Infective endocarditis in an Indian setup: Are we entering the ′modern′ era?

Abstract

Background:The clinical profile of infective endocarditis (IE) has been continuously evolving over last 3-4 decades as highlighted by many studies from developed world.Objectives:To evaluate the recent changes in the spectrum and clinical profile, and outcome of IE in an Indian setup.Materials and Methods:This was a descriptive, cross-sectional study. Demographic, clinical, characteristics, treatment, and outcome were examined in ‘definite’ cases of IE admitted at our institute between July 2005 and December 2010.Results:61 ‘definite’ cases were identified. Mean patient age was 49.3 ± 13.7 years. Male to female ratio was 3.3:1. Rheumatic heart disease was the underlying heart disease in 23 (37.7%) patients. 33 (54.1%) patients had already received antibiotic therapy before presentation to us. Blood cultures were positive in 41 (67.2%) patients. Streptococci and staphylococci were the commonest microbial isolates, 9 (21.4%) patients each. Transesophageal echocardiography (TEE) was done for all the patients. Vegetations were detected in 54 (88%) patients. Surgery was done in 30 (49.2%) patients. In-hospital mortality happened in 4 (6.5%) patients.Conclusions:We recorded several new trends, like: 1) an increasing age, 2) an increasing proportion of patients with no previously known heart disease, 3) improving culture positivity rates, 4) rise in staphylococcal infections, 5) increased usage of TEE, 6) high elective surgical rate, and 7) apparent improved survival rates. These changes point to the fact that ‘modern era’ changes in the profile of IE have started to appear in a selected population in India.

Infective Endocarditis in Low- and Middle-Income Countries

“…Staphylococcus accounts for 15-50% of cases with Staphylococcus aureus more common than coagulase negative Staphylococcus (CoNS). [19][20][21][22][23]25,31,32,34 Comparison with pre-millennial ranges shows an increase in Staphylococcus which was previously reported in less than 20% of cases. 11,13,28 The emergence of Staphylococcus as a leading cause of IE in LMICs, a trend that was also previously noted in HICs, may reflect medical technology advances, increased hospital contact and increasing comorbidities.…”

“…[19][20][21][22][23][24] Nel et al 25 however, reported a much higher (78%) prevalence of underlying RHD in their study in South Africa, a country where RHD is endemic. 26 Overall, this range of underlying RHD in IE represents a decline from the 45-80% reported in earlier (pre-2000) LMIC studies.…”

“…2 Degenerative valve disease (DVD) contributes little to the IE epidemiology in LMICs, accounting for less than 10% of cases. 19,21,23,32 Elbey et al 31 however, reported a high rate of DVD (23%) in a multicentre retrospective study in Turkey. Mean patient age was 47 years, higher than that typically seen in LMIC studies, which may explain the higher rate of DVD.…”

“…15 Underlying CHD accounts for 5-23% of reported IE cases. 19,21,[23][24][25]31,32 Math et al 20 reported CHD as the leading cause of IE (39%) in northern India. This study was conducted in a cardiac surgery centre and included a large paediatric population which may account for the higher findings of CHD.…”

“…[19][20][21][22][23]31,32 UMIC studies account for the higher figures in these ranges, which reflects advances in medical technology and higher access to cardiac surgery. 21,22 Indeed, the largest report of PVE cases from a LMIC comes from Simsek-Yavuz et al 21 who reported findings from a referral centre in Turkey (an UMIC) in which 141 patients (44%) among 325 IE cases had PVE.…”