496 Internacional Journal of Cardiovascular Sciences. 2015;28(6):496-503
ORIGINAL MANUSCRIPT
Hospital Evolution of Patients with Infective Endocarditis in Public Hospital in Belém, Pará, Brazil Lucianna Serfaty de Holanda1, Juliana Fonseca de Araújo Daher1, Alberto Freire Sampaio Costa2, Dilma Costa de Oliveira Neves1, Vitor Bruno Teixeira de Holanda3
1Centro Universitário do Estado do Pará – Curso de Graduação em Medicina – Belém, PA – Brazil 2Centro Universitário do Estado do Pará – Hospital de Clínicas Gaspar Vianna – Serviço de Cardiologia – Belém, PA – Brazil 3Hospital Saúde da Mulher – Serviço de Cardiologia – Belém, PA – Brazil
Abstract
Background: The time course of disease knowledge enables advances in techniques that promote early diagnosis which, consequently, is important for the survival of patients with infective endocarditis (IE). Objective: To describe the hospital evolution of patients with infective endocarditis in a public hospital in Belém, Pará, Brazil. Methods: Observational, descriptive, prospective case series study. The study included a review of the medical records of 18 patients with IE from Hospital de Clínicas Gaspar Vianna (HCGV), who were part of the hospital’s spontaneous demand and who met the inclusion criteria adopted. Social and demographic data and clinical evolution were analyzed. Results: Of the 18 patients studied, there was predominance of males (72.2%), aged between 39-59 years (50.0%), level of education: incomplete primary education (61.1%) and monthly income two to four minimum wages (55.5%). The most prevalent risk factor was the presence of biological valve prosthesis (36.0%), 66.5% of blood cultures were negative, the aortic valve was the most affected (44.4%). Valve dysfunction was the most frequent complication (26.5%), the medical and surgical treatment was the most used (55.5%), criterion for surgery was severe impairment (33.3%). The time to diagnosis was 27.7 days, time to treatment after diagnosis was 2.4 days and the outcome most found was death (50.0%). Conclusion: Half of the patients died with a percentage well above what is found in the literature.
Keywords: Endocarditis, bacterial; Endocarditis; Clinical evolution
Introduction The main gateways of microorganisms in the bloodstream are oral cavity, skin and upper airways. The initial event in the development of infective During simple procedures, such as dental treatment, endocarditis (IE) is endothelial injury caused by transient bacteremia may occur, during which the deposition of immune complexes ─ such as in rheumatic microorganisms settle on preexisting clots, generating disease ─ or turbulent blood flow ─ as in mitral valve an infected vegetation, which may lead to the destruction reflux ─ giving rise to nonbacterial thrombotic of the involved structure, as well as other surgeries in endocarditis (NBTE)1. general2-6.
Corresponding author: Luciana Serfaty de Holanda Av. Alm Barroso, 3775 – Souza - 66613-903 – Belém, PA – Brazil E-mail: [email protected]
DOI: 10.5935/2359-4802.20150076 Manuscript received on December 11, 2015; approved on January 15, 2016; revised on February 02, 2016. Int J Cardiovasc Sci. 2015;28(6):496-503 Holanda et al. 497 Original Manuscript Hospital Evolution of Patients with IE
Diagnosis of IE is based on the modified Duke criteria The time course of disease knowledge and imaging methods in the recognition of valvular enabled advances in diagnostic techniques, ABBREVIATIONS AND ACRONYMS vegetations which, combined with clinical and especially in echocardiography. In 1,7 bacteriological data, enable a more precise diagnosis . addition, there was a greater possibility • CHF — congestive heart Echocardiography currently stands out as an essential of performing heart surgery, even with failure diagnostic tool, and it identifies complications, provides the infectious process in activity, and • HCGV – Hospital de Clínicas prognostic information and assists in the proper new prophylaxis recommendations for Gaspar Vianna management of patients8,9. Transthoracic antibiotics before intervention procedures15. • IE — infective endocarditis echocardiography (TTE) has a lower cost and greater • IV — intravenous As for treatment, with early surgical availability in hospitals, while transesophageal • NBTE — nonbacterial echocardiography (TEE) results in higher accuracy8,10. repair, another presentation of the thrombotic endocarditis disease appeared, namely prosthesis • TEE — transesophageal The choice of echocardiographic modality must consider endocarditis, which is difficult to echocardiography the clinical pre-test probability of the disease. The diagnose and difficult to establish • TTE — transthoracic 12 echocardiography employment of TTE is considered appropriate when this therapeutic management . probability is between 2-3%, while TEE must be used With the emergence of new increasingly when the probability is between 4-60%8,10,11. effective antibiotics, clinical treatment has enabled the cure of endocarditis with or without associated surgical The evolution of echocardiography, with the possibility treatment12. of transesophageal tests, allowed viewing changes that were not possible with TTE and even less with the first According DATASUS16, mortality from IE in Pará has echocardiography devices. The type of treatment and its been increasing steadily. Within five years (2009 to 2013), time have also changed12. 76 deaths from IE were recorded, with an approximate average of 5 deaths/year, ranging from 10 deaths in New imaging techniques in cardiology, including 2010 to 20 deaths in 2012, without restriction to sex and magnetic resonance imaging and computed tomography age. scans have been used in the evaluation of this disease, with promising results8. The total number of deaths in the state of Pará, in individuals aged 15-80, from 2010-2013, was 92,178; of Advances in laboratory tests allowed faster and more this number, 54 were from IE14. There is no data for the accurate detection of the etiological agents causing the years 2014 and 2015. In Belém, state of Pará, there were 12 problem and more effective mitigation of these agents . 23 deaths from IE, as follows: 5 in 2011, 10 in 2012 and When available for heart surgery or autopsy, pathology 8 in 201316. tests of the vegetation is the gold standard for diagnosing 8 endocarditis and can suggest its etiology . Given the few studies on infective endocarditis in Brazil, especially in the last decade12 and the progressive increase IE presents high morbidity and mortality with mortality of mortality from IE, due to systemic complications, rates of 20-30%, rising up to over 50% in high-risk groups. despite the advances in diagnostic methods and The prognosis correlates with rapid diagnosis and proper treatment, this study aims to analyze the hospital 4,10,13,14 therapy . evolution of patients affected by IE considering the social and demographic profile and the risk factors involved. Complications may occur by destruction of structures at the site of infection, embolic events, metastatic lesions and immune-mediated infections2. Methods
The emergence of congestive heart failure (CHF) An observational, descriptive, prospective case series secondary to embolization adversely impacts the study with analysis of medical records of 18 patients with prognosis of the disease. Other complications include infective endocarditis from Hospital Gaspar Vianna in perivalvular and myocardial abscesses2. Belém, PA, Brazil, from January 2010 to April 2015. 498 Holanda et al. Int J Cardiovasc Sci. 2015;28(6):496-503 Hospital Evolution of Patients with IE Original Manuscript
This study was approved by the Research Ethics (p<0.0001). There was a predominance of monthly Committee of the institution under nº 1.030.404/ 2015 income between two and four minimum wages in 55.5% according to the CNS Resolution 466/12. Because it is a (n=10) of the cases. retrospective study, Informed Consent Form was not required. Biological valve prosthesis was the most common risk factor (36.0%) followed by hemodialysis (16.0%) and The inclusion criteria were: patients who were part of dental procedures (12.0%) (p=0.0028). the hospital’s spontaneous demand, with infective endocarditis, of both sexes, aged ≥18 and ≤90 or with The most common complications found in patients with reported IE, with positive blood culture tests, IE after diagnosis was valvular impairment (26.5%), echocardiogram and/or histopathology tests conducted followed by congestive heart failure and sepsis, with no in HCGV, as well as those with a diagnosis established significant difference (p=0.598) (Table 1). by the modified Duke criteria17. Patients with incomplete medical records and those who were no longer in the Table 1 hospital files were excluded. Complications experienced by patients after diagnosis of infective endocarditis The following sociodemographic variables were collected from the medical records: age, sex, education, Complications n % average monthly household income and origin. Risk factors: mitral valve prolapse, rheumatic disease, Valvar impairment 9 26.5 * complex congenital heart disease, use of intravenous drugs, septal hypertrophy, previous dental procedure, Congestive heart failure 7 20.6 * hemodialysis, diabetes mellitus, HIV infection, Sepsis 7 20.6 * mechanical valve prosthesis or bioprosthetic valve, type of pathogens (determined through blood test results or Acute renal failure 4 11.8 histopathology test results), affected cardiac valves, medical complications after IE, diagnostic method used Pulmonary embolism 3 8.8 and the type of treatment performed (clinical and clinical-surgical). Pericardial effusion 1 2.9
The program BioEstat version 5.3 was used for statistical Acute lung edema 1 2.9 analysis. Adherence chi-squared non-parametric test was Coagulopathy 1 2.9 applied and significance level of 5% (p<0.05) was adopted as statistically significant difference. Ischemic stroke 1 2.9
Total 34 100.0 Results * p=0.598 (chi-square test) Twenty medical records of patients registered with ICD I33.0 (IE by ICD-10) were found. It was possible to collect data from 18 patients because two died in 2010 and the Regarding the complications, there was a higher medical records were found not for analysis in the incidence of two complications (in 6 patients; 33.3%) and hospital files. the highest number of complications was four (in 2 patients; 11.1%) (Table 2). Among the 18 patients studied, 13 (72.2%) were males (p<0.0001), with predominance of the age group 39-59 Regarding the time to diagnosis from the onset of (n=9), followed by 18-38 (n=6). Average age was symptoms, median of 14 days in hospital stay, ranging from 46.3±16.3 with variation from 18 to 90 years old. 6-90 days, was found. From the onset of symptoms to Incomplete primary education accounted for 61.1% diagnosis, the time observed was the median of 40.5 days (n=11) of patients with statistically significant difference with a minimum of 2 and maximum of 210 days. For Int J Cardiovasc Sci. 2015;28(6):496-503 Holanda et al. 499 Original Manuscript Hospital Evolution of Patients with IE
most patients (27.7%), definitive diagnosis was achieved blood samples taken. As for imaging, transthoracic in a period of time between 5-10 days from the day of echocardiography was requested for all patients, but in hospitalization (Table 3). none of them transesophageal echocardiography was performed.
Table 2 In the decision to maintain clinical treatment as the Number of complications developed by the patients therapy of choice, two major modified Duke criteria were studied used (Table 4). It was found that among the major criteria, Number of complications n % the most observed ones were positive echocardiography with oscillating intracardiac mass on the valve or other 0 2 11.1 support structures, plus valve regurgitation, which did
1 5 27.7 not exist previously.
2 6 33.3 Table 4 3 3 16.6 Criteria used to select the type of treatment in the study 4 2 11.1 population
Total 18 100.0 Clinical criteria n % p-value* Modified Duke criteria
2 major criteria 13 * 72.2 Table 3 Time (in days) for the definitive diagnosis of infective 1 major and 3 minor 2 11.1 endocarditis from hospitalization and length of stay of criteria <0.0001 the study population Potential endocarditis 3 16.7 n % Total 18 100.0
<5 days 4 22.2 Surgery criteria for native valve
Severe impairment 6 33.3 * 5 - 10 days 5 27.7 Vegetation >10 mm 2 11.1 * 11 - 15 days 1 5.5 0.0014 No information 10 55.6 Time to 16 - 30 days 3 16.6 diagnosis Total 18 100.0
> 30 days 4 22.2 Surgery criteria for prosthetic valve
No information 1 5.5 Valvular impairment 5 27.8 * Perivalvar abscesses Total 18 100.0 and intracardiac 2 11.1 * fistulas < 1 month 6 33.3 Vegetation >10 mm 1 5.6 * <0.0001 1 – 2 months 7 38.8 Length of Valve IE with less stay than two months 1 5.6 * > 2 months 5 27.7 from replacement
Total 18 100.0 No information 9 50.0
Total 18 100.0 The most commonly used diagnostic method was the IE — infective endocarditis clinical diagnosis (Duke criteria and sociodemographic *Chi-square test profile) in all patients studied, as well as all patients had 500 Holanda et al. Int J Cardiovasc Sci. 2015;28(6):496-503 Hospital Evolution of Patients with IE Original Manuscript
As for the criteria that defined the decision for surgical Discussion treatment in patients with native valve, there was significant difference between them (p=0.0014). A Incidence of IE in the world remained relatively stable percentage of 33.3% of patients with aortic or mitral from 1950 to 2000, with 3.6 to 7.0 cases per 100,000 regurgitation associated with heart failure (severe patients/year. In areas with higher concentration of impairment) that did not exist previously (Table 4) was populations at high risk of infection, especially among reached. patients depending on intravenous (IV) drugs, the incidence of IE may reach 11.6/100,000 individuals18. In the choice of surgical treatment for patients with prosthetic valve, valve function was the most frequent This would represent an expectation of 18-35 cases per criterion (27.8%) (Table 4). year during the period of the study, and in populations at high risk for endocarditis, an “n” of 58 could There was no significant difference (p=0.2661) between be estimated for the state of Pará, based on about the established treatments. However, there was a higher 2,518.570 admissions recorded in the years of the study proportion of clinical-surgical treatments (Table 5). in DATASUS, which equates to an average of 503,714 hospital admissions/year.
Table 5 Considering that total admissions in HCGV from January Type of treatment established for the patients admitted 2010 to December 2014 was 23,038 cases, an average of 4,068 patients/year, one patient/year, that is, 5 patients Treatment established n % over five years would be expected. The finding was four times higher than the world estimate (20 patients). Clinical 8 44.44 The number found is partially due to the fact that HCGV Clinical-surgical 10 55.56 is a reference in Pará for the treatment of cardiovascular diseases and hemodialysis, thereby increasing the local Total 18 100.0 incidence for infective endocarditis.
p=0.2661 (chi-square test) The sociodemographic profile observed is consistent with that found in a previous study18 in which, on a global level, endocarditis affects more men than women, in a The most prevalent outcome was death (50.0%) followed ratio of 2:1, but the average age of patients gradually by 33.3% of patients with improved discharge and 16.7% increased, and is currently 57.9 years (interquartile range that dropped treatment with no medical initiative (Table 6). 43.2-71.8 years). The incidence of endocarditis by age increased from 5 cases per 100,000 people/year among individuals <50 years of age to 15-30 cases per Table 6 100,000 people/year among individuals from the sixth Outcome of patients with infective endocarditis to the eighth decade of life18.
Resolution of the condition n % A study carried out in Chile19 identified the average age of patients of 49.9 years of age and higher prevalence of Death 9 50.0 males. A number of cases followed between 2006 and 2011 at a public hospital in Rio de Janeiro had an average Improved discharge 6 33.3 age of 47.219,20. In another study, the predominant age range was 40.0-53.5, mostly males, at a ratio of 2.5:121. Drops 3 16.7
The level of education of patients differs from a cross- Total 18 100.0 sectional study that deals with the dental health
p=0.0002 (chi-square test) conditions presented by adults with heart disease with IE, in preparation for cardiac surgery, which showed a Int J Cardiovasc Sci. 2015;28(6):496-503 Holanda et al. 501 Original Manuscript Hospital Evolution of Patients with IE
higher prevalence of patients with incomplete primary The presence of two major Duke criteria or one major education (48.6%). In the same study, the most frequent and three minor criteria were used, and among the major household income was up to two minimum wages, which criteria, the most prevalent one was positive corresponds to the finding of two to four minimum wages22. echocardiography with oscillating intracardiac mass on the valve or other support structures, in addition to valve In a case series21 studying risk factors, the authors found regurgitation that did not exist previously. 9.0% of patients with dental infection, 3.0% with history of hemodialysis, 3.0% with diabetes mellitus m and 6.0% For the decision of medical and surgical treatment of with history of alcoholism. patients with native valve IE, two criteria were used: severe valvular impairment and vegetation greater than The risk factors for developing IE occur more frequently 10 mm. For those with prosthetic valve, the most frequent in individuals with pre-existing heart diseases, with criterion was valvular impairment (Table 4). This result greater predisposition of involvement of the native is corroborated by some studies in which patients with valve1,23. However, the involvement of mechanical echocardiographic characteristics of high risk underwent prostheses presents greater risk in the first three months, early surgery, specifically those patients with vegetation equating to the risk of the native valve after five years of bigger than 10 mm2,27-29. evolution. The presence of intracardiac devices such as pacemakers and implantable defibrillators can serve as In a little more than half of the patients, the criteria for support for thrombi and vegetations1,24. choosing surgical treatment were not described in the medical records. It is assumed that the absence of such However, the risk factors in developed countries have information in the medical record is due to the hospital’s shifted from rheumatic disease (most often in the mitral medical-surgical practice that takes the failure of valve followed by aortic valve) and congenital heart antibiotic therapy as a criterion. disease to the use of intravenous medication, degenerative valve disease in the elderly, intracardiac devices, infections The most prevalent treatment was clinical-surgical therapy originated in health services and hemodialysis1,18,25. followed up by clinical therapy (Table 5). This finding is consistent with the cases series held in Rio de Janeiro, The finding of the most affected heart valve was which showed 64.0% of patients undergoing surgical consistent with the findings of another study that found treatment29 and another study done in Chile, with 37.7%19. higher prevalence of mitral and aortic valves26. Infections of the tricuspid and/or pulmonary valve occur more in Three patients dropped the treatment, one of whom intravenous drug users and as a complication related to dropped it before transthoracic echocardiogram, which deep vascular catheter infection. The pulmonary valve was detrimental to the patient’ inclusion following the is rarely affected26. Duke criterion, so the patient’s diagnosis was based on clinical and demographic characteristics. Valvular impairment was the most frequent complication (Table 1). Comparative studies showed embolisms and The most frequent outcome of the patients studied was CHF as the main complications of IE20. death (Table 6), a rate much higher than that observed in the Chilean study of 33 cases of IE, which found 6.0% of Although the time between the onset of symptoms and mortality21 and another study with 151 cases of IE, in a diagnosis has ranged between 2 and 210 days, the average hospital in Rio de Janeiro, which found 32.0% of deaths20. length of hospital stay was lower than that found by Franco et al.21, who found an average of 67 days with a The finding of 50.0% mortality is probably related to the minimum of 4 and maximum of 224 days (Table 3). number of risk factors presented by the patients. It was observed that patients who evolved to death also had In the diagnosis by the Duke criteria, blood culture and two or more complications. TTE were auxiliary methods in the diagnosis, the latter being decisive for the diagnosis, perhaps because Gaps found in the medical records, particularly with echocardiogram is the cornerstone diagnosis in infective respect to risk factors and clinical and demographic endocarditis, with specificity value higher than 95% and profile generated some difficulty in the execution of this sensitivity close to 70%19. study, in addition to social damage, since the availability 502 Holanda et al. Int J Cardiovasc Sci. 2015;28(6):496-503 Hospital Evolution of Patients with IE Original Manuscript
of this information provides greater preventive possibility Potential Conflicts of Interest of infective endocarditis. This study has no relevant conflicts of interest.
Sources of Funding This study had no external funding sources. Conclusion Academic Association In the analysis of the evolution of most patients, there This manuscript represents the Final Term Paper (TCC) in were two additional risk factors unrelated to the length Medicine of Lucianna Serfaty de Holanda from Centro of hospital stay resulting in death. Universitário do Estado do Pará.
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