Infectious endocarditis in patients with cirrhosis of the liver: a model of infection in the frail patient

Abstract

Abstract:To know whether cirrhosis is a predisposing cause of IE and to determine the microbiology, prognosis and the role of cardiac surgery on mortality. Review of cases of infectious endocarditis in a university-affiliated hospital during 10 years. Thirty-one(9.8%) patients among 316 cases of infectious endocarditis had hepatic cirrhosis. Valve disorders were present in 62.2% of cirrhotic patients and infection occurred on aortic(48%) and mitral valves(45%).Endocarditis was hospital-acquired in 14(45%) and 11(17.7%) of cirrhotic and controls respectively(OR 3.82;95%CI:1.46-9.99;p 0.005).Staphylococcus aureus was the most common causative microorganism but βeta-hemolytic streptococci were most frequently isolated in cirrhotic patients (OR 8.75; 95% CI: 1.7-45.2;p 0.001).Renal failure was more frequent in patients with cirrhosis (OR 8.23; p 0.001).Cirrhotic patients had a higher mortality(51% vs 17.7%; OR 4.95;95%CI:1.89-12.91;p 0.001) associated with the severity of liver disease. Valve replacement was performed less frequently in cirrhotic patients(56.2% vs 92%) and the operative mortality was extremely high in patients with stages B and C. Hepatic cirrhosis is a frequent comorbid condition in patients with endocarditis. Due to the presence severe hepatic dysfunction, cardiac surgery is not undertaken even when indicated and mortality is high in stages B and C. Endocarditis is a serious hazard for hospitalized cirrhotic patients.Response to Reviewers: Dear Dr. Van Belkum:Thank you very much for the opportunity of revising the above mentioned manuscript. In doing the revision, I have taken into account all the suggestions of the reviewer.Firstly, let me tell you why we chose to perform a case-control study instead of a case-cohort comparison. A case-control study is a simple and very useful investigative tool to identify factors that may contribute to the understanding of many medical conditions. In this case, we compared patients with cirrhosis of the liver and endocarditis with subjects with endocarditis but without such underlying disease. In short, we looked back to see if there were characteristics of these patients that differ from those who did not have cirrhosis. The main reasons of our choice were: 1. Simplicity. 2. Accuracy. Because patients were seen over a relatively long period -10 years-we tried to bring nearer cases and controls to avoid biases associated with changes in diagnostic techniques (use of TEE, blood cultures), antibiotic usage or surgical team over the time. For this reason we selected two controls for each case: the previous and the consecutive to the index case.Reviewer:1. Our patients with cirrhosis of the liver were not on any type of chronic antimicrobial therapy with fluoroquinolones or other agents such as those that are administered for the prevention of primary bacterial peritonitis. We have included a short comment on this in the last paragraph of page 7. This is an interesting comment because such intervention may eventually favour enterococcal infections. Our cases, enter...

Epidemiology of Infective Endocarditis in Spain in the Last 20 Years

“…32 Cirrhosis predisposes to the development of concomitant infections due to associated immunosuppression, ambulatory invasive procedures, and frequent hospitalization. In fact, one recent series reported that approximately 40% of patients with cirrhosis had one HAIE vs <20% of the rest of the population with IE.…”

Bloodstream infections in patients with liver cirrhosis

“…In fact, in LC, like in general population, predisposing valve diseases and left-side endocarditis are common (48% aortic valve IE, 45% mitral valve IE) and S. aureus is the main pathogen accounting for 30-80% of cases followed by Streptococcus spp. 58,60 On the other hand, compared with non-cirrhotic population, IE in patients with liver disease is associated with higher rates of renal failure and worse outcome, and less frequently is managed with valve replacement. 60,61 Endotipsitis is a rare complication of TIPS insertion.…”

“…58,60 On the other hand, compared with non-cirrhotic population, IE in patients with liver disease is associated with higher rates of renal failure and worse outcome, and less frequently is managed with valve replacement. 60,61 Endotipsitis is a rare complication of TIPS insertion. Despite the first description of the disease dates back to 1998, the absence of a standard case definition for endotipsitis or TIPS-related infection could have contributed to an underestimation of its true incidence, which it is esteemed to affect 1 to 5% of patients.…”

Infective endocarditis in patients with hepatic diseases

“…A small series was published in 1994, showing a prevalence of S. aureus infection and a high mortality rate [8]. More recently, Fernández Guerrero et al [7] reported data relative to 31 cirrhotic patients with IE; S. aureus was the most frequently pathogen isolated. Also, in this last paper, the prognosis of cirrhotic patients was worse than those of the controls, for the occurrence of acute renal failure and increased surgeryassociated mortality.…”

“…Few data have been published regarding the epidemiology and outcome of IE in patients with CHD, all in small groups of patients [7,8].…”