ABC | Volume 114, Nº1, January 2019

Original Article Risk Factors for In-Hospital Mortality in Infective Endocarditis Ana Marques, 1 I nês Cruz, 1 Daniel Caldeira, 1,2,3, 4 Sofia Alegria, 1 A na Catarina Gomes, 1 A na Luísa Broa, 1 Isabel João, 1 Hélder Pereira 1 Hospital Garcia de Orta EPE, 1 Almada - Portugal Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, 2 Lisbon, Portugal Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, 3 Lisbon, Portugal Centro Cardiovascular da Universidade de Lisboa - CCUL, Faculdade de Medicina, Universidade de Lisboa, 4 Lisbon, Portugal Mailing Address: Ana Marques • Hospital Garcia de Orta EPE - Av Torrado da Silva 2805-267 – Portugal E-mail: ana.smc.25@gmail.com Manuscript received September 01, 2018, revised manuscript February 21, 2019, accepted March 10, 2019 DOI: https://doi.org/10.36660/abc.20180194 Abstract Background: Infective endocarditis (IE) is associated with severe complications and high mortality. The assessment of mortality rates and predictors for fatal events is important to identify modifiable factors related to the pattern of treatment, in order to improve outcomes. Objectives: We sought to evaluate clinical outcomes of patients with IE and to determine predictors of in-hospital mortality. Methods: Retrospective single-center study including patients with IE admitted during a 10-year period (2006-2015). Data on comorbidities, clinical presentation, microbiology and clinical outcomes during hospitalization were evaluated. Risk factors of in-hospital death were analyzed. A p-value < 0.05 was considered significant. Results: A total of 134 cases were included (73% males, mean age of 61 ± 16 years-old). Half of them had previous valvular heart disease. Healthcare-associated IE and negative blood-cultures occurred in 22% and prosthetic IE in 25%. The aortic valve was the one most often affected by infection. Staphylococcus aureus was the most commonly isolated microorganism. Forty-four (32.8%) patients underwent cardiac surgery. The in-hospital mortality rate was 31.3% (42 patients). The identified risk factors for in-hospital mortality were Staphylococcus aureus etiology (OR 6.47; 95% CI: 1.07‑39.01; p = 0.042), negative blood-cultures (OR 9.14; 95% CI: 1.42-58.77; p = 0.02), evidence of valve obstruction in echocardiography (OR 8.57; 95% CI: 1.11-66.25; p = 0.039), clinical evolution with heart failure (OR 4.98; 95%CI: 1.31‑18.92; p = 0.018) or septic shock (OR 20.26; 95% CI: 4.04-101.74; p < 0.001). Cardiac surgery was a protective factor of mortality (OR 0.14; 95% CI 0.03-0.65; p = 0.012). Conclusion: The risk factors for in-hospital mortality were clinical (heart failure, septic shock), evidence of valve obstruction in echocardiography, Staphylococcus aureus etiology or negative blood cultures. Invasive treatment by surgery significantly decreased the mortality risk. (Arq Bras Cardiol. 2020; 114(1):1-8) Keywords: Endocarditis, Bacterial/mortality; Hospitalization; Comorbidity; Shock Septic; Heart Failure; Risk Factors; Echocardiography/methods; Cardiac Surgery. Introduction Infective endocarditis (IE) is associated with severe complications and high mortality, despite the improvements in its medical and surgical management. 1,2 The diverse nature and evolving epidemiological profile of IE ensure that it remains a diagnostic challenge. 2 The presentation and evolution of IE is highly variable, depending on host factors (such as existence of previous cardiac disease, prosthetic valves or implanted cardiac device, as well as factors that modulate the immune response), the microorganism involved and the adequacy of the provided treatment (antibiotics, heart failure medical treatment, surgery). 2 The interplay of these factors results in an in-hospital mortality rate of patients with IE ranging from 15% to 30%. 3-9 The assessment of mortality rates and predictors for fatal events is important to identify modifiable factors and the pattern of treatment in order to further improve the outcomes. This approach identifies the patients at highest risk of death for whom the level of care should be stepped-up. Therefore, we aimed to evaluate the clinical outcomes of patientswith IE and todeterminepredictors of in-hospitalmortality. Methods A retrospective single-center study was performed, including all consecutive adult patients during a 10-year period (January.2006 to December.2015), in a Portuguese public tertiary general hospital, without on-site cardiac surgery department. The protocol was approved by the institutional review board and local ethics committee. The population of interest was all cases of definite or possible IE according to the modified Duke criteria, 10 including those corresponding to patients that had more than one IE episode. For diagnosis purposes, cultural criteria consider as positive cultures during an extended incubation time for blood cultures of up to 21 days, according to the local protocol for IE suspicion. The cases were all identified 1