Characteristics of infective endocarditis in a developing country-clinical profile and outcome in 192 Indian patients, 1992–2001

Abstract

Total 198 episodes of Duke “definite” infective endocarditis (IE) in 192 patients observed over last 10 years were studied [141 males and 51 females, mean age 27.6±12.7 years (range 4–68 years)]. Majorities of patients (76.5%) were below 40 years of age. Rheumatic heart disease (RHD) was the commonest underlying heart disease (present in 46.9% patients). Probable source of infection could be identified in only 16.6% episodes. None of our patient was intravenous drug abuser. Fever (90.0%), anemia (81.0%), clubbing (58.1%), splenomegaly (60.6%), changing/new murmur (22.7%) were the common clinical findings. Vegetations were present in 89.9% episodes. Blood cultures were positive in 134 (67.7%) episodes (streptococci in 23.2%, staphylococci in 19.7%, gram negative in 13.6%, enterococci in 8.1%, polymicrobial and fungal in 1.5% episodes each). Complications were cardiovascular [congestive heart failure (CHF) in 41.9%, atrioventricular block in 1.5%, cardiac temponade and acute myocardial infarction in 0.5% each), neurological in 16.6%, renal in 13.1% and embolisms in total 21.7% episodes. Total 182 (91.9%) episodes in 176 patients were managed completely [(medical in 140 (76.9%) and surgical in 42 (23.1%) episodes] while patients in remaining 16 (8.1%) episodes left against medical advises before completion of therapy. Total 21% patients (37 out of 176 completely treated patients) died during therapy (cause of deaths; CHF in 11, septicemia in 10, cerebral embolism in 7, post cardiac surgery in 5, ruptured cerebral mycotic aneurysm in 2, ventricular tachycardia in 2 patients). On stepwise logistic regression analysis; cardiac abscess and CHF were independent predictors of cardiac surgery. Similarly, CHF, renal failure and prosthetic valve dysfunction were independent predictors of mortality. To conclude, spectrum of IE in our country is different from the west, but quite similar as reported from developed countries about 40 years ago. IE in our country occurs in relatively younger population with RHD as the commonest underlying heart disease. Streptococci are still the commonest responsible microorganisms. Morbidity and mortality are still high. Early cardiac surgery, whenever indicated, helps in improving outcome of these patients.

Introduction

More than a century after Osler's first comprehensive description [1] and more than half a century after the discovery of penicillin and sulfonamides, infective endocarditis (IE) remains a serious cardiac problem in our country despite the availability of improved diagnostic and therapeutic facilities. Recent studies from the west have shown remarkable changes in the spectrum of IE [2], [3], [4], [5], [6], [7]. These changes are attributable to changes in substrate population, introduction of more accurate diagnostic criteria (Duke criteria), better diagnostic facilities, availability of a range of antibiotics and aggressive surgical approach. Published reports regarding IE are rather scanty from this part of the world [8], [9], [10], [11], [12], [13] and there is no large series from any centre involved in active and aggressive cardiac interventions and surgery. Given the scenario of changing trends and scanty data, an insight into the clinical expression and a comparison with western data is warranted. In this report we describe our experience of IE during last 10 years, its comparison with the western data and evaluation of risk factors for the adverse outcome.