Elsevier

American Heart Journal

Volume 179, September 2016, Pages 42-50
American Heart Journal

Clinical Investigation
Predisposing cardiac conditions, interventional procedures, and antibiotic prophylaxis among patients with infective endocarditis

https://doi.org/10.1016/j.ahj.2016.03.028Get rights and content

Background

Efficacy and safety of antibiotic prophylaxis (AP) for prevention of infective endocarditis (IE) in patients with predisposing cardiac condition (PCC) undergoing invasive procedures is still debated. We sought to assess the prevalence of PCC, the type of interventional procedures preceding the onset of symptoms, and the usefulness of AP in a large cohort of consecutive patients with definite IE.

Methods

We examined 677 (median age 65.34 years; male 492 [73%]) consecutive patients with IE enrolled from July 2007 through 2010 into the Italian Registry of Infective Endocarditis.

Results

Predisposing cardiac condition was present in 341 patients (50%).Thirty-two patients (4.7%) underwent dental procedures. Of 20 patients with PCC undergoing dental procedure, 13 had assumed AP. Viridans group streptococci were isolated from blood cultures in 8 of 20 patients with PCC and prior dental procedure. Nondental procedures preceded IE in 139 patients (21%). They were significantly older and had more comordibities compared with patients undergoing dental procedures. Predisposing cardiac condition was identified in 91 patients. Perioperative antimicrobial prophylaxis was administered to 67 patients. Staphylococcus aureus was the most frequent causative agent. Cardiac surgery was necessary in 85 patients (20 with prior dental and 65 with nondental procedure). Surgical mortality (12% vs 0%, P = .03) and hospital mortality (23% vs 3%, P = .001) were significantly larger among patients with nondental procedures.

Conclusions

In a large unselected cohort of patients with IE, the incidence of preceding dental procedures was minimal. The number of cases potentially preventable by means of AP was negligible. Nondental procedures were more frequent than dental procedures and were correlated with poorer prognosis.

Section snippets

Study design and population

Data from the Registro Italiano della Endocardite Infettiva (RIEI) were used for this study. The RIEI database was created in 2006 and enrollment began in 2007. The background and inclusion criteria of this prospective, multicenter registry of IE have previously been reported.22 From July 2007 to December 2010, patients with IE from 17 Italian centers were enrolled. Patients were prospectively identified using site-specific procedures to ensure consecutive enrollment and were enrolled into RIEI

Results

Figure 1 shows the case selection process. A total of 680 consecutive patients with definite IE were enrolled; 3 patients were excluded because echocardiographic data were not available. The study population was subsequently formed by 677 patients with definite IE (median age 65.34 years; male n = 492 [73%]).

Discussion

In the present study, information on PCCs, interventional procedure, and AP was systematically collected in a large series of consecutive patients with definite IE. The highlights of this observational study are that data are prospectively collected, the cohort is relatively recent, and the multicenter nature of the study increases the generalizability of the results, although most sites are tertiary care centers from a single country. A predisposing cardiac abnormality was identified in 50% of

Conclusions

The epidemiology of IE has dramatically changed in the last years. The predisposing factors for the development of IE have changed, mainly with the decreasing incidence of rheumatic heart disease and the increasing impact of prosthetic heart valves, nosocomial infection, and intravenous drug misuse. The role of AP in preventing IE has been the focus of much debate in recent years. The usefulness of this practice has been questioned, and several national societies have reassessed the current

Acknowledgments

The authors would like to thank Laura McMahon for carefully reading the manuscript and providing help with the editing of the text in English language.

The authors express their gratitude to Anna Castiglione e Gianni Ciccone for the statistical analysis of the results.

RIEI Investigators

Enrico Cecchi, MD; Massimo Imazio, MD; Silvia Ferro, MD; Cristina Cecchi, Rita Trinchero, MD (Cardiology Department, Maria Vittoria Hospital, Torino, Italy). Francesco Giuseppe De Rosa, MD; Filippo Lipani, MD

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