CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 AFRICA 195 people infected with HIV in South Africa.13 However, there are insufficient data on the clinical profile of IE in KwaZulu-Natal (KZN), which had the highest prevalence of HIV infection (18.1%) recorded in the country for 2017.13 This study examines the clinical profile and treatment outcomes of IE at a tertiary hospital in KZN with special reference to HIV-positive patients. Methods A retrospective analysis was conducted on patients with a suspected diagnosis of IE over a 10-year period (June 2006 to June 2016) at Inkosi Albert Luthuli Central Hospital (IALCH). IALCH is an 846-bed tertiary referral centre serving patients from KZN, as well as a portion of the Eastern Cape. The study was approved by the Biomedical Research Ethics Committee (BREC) of the University of KwaZulu Natal (BREC No.BE571/16). Case records of suspected IE (ICD 10 coding I33.0) were identified via the hospital’s database and the patient information was accessed. Only cases that met the modified Duke criteria for definite IE were included in the study.14 Briefly, these included clinical criteria based on microbiological, echocardiographic and clinical features (two major criteria, or one major and three minor criteria, or five minor criteria) and pathological criteria (demonstration of micro-organisms in tissue, or vegetation/intracardiac abscess).14 The demographic data, clinical presentation, laboratory, microbiological, histological and echocardiographic data as well as the clinical and surgical outcomes were captured in Microsoft EXCEL. Statistical analysis Descriptive statistics were used to summarise the demographic, clinical and microbiological variables. The categorical variables are expressed as frequencies and percentages. Continuous variables are expressed as means (± SD). The Student’s t-test was used to compare continuous variables, and chi-squared tests were used to compare categorical variables. A p-value of < 0.05 suggested statistical significance for the variables being evaluated. A univariate and multivariate logistic regression model was performed to ascertain the association of mortality and relevant clinical characteristics. The univariate analysis included the variables for demographic data, onset of IE, valve type, HIV status, New York Heart Association (NYHA) class, fever, clubbing, haematuria, heart failure, embolic events, haemoglobin, white cell count, organism cultured, ejection fraction, presence of vegetations, vegetation size and management type. Variables were retained in the multivariate model if the p-value was < 0.25 or if the variable was a known predictor of mortality. Unadjusted and adjusted odds ratios (OR) are presented with their corresponding 95% confidence intervals (CI). Results One hundred and sixty-one patients with a suspected diagnosis of IE were screened over a 10-year period. Ninety-seven cases were classified as definite IE, 54 cases as possible IE and 10 cases were rejected. The 97 patients with definite IE fulfilled clinical criteria in 80 cases and pathological criteria in the other 17 cases. They comprised the study group and were further classified according to their HIV status (HIV positive, n = 12; HIV negative, n = 85). The mean age of the study population was 29.7 ± 15.6 years. The majority were of black African descent (79.4%) and were under the age of 30 years (n = 59, 60.8%). Among the HIV-negative subjects, there was a male predominance with a M:F ratio of 1.7:1, whereas nine of the 12 HIV-positive subjects were female (Table 1). The most frequent predisposing factor to IE in this study population was underlying RHD, which was present in 82 cases (84.5%) and included all 12 of the HIV-positive subjects. IE secondary to congenital heart disease (six cases), indwelling venous catheters (five), IV drug use (two), pacemaker sepsis (one) and septic arthritis (one) were present in the remaining 15 subjects. In 28 cases (28.9%), the onset of IE was acute. There was no significant difference in the mode of onset between the HIV-positive and HIV-negative subgroups (25.0 vs 29.4%, p = 0.752) (Table 1). Left-sided disease predominated in both groups (HIV positive, n = 12, 100%; HIV negative, n = 73, 85.9%, p = 0.164). Ten cases (10.3%) of prosthetic valve endocarditis were observed, none of whom were HIV positive. Non-valvular IE (related to pacemaker sepsis) was identified in one HIV-negative subject. The clinical presentation was characterised by pallor (80.4%) and high-grade dyspnoea (NYHA III and IV) in 67% of the subjects. Clubbing (75.0 vs 35.3%, p = 0.009), haematuria (58.3 vs 29.4%, p = 0.046) and splenomegaly (33.3 vs 9.4%, p = 0.018) were more common in the HIV-positive group. Heart failure, acute kidney injury and embolic episodes were the most common complications of IE. There was no difference in the prevalence of heart failure (66.7 vs 61.2%, p = 0.714), acute kidney injury (33.3 vs 28.2%, p = 0.280) or embolic events (33.3 vs 45.5%, p = 0.503) between the HIV-positive and HIV-negative subgroups, respectively (Table 2). There were four cases of repeat infection in the HIV-negative group. Table 1. Baseline characteristics of IE stratified by HIV status Parameters HIV (+) n = 12 (%) HIV (–) n = 85 (%) Total n = 97 (%) p-value Age, years (mean ± SD) 33.8 ± 9.0 29.2 ± 16.3 29.7 ± 15.6 0.211 Gender Male* 3 (25.0) 54 (63.5) 57 (58.8) 0.011 Female 9 (75.0) 31 (36.5) 40 (41.2) Onset Acute 3 (25.0) 25 (29.4) 28 (28.9) 0.752 Non-acute 9 (75.0) 60 (70.6) 69 (71.1) Site Left side 12 (100.0) 73 (85.9) 85 (87.6) 0.164 Right side 0 (0.0) 12 (14.1) 12 (12.4) Valve type Native 12 (100.0) 74 (87.0) 86 (88.7) 0.417 Prosthetic 0 (0.0) 10 (11.8) 10 (10.3) Non-valvular** 0 (0.0) 1 (1.2) 1 (1.0) Predisposing factors Poor dentition 2 (16.7) 11 (12.9) 13 (13.4) 0.723 Pregnancy 0 (0.0) 3 (3.5) 3 (3.1) 0.509 Rheumatic heart disease 12 100.0) 70 (82.4) 82 (84.5) 0.129 Septic arthritis 0 (0.0) 1 (1.2) 1 (1.0) 0.706 Congenital heart disease 0 (0.0) 6 (7.1) 6 (6.2) 0.342 Pacemaker lead sepsis 0 (0.0) 1 (1.2) 1 (1.0) 0.706 Venous catheter sepsis 0 (0.0) 5 (5.9) 5 (5.2) 0.388 *Male gender was more common in the HIV-negative group. The rest of the baseline characteristics were similar in both groups. **Pacemaker lead sepsis.
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