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Patients Diagnosed with Infective Endocarditis: a Retrospective Chart Review

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Patients Diagnosed with Infective Endocarditis: a Retrospective Chart Review Patients Diagnosed with Infective Endocarditis: A Retrospective Chart Review Thesis Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University By Chloe A. Wong, DMD Graduate Program in Dentistry The Ohio State University 2020 Thesis Committee Ashok Kumar DDS, MS, Advisor Paul Casamassimo, DDS, MS Daniel Claman, DDS John Kovalchin, MD William Hunt, MD Copyrighted by Chloe A. Wong DMD 2020 2 Abstract Purpose: To describe characteristics and associations of risk factors for patients admitted to Nationwide Children’s Hospital (NCH) for infective endocarditis (IE), and to provide a descriptive overview of IE in a representative U.S. children’s hospital. Methods: A retrospective chart review of electronic medical records from January 1, 2008 to January 1, 2020 of patients who met the modified Duke criteria for definite or possible IE. Study variables include demographics, medical and cardiac history, predisposing conditions and risk factors, bacterial isolates, hospital course, treatment, complications, and dental history. Results: Initial search query found 242 patients. 67 patients met inclusion criteria. 69% had an underlying cardiac condition. S. aureus and viridans streptococcus were most common. Age was significantly associated with presence of intracardiac hardware. The mean length of hospital stay was 25 days and the mortality rate was 9%. 32% patients had a dental consult during admission. Conclusion: Increased survival of children with significant heart conditions increases the likelihood of them becoming pediatric dental patients. Occurrence of IE in healthy children and the questioning of IE association with dental procedures suggest further research is needed. It is recommended that pediatric dentists are aware of cardiac and non-cardiac factors that place patients at risk for IE, focus on prevention of oral disease, be up to date with guidelines for IE prophylaxis, and have a definitive plan before dental treatment. ii Dedication This document is dedicated to my family, who has supported me throughout my education and my research advisors, Dr. Ashok Kumar and Dr. Paul Casamassimo. iii Acknowledgments I would like to thank my thesis committee for their support and guidance throughout my project, as well as Dr. Jin Peng for helping me with my data analysis. iv Vita June 2009 ............................................................................................. Freehold Boro High School May 2013 ................................... B.A., Child Development, Community Health, Tufts University May 2018 ................................................................... D.M.D, Harvard School of Dental Medicine 2018 to present ................................................................ Resident, Division of Pediatric Dentistry The Ohio State University and Nationwide Children’s Hospital Fields of Study Major Field: Dentistry v Table of Contents Abstract ........................................................................................................................................... ii Dedication ...................................................................................................................................... iii Acknowledgments .......................................................................................................................... iv Vita .................................................................................................................................................. v List of Tables ................................................................................................................................ vii List of Figures .............................................................................................................................. viii Chapter 1. Introduction ................................................................................................................... 1 Chapter 2. Methods ....................................................................................................................... 11 Study Design ............................................................................................................................. 11 Study Variables ......................................................................................................................... 11 Data Analysis ............................................................................................................................ 12 Chapter 3. Results ......................................................................................................................... 14 Demographics ........................................................................................................................... 14 Predisposing Conditions and Risk Factors ............................................................................... 17 Diagnosis................................................................................................................................... 19 Treatment .................................................................................................................................. 20 Outcomes .................................................................................................................................. 21 Dental History ........................................................................................................................... 22 Chapter 4. Discussion ................................................................................................................... 24 Chapter 5. Conclusion ................................................................................................................... 31 Bibliography ................................................................................................................................. 33 vi List of Tables Table 1 Summary of Demographics ............................................................................................. 15 Table 2 Distribution of CHD Lesions ........................................................................................... 18 Table 3 Symptoms at Time of Admission .................................................................................... 19 Table 4 Causative Organisms of IE in Patients with and without Underlying CHD .................... 20 Table 5 Demographics and Cardiac Risk Factors in Prior Studies ............................................... 26 Table 6 Diagnostic Variables and Outcomes in Prior Studies ...................................................... 27 Table 7 Dental Variables Assessed in Prior Studies ..................................................................... 29 vii List of Figures Figure 1 Pathogenesis of Infective Endocarditis ............................................................................ 2 Figure 2 Modified Duke Criteria .................................................................................................... 4 Figure 3 Timeline of Variables ..................................................................................................... 13 Figure 4 Number of IE Cases by Year .......................................................................................... 14 Figure 5 Gender Distribution ........................................................................................................ 16 Figure 6 Age Distribution ............................................................................................................. 16 Figure 7 Ethnicity Distribution ..................................................................................................... 17 Figure 8 Dental Needs of Patients with Dental Consults (N=21) ................................................. 23 Figure 9 Dental Treatment Rendered to Patients with Dental Consults (N=21) .......................... 23 viii Chapter 1. Introduction Infective endocarditis (IE) is a microbial infection of the endocardial surface of the heart (Baltimore et al., 2015). The challenges posed by IE are significant. It is heterogeneous in etiology, clinical manifestations, and course. Lack of research infrastructure and funding, with few randomized controlled trials, inhibit a guide to prevention and treatment. Longstanding controversies such as the timing of dental treatment or the role of antibiotic prophylaxis have not been resolved (Cahill et al., 2017). IE develops via different mechanisms in damaged endothelium. Endothelium can be damaged through multiple mechanisms, which include turbulent flow due to abnormal cardiac structures, direct damage produced by a foreign body, such as an implantable electronic device or prosthetic valve, directly against the endothelial structure or indirect damage when a device interferes with normal blood flow. The damaged endothelium elicits a host response that includes platelet and fibrin deposition which serves as a nidus for bacterial colonization in patients with bacteremia (Baltimore et al., 2015). Bacteria that enter the bloodstream can be carried to the heart and cause IE. IE can also be caused by direct infection of indwelling devices, such as prosthetic valves or leads, at time of placement, causing a surgical site infection. In the case of staphylococcal, streptococcal, and enterococcal species, bacterial adhesions then attach to either host cell 1 structures or extracellular molecules that bind to host cells
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