Clinical epidemiology in Italian Registry of Infective Endocarditis (RIEI): Focus on age, intravascular devices and enterococci

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Highlights

  • RIEI analyzed clinical epidemiology in 677 Italian patients with definite IE.

  • IE in Italy has shifted to a more acute disease than previously described.

  • IE affects older and more debilitated patients.

  • IE is characterized by a high rate of staphylococcal and enterococcal, infections especially in IE on left prosthetic valve or cardiac device.

  • A relevant medical problem is IE in patients with cardiac devices.

Abstract

Introduction

The epidemiology of infective endocarditis (IE) is changing due to a number of factors, including aging and health related comorbidities and medical procedures. The aim of this study is to describe the main clinical, epidemiologic and etiologic changes of IE from a large database in Italy.

Methods

We prospectively collected episodes of IE in 17 Italian centers from July 2007 to December 2010.

Results

We enrolled 677 patients with definite IE, of which 24% health-care associated. Patients were male (73%) with a median age of 62 years (IQR: 49–74) and 61% had several comorbidities. One hundred and twenty-eight (19%) patients had prosthetic left side IE, 391 (58%) native left side IE, 94 (14%) device-related IE and 54 (8%) right side IE. A predisposing cardiopathy was present in 50%, while odontoiatric and non odontoiatric procedures were reported in 5% and 21% of patients respectively. Symptoms were usually atypical and precocious. The prevalent etiology was represented by Staphylococcus aureus (27%) followed by coagulase-negative staphylococci (CNS, 21%), Streptococcus viridans (15%) and enterococci (14%). CNS and enterococci were relatively more frequent in patients with intravascular devices and prosthesis and S. viridans in left native valve. Diagnosis was made by transthoracic and transesophageal echocardiography in 62% and 94% of cases, respectively. The in-hospital mortality was 14% and 1-year mortality was 21%.

Conclusion

The epidemiology is changing in Italy, where IE more often affects older patients with comorbidities and intravascular devices, with an acute onset and including a high frequency of enterococci. There were few preceding odontoiatric procedures.

Introduction

Infective endocarditis (IE) is a relatively rare disease that still presents relevant diagnostic and therapeutic issues since the epidemiology is continuously changing, together with its protean clinical manifestations [1], [2], [3], [4], [5], [6], [7]. The morbidity is mostly due to heart failure, severe infection or systemic embolization, including stroke and the in-hospital mortality is reported to be around 15–26%, with 1-year mortality of around 35–40% [1], [2], [3], [4], [5], [6], [7], [8], [9]. Historically, IE occurred predominantly in patients with an underlying heart disease, either congenital or acquired in rheumatic heart disease, and was mainly a consequence of community-acquired bacteremia, including cases after invasive dental or medical procedures. Streptococcus viridans was the most common responsible bacteria and aortic and mitral valves were more frequently involved [10]. Every decade there are reports of changing epidemiology of IE, secondary to the complex interaction between microorganisms and patient characteristics [3].

In industrialized nations IE is now prevalently affecting elderly patients with comorbidities, who often develop IE as a result of health care-associated non cardiac or cardiac invasive procedures or as a complication of bacteremia in patients with prosthetic valves or cardiac devices. The epidemiology is also changing in intravenous drug abusers (IDA), with new microorganisms continuously reported, with or without typical clinical scenarios [1], [2], [3]. In recent years there have been some hospital-based studies with new epidemiological details such as increasing numbers of IE due to staphylococci or enterococci or in patients with prosthetic valve or endocavitary devices; these changes are less evident among population-based studies [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25].

Due to important regional differences [13], [16], the study of local and national epidemiology is of utmost interest to identify a new epidemiological change which may lead to new diagnostic and therapeutic strategies [26]. The Italian Registry of Infective Endocarditis (Registro Italiano delle Endocarditi Infettive — RIEI) is a multicenter, prospective, collaborative study that has been created with the specific aims to analyze the changing epidemiology of IE in Infectious Disease, Cardiology and Cardiosurgical wards [27]. In this paper we report the data collected by the RIEI between July 2007 and December 2010.

Section snippets

Material and methods

The RIEI is coordinated by the Cardiology Department in Maria Vittoria Hospital, Turin, Italy and is designed to prospectively enroll consecutive definite IE cases, according to the modified Duke criteria [28] in the 17 participating centers (11 of which are in the north of Italy) since July 2007 [27], [29]. Data were collected during the hospitalization by specific record forms and electronically through a website.

Patient population: socio-demographic characteristics at admission

A total of 680 patients were enrolled; three patients were excluded from the statistical analysis because echocardiographic data were not available. The main clinical characteristics and comorbidities are described in Table 1 with subgroup distinction according to echocardiographic localization of infection (Table 1 in the Supplementary Appendix). The majority of patients were male (492; 72.67%) and the median age was 65.34 years (range: 13–91; interquartile range 49.60–74.39). There were

Discussion

IE is a relatively uncommon disease with significant morbidity and mortality. The pathogenesis of IE is variably determined by four physio-pathological factors classically described by Osler [32]: persistent bacteremia, predisposing heart disease, endocardial involvement and vascular events. The epidemiology of IE is historically characterized by an initial period with data collected mostly from case reports or small case series from single sites and only later by some population-based studies

Study limitations

The RIEI is an observational study performed both in referral and non-referral centers for IE, with the prevalent involvement of Cardiological and Cardiosurgical wards as compared to Infectious Disease wards. Potential selection bias in this setting is less evident than in other studies [13], [19], but is probably present, as 45% of patients are referred to study centers from other hospitals.

Conclusions

Infective endocarditis is a serious disease despite recent advances in diagnosis and treatment. There are important differences in sub-groups of patients based on site of infection and pattern of IE acquisition. Of particular interest, IE in Italy has shifted to a more acute disease, affecting older patients with comorbidities and is characterized by a high rate not only of staphylococcal, but also of enterococcoccal infections, especially in patients with IE on left prosthetic valve or cardiac

Conflict of interest

None.

Acknowledgments

RIEI Investigators: Enrico Cecchi, M.D., Massimo Imazio, M.D., Silvia Ferro, M.D., Cristina Cecchi, Rita Trinchero, M.D. (Cardiology Department, Maria Vittoria Hospital, Torino-Italy). Francesco Giuseppe De Rosa, M.D., Filippo Lipani, M.D. (Department of Medical Sciences, University of Turin; Infectious Diseases at Amedeo di Savoia Hospital, Torino- Italy). Pietro Caramello, M.D., Antonio Macor, M.D. (Infectious Diseases Department, Amedeo di Savoia Hospital, Torino-Italy). Fabio Chirillo,

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