Cancer and Infective endocarditis: diagnosis and prognostic impact. Results of the ESC-EORP EURO-ENDO (European infective endocarditis) registry: a prospective cohort study
Authors: Cosyns B , Roosens B , Lancellotti P , Marchetta S , Scheggi V , Vilacosta I , Pasquet A , Piper C , Reyes G , Mahfouz E , Kobalava Z , Piroth L , Kasprzak J.D , Iung B , Habib G 
Published: November 2020

Abstract

Background
Little is known about the characteristics of infectious endocarditis (IE) in cancer patients, although their risk may be higher and their presentation non-specific.

Purpose
This study sought to assess the prevalence of cancer in patients with IE in the EURO-ENDO registry and to determine their baseline characteristics, management, outcomes in comparison to cancer-free patients with IE.

Methods
Data were collected from a prospective cohort of 3085 adult patients enrolled in 40 countries between January 2016 and March 2018 with a diagnosis of IE based on the ESC 2015 diagnostic criteria. Clinical, biological, microbiological and echocardiographic findings, use of other imaging techniques, medical therapy, complications, theoretical indications for surgery, in-hospital mortality, and 1-year mortality were analysed in IE patients with and without cancer.

Results
359 (11.6%) cancer patients with IE were identified and compared with 2726 IE patients without cancer. IE was community-acquired in 225/361 (74.8%), and more often nosocomial (18.6%) in healthcare associated cases. IE was native in 209 (60.4%), prosthetic in 97 (28%) and device-related in 30 (8.7%) patients. Microorganisms involved were Enterococci in 72/303 (23.8%), methicillin-sensitive Staphylococci in 63/303 (20.8%), and Streptococcus gallolyticus in 33/303 (10.9%) patients. IE cancer patients received more long-term cortico-therapy and immunosuppressive treatment compared to cancer free IE patients (9.1% vs. 3.9%, P&lt;0.0001 and 11.7% vs. 2.7%, P&lt;0.0001, respectively). Acute renal failure was the most frequent complication, observed in 25.9% of patients, followed by embolic events (21.7%). Congestive heart failure and cardiogenic shock occurred more frequently in cancer patients (18.1% vs. 13.4%, P=0.016; 10.1% vs. 6.3%, P=0.011, respectively).
Cancer IE patients were more frequently treated with amoxicillin (35.8% vs. 26.3%; P=0.0002) and daptomycin (15.2% vs. 10.6%; P=0.0096), but less frequently treated with vancomycin (34.6% vs. 44.9%, P=0.0003). According to the ESC guidelines, theoretical indication for cardiac surgery was not significantly different between groups (65.5% vs. 69.8%, P=0.091), but was effectively less performed when indicated in cancer IE patients during hospitalisation (65.5% vs. 75.0%, P=0.0018).
Compared to cancer-free IE patients, in-hospital and 1-year death occurred in 23.4% vs. 16.1%, P=0.006, and 35.7% vs. 23.1%, P&lt;0.001, respectively. Predictors of mortality by multivariate analysis were creatinine &gt;2 mg/dL, congestive heart failure and unperformed cardiac surgery (when indicated).

Conclusion
We report the largest contemporary series of patients with IE and cancer. The prevalence of cancer in IE patients is common and associated with a worse outcome. Patients with IE and cancer have different clinical characteristics than the general population and should require a specific management.

Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Pharmacological.