Health care-associated native valve endocarditis: importance of non-nosocomial acquisition.

BACKGROUND: The clinical profile and outcome of nosocomial and non-nosocomial health care-associated native valve endocarditis are not well defined. OBJECTIVE: To compare the characteristics and outcomes of community-associated and nosocomial and non-nosocomial health care-associated native valve endocarditis. DESIGN: Prospective cohort study. SETTING: 61 hospitals in 28 countries. PATIENTS: Patients with definite native valve endocarditis and no history of injection drug use who were enrolled in the ICE-PCS (International Collaboration on Endocarditis Prospective Cohort Study) from June 2000 to August 2005. MEASUREMENTS: Clinical and echocardiographic findings, microbiology, complications, and mortality. RESULTS: Health care-associated native valve endocarditis was present in 557 (34%) of 1622 patients (303 with nosocomial infection [54%] and 254 with non-nosocomial infection [46%]). Staphylococcus aureus was the most common cause of health care-associated infection (nosocomial, 47%; non-nosocomial, 42%; P = 0.30); a high proportion of patients had methicillin-resistant S. aureus (nosocomial, 57%; non-nosocomial, 41%; P = 0.014). Fewer patients with health care-associated native valve endocarditis had cardiac surgery (41% vs. 51% of community-associated cases; P < 0.001), but more of the former patients died (25% vs. 13%; P < 0.001). Multivariable analysis confirmed greater mortality associated with health care-associated native valve endocarditis (incidence risk ratio, 1.28 [95% CI, 1.02 to 1.59]). LIMITATIONS: Patients were treated at hospitals with cardiac surgery programs. The results may not be generalizable to patients receiving care in other types of facilities or to those with prosthetic valves or past injection drug use. CONCLUSION: More than one third of cases of native valve endocarditis in non-injection drug users involve contact with health care, and non-nosocomial infection is common, especially in the United States. Clinicians should recognize that outpatients with extensive out-of-hospital health care contacts who develop endocarditis have clinical characteristics and outcomes similar to those of patients with nosocomial infection. PRIMARY FUNDING SOURCE: None.

Predictores de mortalidad intrahospitalaria de la endocarditis infecciosa en la República Argentina: resultados del EIRA-II / Predictors of in-hospital mortality due to infective endocarditis in the Argentine Republic: results of EIRA II Study

Objetivo: Determinar la mortalidad hospitalaria y los marcadores clínicos relacionados con la mortalidad de la endocarditis infecciosa (EI) en la República Argentina. Métodos: Registro prospectivo, multicéntrico (82 centros de 16 provincias de la Argentina) de EI definidas o posibles según los criterios Duke, entre junio de 2001 y noviembre de 2002. Resultados: Se evaluaron 470 episodios de EI en 452 pacientes (edad media: 58,1 ± 17,6 años; sexo masculino 69,7 por ciento; EI definida 83 por ciento y posible 17 por ciento). Bacteriología: Staphylococcus 38 por ciento (S. aureus 30 por ciento, Staphylococcus coagulasa negativo por ciento), Streptococcus 39,4 por ciento (S. viridans 36,8 por ciento), Enterococcus 10,8 por ciento, HACEK 6,6 por ciento, hemocultivos negativos 17,7 por ciento. Existía cardiopatía subyacente en el 66,4 por ciento y EI de válvula protésica en el 19,2 por ciento. Se indicó tratamiento quirúrgico en el 33,3 por ciento de los pacientes. La mortalidad fue del 24,3 por ciento. En el análisis de regresión logística fueron predictores independientes de mortalidad: edad > 65 años (OR 2,1; IC 95 por ciento, 1,1-3,96; p = 0,024); insuficiencia cardíaca en la evolución (OR 5,9; IC 95 por ciento, 3,1-10,9; p < 0,001), shock séptico (OR 25,1; IC 95 por ciento, 9,9-62,5; p < 0,001), insuficiencia hepática (OR 12,2, IC 95 por ciento, 1,9-76,9; p = 0,008); hipertermia persistente (OR 2,3, IC 95 por ciento, 1,2-4; p = 0,014); la alteración del estado de conciencia y el accidente cerebrovascular presentaron fuertes tendencias sin significación estadística. Conclusiones: La mortalidad de la EI en la Argentina es alta. Variables de determinación sencilla constituyen marcadores asociados en forma independiente con mayor mortalidad, cuyo empleo para identificar pacientes de alto riesgo puede resultar de utilidad para guiar la toma de decisiones.