THE INCREASING IMPORTANCE OF HEALTH CARE-ASSOCIATED INFECTIVE ENDOCARDITIS

Transcription

1 THE INCREASING IMPORTANCE OF HEALTH CARE-ASSOCIATED INFECTIVE ENDOCARDITIS Javier López Díaz Instituto de Ciencias del Corazón (ICICOR) Hospital Clínico de Valladolid, Spain No conflict of interest

2 Page 2 INTRODUCTION

3 Introduction Age* Rheumatic* Dental manipulation* S. viridans* Page 3 * p<0.05 Endoval database: n~ 1000

4 Trends in mortality rates in infective endocarditis mortality Increasing age Increasing HCAIE pre-antibiotic antibiotics CV surgery Page 4 Kay et al. NEJM 1961; Cates et al. QJM 1951; Wallace et al. Circulation 1965

5 Patient distribution by decades 160 n >90 years Page 5 López J, et al. Circulation 2010

6 Increasing mortality in old patients Page 6 Durante-Mangoni E. Arch Intern Med 2008

7 Trends in mortality rates in infective endocarditis mortality Increasing age Increasing HCAIE pre-antibiotic antibiotics CV surgery Page 7 Kay et al. NEJM 1961; Cates et al. QJM 1951; Wallace et al. Circulation 1965

8 Page 8 DEFINITIONS

9 Definitions Conceptually, heath care-associated infective endocarditis (HCAIE) is that endocarditis in which the infection has been acquired in a health care environment Confusion in the terminology Guidelines definitions Page 9

10 Definition Page 10 Habib G, et al. Eur Heart J 2009

11 Page 11 EPIDEMIOLOGY

12 Epidemiology 57.5% 42.5% CAIE HCAIE Correa de Sa, et al. Mayo Clin Proc 2010 Page 12

13 Epidemiology 7.5% 50% 42.5% CAIE Non nosocomial HCIE Nosocomial IE Correa de Sa, et al. Mayo Clin Proc 2010 Page 13

14 Epidemiology 57.5% 42.5% CAIE HCAIE 43% 57% Correa de Sa, et al. Mayo Clin Proc 2010 Sy RW, et al. Eur Heart J 2010 Page 14

15 Epidemiology: native valve IE 35% 65% CAIE HCAIE 24% 76% Benito N, et al Arch Intern Med 2009 Lomas JM, et al. Clin Microbiol Infect 2010 Page 15

16 Regional differences in prevalence of HCAIE Page 16 Benito N, et al. Arch Intern Med 2009

17 Page 17 PROFILE OF HCAIE

18 Demographic profile Health Community p Care IE IE Age, median age ± SD 65 ± ± Female sex 53% 27% <0.05 Charlson index, mean value ± SD 2.5 ± ± Diabetes mellitus 25% 13% <0.001 Cancer 16% 7% <0.001 Chronic renal failure 21% 5% <0.001 Immunosuppresive therapy 4% 15% <0.001 Fernández-Hidalgo N. Clin Infect Dis 2008 Sy RW. Eur Heart J 2010 Page 18 Benito N. Ann Intern Med 2009 Lomas JM. Clin Microbiol Infect 21010

19 Clinical and echocardiographic profile Health Community p Care IE IE Prosthetic valve 29% 18% Aortic alone 31% 45% Mitral alone 43% 28% Heart faliure 20% 13% Septic shock 22% 11% <0.001 Acute renal failure 51% 24% <0.001 Lenght of stay, days, median (IQR) 35 (17-50) 30 (15-44) <0.001 Fernández-Hidalgo N. Clin Infect Dis 2008 Sy RW. Eur Heart J 2010 Page 19 Benito N. Ann Intern Med 2009 Lomas JM. Clin Microbiol Infect 21010

20 Microbiological profile Health Care IE Staphylococcus aureus 34% MRSA 29% Enterococcus species 23% Coagulase negative staphylococci species 22% Viridans group streptococci 11% Other 8% Negative cultures 2% Page 20 Fernández-Hidalgo N, et al. Clin Infect Dis 2008

21 Microbiological profile Health Community p Care IE IE Staphylococcus aureus 34% 21% MRSA 29% 7% Enterococcus species 23% 8% 0.01 Coagulase negative staphylococci species 22% 8% 0.01 Viridans group streptococci 11% 27% Other 8% 12% 0.32 Negative cultures 2% 7% 0.16 Page 21 Fernández-Hidalgo N, et al. Clin Infect Dis 2008

22 Microbiological profile Health Community p Care IE IE Staphylococcus aureus 34% 21% MRSA 28% 7% Enterococcus species 23% 8% 0.01 Coagulase negative staphylococci species 22% 8% 0.01 Viridans group streptococci 11% 27% Other 8% 12% 0.32 Negative cultures 2% 7% 0.16 Page 22 Fernández-Hidalgo N, et al. Clin Infect Dis 2008

23 Page 23 OUTCOME IMPLICATIONS

24 In-hospital mortality Nº patiens (HCAIE/CAIE) Mortality HCAIE Mortality CAIE Fernández-Hidalgo N 83/209 46% 22% <0.005 Benito N 557/ % 13% <0.001 Lomas JM 127/666 45% 24% <0.001 Sy RW 463/ % 11% <0.001 p Page 24 HCAIE: health care associated infective endocarditis CAIE: community-acquired infective endocarditis

25 Outcome Page 25 Sy RW, et al. Eur Heart J 2010

26 Predictors of in-hospital mortality in IE Page 26

27 Predictors of in-hospital mortality in HCAIE Enterococcus species Surgery indicated but not performed Congestive heart failure Stroke OR 0.18 CI 95% ( ) OR 3.74 CI 95% ( ) OR 5.48 CI 95% ( ) OR 8.95 CI 95% ( ) Page 27

28 Page 28 WHAT CAN WE DO?

29 What can we do? 1) Prevention - Avoid unnecesary iv lines - Asepsia in invasive manipulations - Protocols care vascular accesses Page 29

30 What can we do? 1) Prevention 2) Early diagnosis 3) Antibiotic treatment according to the microbiological profile 4) Aggresive surgical treatment? 5) Experienced centres Page 30

31 What can we do? 1) Prevention 2) Early diagnosis 3) Antibiotic treatment according to the microbiological profile 4) Aggresive surgical treatment? 5) Experienced centres Page 31

32 What can we do? 1) Prevention 2) Early diagnosis 3) Antibiotic treatment according to the microbiological profile 4) Aggresive surgical treatment? 5) Experienced centres Page 32

33 What can we do? 1) Prevention 2) Early diagnosis 3) Antibiotic treatment according to the microbiological profile 4) Aggresive surgical treatment? 5) Experienced centres Page 33