons in the rise and fall of disease

Circulation

Incidence of acute rheumatic fever — a suburban community hospital experience during the 1970's

Clin Pediatr (Phila)

Acute rheumatic fever — a vanishing disease in suburbia

JAMA

Community prevention and control of cardiovascular disease: report of a WHO expert committee

WHO Tech Rep Series no. 732

Rheumatic fever and rheumatic heart disease: report of a WHO study group

WHO Tech Rep Series no. 764

Echocardiographic documentation of vegetative lesions in infective endocarditis: clinical implications

Circulation