The changing landscape of infective endocarditis in South Africa

Background. Little is known about the current clinical profile and outcomes of patients with infective endocarditis (IE) in South Africa (SA). Objectives. To provide a contemporary and descriptive overview of IE in a representative SA tertiary centre. Methods. We conducted a retrospective review of the records of patients admitted to Groote Schuur Hospital, Cape Town, between 2009 and 2016 fulfilling universal criteria for definite or possible IE, in search of demographic, clinical, microbiological, echocardiographic, treatment and outcome information. Results. A total of 105 patients fulfilled the modified Duke criteria for IE. The median age of the cohort was 39 years (interquartile range (IQR) 29 - 51), with a male preponderance (61.9%). The majority of the patients (72.4%) had left-sided native valve endocarditis, 14.3% had right-sided disease, and 13.3% had prosthetic valve endocarditis. A third of the cohort had rheumatic heart disease. Although 41.1% of patients with left-sided disease had negative blood cultures, the three most common organisms cultured in this subgroup were Staphylococcus aureus (18.9%), Streptococcus spp. (16.7%) and Enterococcus spp. (6.7%). Participants with right-sided endocarditis were younger (29 years, IQR 27 - 37) and were mainly intravenous drug users (73.3%), and the majority cultured positive for S. aureus (73.3%) with frequent septic pulmonary complications (40.0%). The overall in-hospital mortality was 16.2%, with no deaths in the group with right-sided endocarditis. Predictors of death in our patients were heart failure (odds ratio (OR) 8.16, 95% confidence interval (CI) 1.77 - 37.70; p=0.007) and age >45 years (OR 4.73, 95% CI 1.11 - 20.14; p=0.036). Valve surgery was associated with a reduction in mortality (OR 0.09, 95% CI 0.02 - 0.43; p=0.001). Conclusions. IE remains an important clinical problem in a typical teaching tertiary care centre in SA. In this setting, it continues to affect mainly young people with post-inflammatory valve disease and congenital heart disease. The in-hospital mortality associated with IE remains high. Intravenous drug-associated endocarditis caused by S. aureus is an important IE subset, comprising ~10% of all cases, which was not reported 15 years ago, and culture-negative endocarditis remains highly prevalent. Heart failure in IE carries a significant risk of death and needs a more intensive level of care in hospital. Finally, cardiac surgery was associated with reduced mortality, with the largest impact in patients with heart failure

Management Challenges of Pediatric Infective Endocarditis at Tertiary Level in Rwanda

Background: Management of Infective Endocarditis (IE) has been of great challenge for many years. Rapid diagnosis; effective treatment; and prompt recognition of complications are essential to good patient outcome as this condition is associated with a high morbidity and mortality in both adults and pediatric patients. In limited resources settings; management of IE is still a challenge due to early inappropriate antibiotherapy and therefore difficulties in its diagnosis and treatment. Objectives: To elicit challenges in management of patients suspected of IE at tertiary level in Rwanda. Methods: We report four patients with IE. For these patients; Duke's criteria were considered in making the diagnosis. Results and Conclusion: IE has protean clinical symptoms and signs; and can be of challenging diagnosis. The patients reported constituted a clinical challenge in the diagnosis and management of IE but most of them had had favorable outcome. The main clinical challenge was the prolonged stay to peripheral settings with inappropriate antibiotherapy which made most of the blood cultures falsely negative. Echocardiography and serial blood cultures provide the key to diagnosis as per Dukes criteria. Being alert to this mentioned challenge is crucial. As the key investigations are not steadily available in most peripheral health facilities; we strongly recommend early referral to tertiary level for all cases of suspected IE before initiation of antibiotherapy

Endocardite infectieuse en milieu cardiographique Dakarois : etude descriptive a propos de 39 cas

L'endocardite infectieuse est une complication frequente des cardiopathies rhumatismales. L'objectif de ce travail etait de faire une etude descriptive de l'endocardite infectieuse; en milieu hospitalier Dakarois.Il s'agit d'une etude retrospective; descriptive; realisee a la clinique cardiologique de l'hopital Aristide Le Dantec; durant la periode allant de Janvier 2004 a Decembre 2008. Etaient inclus tous les patients hospitalises et traites pour endocardite infectieuse certaine ou probable; selon les criteres de Durack. Nous avons etudie les parametres epidemiologiques; cliniques; biologiques et echocardiographiques.Le nombre total d'admissions dans le service durant la periode d'etude etait de 3746 patients; dont 870 pour valvulopathies rhumatismales. Nous avions enregistre 39 cas d'endocardite infectieuse soit une prevalence de 1;04et 4;48valvulopathies rhumatismales. L'age moyen de nos patients etait de 24 plus ou moins 11;5 ans avec des extremes de 6 et 52 ans. Plus de la moitie des patients soit 58;9(23 patients) avaient moins de 25 ans. On notait une legere predominance feminine avec un sex-ratio homes/femmes de 0;95. La porte d'entree etait essentiellement bucco-dentaire 40. L'anemie etait constante avec un taux d'hemoglobine moyen a 8;4g/dl. Les hemocultures etaient positives chez 6 patients et le Staphylococcus Aureus etait le germe le plus retrouve. L'electrocardiogramme avait montre des troubles du rythme et de la conduction respectivement dans 69;2 et 10;2des cas. L'echographie cardiaque mettait en evidence des vegetations chez tous les patients; une rupture de cordage dans 6 cas et un abces chez trois patients.L'endocardite infectieuse constitue encore une realite dans nos regions. Elle survient habituellement sur cardiopathie rhumatismale. Son diagnostic repose sur les hemocultures et l'echocardiographie

Surgery for Infective Endocarditis

The last decade has seen many changes in the landscape of infective endocarditis (IE) - ranging from the epidemiology; microbiology; diagnostic techniques and indication for antibiotic prophylaxis. Unfortunately; the role of surgery in the patient with endocarditis; including the indication; timing and type of surgery continues to be plagued by controversy. Although surgery has an important and established role in critically ill patients with endocarditis; the choice between medical therapy and surgery is often less clear cut and poses a major challenge to the physician treating this condition. The following article summarises some of these controversies including indications for surgery in native and prosthetic valve endocarditis; the timing of surgery; the choice of prostheses and issues surrounding anti-coagulation

Edocardite infectieuse aigue sur catheter chez des hemodialyses: a propos de trois cas au CHUYO de Ougadougou

The authors report three cases of catheter-related acute infective endocarditis (IE) in hemodialysis patients observed at our hospital over a 10-months period. There were two men and women respectively 43; 33 and 40 years old. They suffered from hypertension for many years and end-stage renal failure since a month before hemodialysis. The diagnosis of IE was suspected clinically (non controlled infection and heart failure). Every patient had central venous in two or three locations. Femoral and jugular venous septic thrombophlebitis were related to staphylococcus aureus. The catheters were with drawn; their cultures showed staphylococcus aureus. Hemocultures were sterile. Vegetations and mutilations were found by echocardiography on aortic valve. These three cases are related to acute IE; all patients have died. Catheter-related acute IE prognosis is bad and some investigations (hemocultures; echocardiography) are needed regularly in patients with risk in order to give drugs and to remove catheter

Prophylaxie de l'endocardite infectieuse en chirurgie dentaire

Chez les sujets porteurs de cardiopathies; une antibioprophylaxie bien adaptee et appliquee lors des situations ou gestes invasifs dentaires devrait diminuer le taux des greffes osleriennes qui sont grevees d'une morbi- mortalite importante. La sphere bucco-dentaire reste le site le plus pourvoyeur de bacteriemies. La prescription de l'antibioprophylaxie depend de la cardiopathie sous-jacente et du type de geste bucco-dentaire a realiser. Son efficacite a ete clairement prouvee par de nombreux auteurs qui ont demontre une reduction extremement variable mais significative du risque d'endocardite infectieuse. Le succes de cette prevention est etroitement lie a la diffusion et a l'application des recommandations sur l'antibioprophylaxie et a une meilleure collaboration Medecins- Chirurgiens dentistes

Aspects echocardiographiques des endocardites infectieuses a Abidjan : a propos de 50 cas

L'endocardite infectieuse (EI) represente a l'Institut de Cardiologie d'Abidjan 1;6 pour cent des hospitalisations. Les auteurs etudient 50 dossiers dans lesquels l'hemoculture n'a ete positive que dans 30 pour cent des cas alors que l'echocardiographie l'a ete dans 92 pour cent. Les auteurs ont observe surtout des vegetations volumineuses (82 pour cent). Des lesions mutilantes existaient dans 26 pour cent. La fonction contractile ventriculaire gauche etait le plus souvent normale. Dans 20 pour cent des cas; il existait soit un epanchement; soit un decollement pericardiques. Les lesions predominaient sur les valves du coeur gauche (79 pour cent) mais 11 lesions interessaient le coeur droit isolement (21 pour cent) le plus souvent sur cardiopathie congenitale. Dans 47 pour cent des cas; les lesions sont survenues sur coeur sain; dans 30 pour cent des cas sur valvulopathies rhumatismales; dans 17 pour cent des cas sur cardiopathie congenitale et dans 6 pour cent des cas sur prothese. Chez les 21 patients non operes; on a constate la disparition des vegetations chez 4 patients. Les auteurs soulignent l'interet de l'echocardiographie notamment dans le contexte de l'Afrique Noire

Un diagnostic inhabituel d'une fievre prolongee chez un cardiaque: le kala-azar

Les poussees de fievre rhumatismale et l'endocardite infectieuse sont parmi les principales causes d'une fievre au long cours chez un cardiaque. Parfois; la non confirmation des diagnostics habituels par le bilan complementaire fait evoquer d'autres etiologies. Le contexte epidemiologique de certaines affections febriles; est; dans ce cas; essentiel dans l'orientation de discussion diagnostique. Les auteurs rapportent un cas d'association forfuite d'une valvulopathie rhumastimale et de leishmaniose viscerale chez un adulte jeune et en discutent les aspects epidemiologique; diagnostique et therapeutique