Temporary trends of cardiac device related infective endocarditis in a tertiary referral center between 2006 and 2022
Authors: Denes M , Bence A , Matus M , Kolossvary M , Foldesi C S , Vertesaljai M 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Infective endocarditis (IE) is a rare, but life-threatening complication of cardiac device implantation. Despite recent preventive strategies and advances in antimicrobial and surgical treatment, morbidity and mortality rates are still high.

Aims
The objective of our study was to assess the epidemiological characteristics, temporal trends and mortality rates of cardiac device related IE (CDRIE) in our high-volume, tertiary referral center.

Methods
retrospective data collection was performed between January 1, 2006 and March 31, 2022. Median follow-up was 3.8 yrs (IQR: 0.6 – 9.2 yrs). Patients admitted between 2006 and 2013 (group 1) and between 2014 and 2022 (group 2) were compared to assess temporal trends. Thirty-day, 6-month and 1-year mortality rates were estimated.

Results
During the observed 17 years 82 patients were admitted with CDRIE (61 males [74%]), mean age: 57.3 ±18 yrs; 6 VVI, 7 VDD, 17 VVI-ICD, 24 DDD, 10 DDD-ICD and 18 CRT devices [4 CRT-P, 14 CRT-D]); median time since first implantation was 3.8 yrs [IQR: 1.1 – 6.6 yrs]). Staphylococci were the most prevalent infective agents (62%), S. aureus (SA) infection was found in 37 cases (out of whom 13 were MRSA [16%]), coagulase negative Staphylococcus in 14 cases (17%), Enterococcus faecalis in 9 cases (11%), streptococci in 4 cases (5%), blood culture was negative in 13 cases (15%), and in 5 cases other pathogens were the underlying microorganism. Patients in Group 1 (n=42) did not differ from patients in Group 2 (n=40) in terms of age, male gender or ejection fraction. Patients in Group 2 had higher CRP level at admission (42,9 [IQR:34-55] mmol/l vs 90 [IQR:25-60] mmol/l, p=0.02). ICD lead (29% vs 67%, p&lt;0.001) and E. faecalis infection (2% vs 20%, p=0.03) and percutan extraction (55% vs 75%, p=0.05) were more prevalent in Group 2. The 30-day and 6-month mortality rates were worse in Group 2 than in Group 1 (2% vs 17.5% p=0.03; and 16% vs 35% p=0.04 resp.) while the 1-year mortality did not differ (24% vs 40%). The all-cause mortality was 10% at 30 days, 26% at 6 month and 32% at 1 year. Univariate regression showed that age (HR: 1.03 [1.01-1.07] p&lt;0.05), ejection fraction (HR: 0.96 [0.93-0.98] p&lt;0.005), ICD lead (HR: 4.89 [1.82-14.40] p&lt;0.005) and the time since first implantation (HR: 0.88 [0.77-0.98] p&lt;0.05) were the predictors of 1-year mortality. However, in Cox multiple regression model only age (HR: 1.05 [1.004-1.1] p&lt;0.05) and ICD lead (HR: 1.16 [1.16-17.38] p&lt;0.05) remains independent predictors of outcome at 1 year.

Conclusions
In the past 17 years the most prevalent underlying microorganism were staphylococcal species, although Enterococcus faecalis infection increased over time. Patients with CDRIE had poor prognosis, every third patient died at 1 year after diagnosis. The short-term prognosis is even worse in the past few years than before, which may be a negative consequence of limited accessibility of healthcare due to COVID 19 pandemic.