CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 194 AFRICA A 10-year retrospective analysis of the clinical profile and outcomes of infective endocarditis at a tertiary hospital in KwaZulu-Natal, South Africa Nerissa Sanrisha Naidoo, Somalingum Ponnusamy, Datshana Prakesh Naidoo Abstract Objective: To examine the clinical profile and treatment outcomes of infective endocarditis (IE) at a tertiary hospital in KwaZulu-Natal. Methods: A 10-year retrospective analysis was conducted on cases of definite IE (modified Duke criteria). Results: Ninety-seven subjects (HIV infected, n = 12) satisfied the study criteria (mean age 29.7 ± 15.6 years, M:F 1.4:1). Underlying rheumatic heart disease was present in 84.5% and severe dyspnoea in 67.0% of cases. Staphylococcus aureus was the commonest pathogen isolated (18.6%). Heart failure was present in 61.9% and vegetations were identified in 85 (87.6%) subjects, resulting in 41 (42.3%) embolic events. The clinical profile and outcomes were similar in the HIV-positive and -negative patients. Surgery was performed in 73 subjects (surgical mortality rate 9.5%, total mortality rate 26.4%). Multivariate analysis identified acute-onset IE [odds ratio (OR) 251.46, 95% confidence interval (CI) 1.18–5343.63, p = 0.043], vegetation size > 15 mm (OR 222.60, 95% CI 1.04–4730.34, p = 0.043) and medical management only (OR 20.89, 95% CI 2.12–200.06, p = 0.037) as predictors for increased in-hospital mortality. Conclusion: IE affects young people with underlying rheumatic heart disease and is associated with high morbi-mortality attributable to advanced disease at presentation and to haemodynamic failure resulting from valve destruction due to acute onset of aggressive infection. Keywords: infective endocarditis, HIV positive, rheumatic heart disease, vegetations, surgery Submitted 22/2/21, accepted 13/12/21 Published online 18/1/22 Cardiovasc J Afr 2022; 33: 194–199 www.cvja.co.za DOI: 10.5830/CVJA-2021-063 Infective endocarditis (IE) is an infection that poses a serious health concern for subjects in both the developing and the developed world.1 Despite significant advances in the diagnosis and management, this condition remains a serious challenge.2 Of concern is that neither the incidence nor the mortality rate of IE has decreased over the last few decades.2 In a retrospective, population-based study set in Spain, Olmos et al. reported an in-hospital mortality rate for IE of 20.4%.3 This figure is in keeping with current literature from the Western world, demonstrating a 16–20% in-hospital mortality rate for community-acquired IE, increasing to 24–50% for hospitalacquired IE, and a high one-year mortality rate of 40%.4 It has been postulated that the current high mortality rates associated with IE in the West are due to changes in the riskfactor profile of patients presenting with IE.5 The age-related incidence of IE has changed from a younger to a more elderly patient population.6 There is also a higher incidence of IE in intravenous (IV) drug users and subjects with degenerative valve disease, previous valve surgery, intracardiac devices and in-dwelling catheters.6 This change in the risk-factor profile for IE is considered to be one of the main reasons for the change in the pathogen profile of IE.7 Staphylococcus aureus has emerged as the most common organism isolated in both native and prosthetic valve endocarditis.7 Despite these changing trends in the Western world, IE in southern Africa remains a disease that is predominantly seen in a younger patient population, with rheumatic heart disease (RHD) remaining the main predisposing factor.8 The relationship between chronic RHD and IE, and the emergence of HIV infection was highlighted in two South African studies. The first was a three-year prospective study of IE in Stellenbosch, South Africa, by Koegelenberg et al., who found underlying RHD in 76.6% of their study population.9 None in their study population was an IV drug user and only one subject with definite IE was HIV positive.9 In the second study, also from the Western Cape, South Africa, Koshy et al. reported underlying RHD in 84% of their study population, of whom 8% were HIV infected.10 The impact of HIV infection and the related degree of immunosuppression in subjects with IE has not been clearly defined.11 In Western series, IE in HIV-positive patients has almost exclusively been associated with IV drug users.11 In a 15-year review of 54 infectious disease centres in Italy, Cicalini et al. observed that IV drug abuse was the most important risk factor for the development of IE in HIV-infected patients.11 With the increased susceptibility to bacterial infection caused by HIV-related immunosuppression, it is worth noting that IE is rarely considered a complication of the acquired immunodeficiency syndrome (AIDS).12 Currently HIV infection continues to pose a serious health concern in Third-World settings, with an estimated 7.9 million Department of Internal Medicine, University of KwaZulu Natal, Durban, South Africa Nerissa Sanrisha Naidoo, MB ChB, MMed, FCP (SA), nerissas.naidoo@gmail.com Department of Cardiology, University of KwaZulu Natal, Durban, South Africa Somalingum Ponnusamy, MB ChB, FCP (SA), Cert Cardiology (Physicians) (SA) Datshana Prakesh Naidoo, MD, FRCP
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