ABSTRACT
The infecting pathogen and its susceptibility to antibiotics is used to suggest prognosis in endocarditis. A case study was performed in a tertiary referral cardiology centre to assess the contribution of the measurement of minimum inhibitory concentration (MIC) to the decision to treat endocarditis surgically. The records were examined of 125 patients admitted between 1981 and 1999 in whom the minimum inhibitory concentration for the pathogen had been measured. The measures of outcome were mortality at time of hospital discharge and at 6 months, surgical referral and cure by medical treatment. Endocarditis caused by Staphylococcus aureus with a raised MIC of flucloxacillin (methicillin) was associated with higher mortality even if glycopeptides were used in treatment (< or = 35 mg/l 0/7 versus MIC 1-2 mg/l 4/13, P = 0.01). Elevated MICs of flucloxacillin in S. aureus infection or of gentamicin in streptococcal disease were associated with surgical intervention. There were no significant differences between bacterial pathogens in mortality, surgical referral or cure by medical treatment. The measurement of MIC appears prognostically important in deciding the surgical management of endocarditis.
Subject(s)
Anti-Bacterial Agents/pharmacology , Endocarditis, Bacterial/surgery , Gram-Positive Cocci/drug effects , Endocarditis, Bacterial/microbiology , Endocarditis, Bacterial/mortality , Female , Gentamicins/pharmacology , Humans , Male , Microbial Sensitivity Tests , Middle Aged , Penicillins/pharmacology , Predictive Value of Tests , Staphylococcal Infections/microbiology , Staphylococcal Infections/mortality , Staphylococcal Infections/surgery , Staphylococcus aureus/drug effects , Streptococcal Infections/microbiology , Streptococcal Infections/mortality , Streptococcal Infections/surgery , Streptococcus/drug effectsABSTRACT
OBJECTIVE: To identify clinical markers available within the first 48 hours of admission that are associated with poor outcome in infective endocarditis. DESIGNS: Retrospective cohort study. SETTING: Teaching hospital. PATIENTS: 208 of 220 patients with infective endocarditis. METHODS: Consecutive patients with infective endocarditis presenting between 1981 and 1999 to a tertiary centre were studied. Clinical, echocardiographic, and haematological data recorded within 48 hours of admission were obtained. Data were analysed using logistic regression models. MAIN OUTCOMES MEASURES: Mortality at discharge and at six months. RESULTS: Data were obtained for 93% of patients who were eligible for inclusion. 194 (93%) were positive for Duke criteria. Mean age was 52 (1.2) years, and 138 (66%) were men. 82 (39%) were transferred from other hospitals. 181 (87%) were blood culture positive, and 47 (23%) infections were Staphylococcus aureus. The infection was located on aortic (n = 85, 41%), mitral (n = 77, 37%), tricuspid (n = 18, 9%), and multiple valves (n = 20, 10%). 67 (32%) had prosthetic valve endocarditis. 48% of the cohort were managed with antibiotics alone. Mortality at discharge was 18% and at six months 27%. Duration of illness before admission, age, sex, valve infected, infecting organism, and left ventricular function were not predictors of adverse mortality. However, abnormal white cell count, serum albumin concentration, serum creatinine concentration, or cardiac rhythm, the presence of two major Duke criteria, or visible vegetation conferred a poor prognosis. CONCLUSIONS: Conventional prognostic factors in this study did not appear to predict outcome early during hospital admission. However, simple clinical indices, which are readily available, are reliable, cheap, and potentially powerful predictors of poor outcome.
