Endocardite infecciosa por bactérias gram-negativas não-HACEK: estudo multicêntrico
Endocardite infecciosa por bactérias gram-negativas não-HACEK: estudo multicêntrico
Data
2021-05
Autores
Sousa, Leonardo Paiva de
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
Endocardite infecciosa (EI) permanece como doença com alta morbimortalidade.
Endocardites causadas por bactérias não usuais, como bactérias Gram-negativas
não-HACEK (BGNNH), têm aumentado. Estes microrganismos podem estar
associados a formas mais graves de EI. Estudos sugerem que infecções relacionadas
à assistência à saúde parecem estar associadas à EI causada por BGNNH, inclusive
a realização de procedimentos cirúrgicos, como troca valvar cardíaca, a inserção de
marca-passo e outros. O objetivo deste estudo é descrever as características clínicas
e fatores de risco associados à aquisição de EI por BGNNH. Este estudo prospectivo
observacional incluiu pacientes com diagnóstico definitivo de EI através dos critérios
modificados de Duke com cultura positiva para BGNNH em 4 hospitais no Brasil entre
os anos de 2006 e 2019. Dos 1154 pacientes incluídos, 38 (3,3%) apresentaram EI
por BGNNH. A mediana de idade foi de 57 (intervalo interquartílico, 43-69) anos. Eram
do sexo masculino 25/38(65,8%) e 32/38(84,2%) apresentou EI aguda. Os agentes
etiológicos mais comuns foram Pseudomonas aeruginosa e Klebsiella spp. (8
episódios, 21% cada), Serratia marcescens (6 episódios, 16%), Enterobacter spp. (6
episódios, 16%), Acinetobacter spp. e Burkholderia cepacia (3 episódios, 10% cada).
Piora da função cardíaca foi encontrada em 18/38(47,4%) dos pacientes. Eventos
embólicos ocorreram em 18/38(47,4%) sendo a maioria para o sistema nervoso
central 7/38(18,4%). Comorbidades foram frequentes, como insuficiência cardíaca
prévia 19/38(50%) e doença renal crônica 17/38(44,7%). Regurgitação valvar nova foi
encontrada em 5/38(13,2%), vegetações aórticas em 17/38(44,7%) e mitrais em
16/48(42,1%). Valvas protéticas foram afetadas em 19/38(50%) e dispositivos
cardíacos em 6/8(15,8%). Exposição a cuidados de saúde recentes foi identificado em
52,6% dos pacientes. Mortalidade foi de 19/38(50%). A maioria das infecções foi
causada por agentes susceptíveis a maioria das classes de antimicrobianos
30/38(79%). Fatores relacionados a óbito foram presença de cateter venoso central
(OR=5,93, IC=1,29-27,3, p=0,017), ter disfunção renal crônica (p=0,049, IC=1,20-19,1
e OR=4,8) e hemodiálise (OR=16,2 IC=1,78-147, p=0,008). A incidência de EI por
BGNNH encontrada foi similar a encontrada em estudos prévios. Infecções
nosocomiais envolvendo enterobactérias e Pseudomonas aeruginosa, patógenos
oportunistas e formadores de biofilme predominaram. Valvas protéticas e demais
dispositivos intracardíacos foram mais afetados com alta taxa de mortalidade.
Infective endocarditis (IE) is still a disease with high morbimortality. The etiology of IE is changing. Endocarditis caused by bacteria not commonly associated with this pathology, like non-HACEK Gram-negative bacilli (GNB), has increased. These microorganisms may be involved in more aggressive forms with multiple IE cardiac lesions. Studies suggest that surgical procedures, including pacemaker insertion and heart valve replacement are implicated in IE due to GNB. The aim of this study is to describe the clinical characteristics and risk factors associated to IE due to GNB in a large multi-national cohort. This prospective observational study included consecutive patients with definitive IE diagnosed by modified Duke criteria with positive culture for GNB in 4 hospitals in Brazil between 2006 and 2019. Of 1154 patients enrolled, 38 (3.3%) had IE due to GNB. The median age of the cohort was 57 (interquartile range, 43-69) years. Majority 25/38(65.8%) were male and 32/38(84.2%) had acute IE. Most common etiologies were Pseudomonas aeruginosa and Klebsiella sp. (8 episodes, 21% each), Serratia marcescens (6 episodes, 16%), Enterobacter sp., (6 episodes, 16%), Acinetobacter sp. and Burkholderia cepacia (3 episodes, 10% each). Worsening heart failure was found in 18/38(47.4%) of subjects. IE was associated with a higher prevalence of embolic events 17/38(47.4%) mostly to the central nervous system 7/38(18.4%). High rates of comorbidities as heart failure 19/38(50%) and chronic renal disease 18/38(44.7%) were found. Valvular regurgitations were detected in 5/38(13.2%) and vegetations were most localized on aortic valves 17/38(44.7%). Prosthetic valves 19/38(50%) and device-related IE 6/8(15.8%) were more common. Health care exposure was found in 52.6% of patients. Mortality was 19/38(50%). 30/38(79%) of IE due to GNB were caused by microorganisms susceptible to most microbial agents. Risk factors associated to mortality were found in patients indwelling central venous catheter (OR=5,93, CI=1,29-27,3, p=0,017), with chronic kidney disease (p=0,049, CI=1,20-19,1 e OR=4,8) and performed hemodialysis (OR=16,2 CI=1,78-147, p=0,008). IE due to GNB rates were similar to previous studies. Pseudomonas aeruginosa is a classical opportunistic pathogen and well-known for its tendency to colonize surfaces in a biofilm. These characteristics might also explain the reason why health care-related infection was more often found. Prosthetic valve and intracardiac devices were more affected characterized by a high mortality rate.
Infective endocarditis (IE) is still a disease with high morbimortality. The etiology of IE is changing. Endocarditis caused by bacteria not commonly associated with this pathology, like non-HACEK Gram-negative bacilli (GNB), has increased. These microorganisms may be involved in more aggressive forms with multiple IE cardiac lesions. Studies suggest that surgical procedures, including pacemaker insertion and heart valve replacement are implicated in IE due to GNB. The aim of this study is to describe the clinical characteristics and risk factors associated to IE due to GNB in a large multi-national cohort. This prospective observational study included consecutive patients with definitive IE diagnosed by modified Duke criteria with positive culture for GNB in 4 hospitals in Brazil between 2006 and 2019. Of 1154 patients enrolled, 38 (3.3%) had IE due to GNB. The median age of the cohort was 57 (interquartile range, 43-69) years. Majority 25/38(65.8%) were male and 32/38(84.2%) had acute IE. Most common etiologies were Pseudomonas aeruginosa and Klebsiella sp. (8 episodes, 21% each), Serratia marcescens (6 episodes, 16%), Enterobacter sp., (6 episodes, 16%), Acinetobacter sp. and Burkholderia cepacia (3 episodes, 10% each). Worsening heart failure was found in 18/38(47.4%) of subjects. IE was associated with a higher prevalence of embolic events 17/38(47.4%) mostly to the central nervous system 7/38(18.4%). High rates of comorbidities as heart failure 19/38(50%) and chronic renal disease 18/38(44.7%) were found. Valvular regurgitations were detected in 5/38(13.2%) and vegetations were most localized on aortic valves 17/38(44.7%). Prosthetic valves 19/38(50%) and device-related IE 6/8(15.8%) were more common. Health care exposure was found in 52.6% of patients. Mortality was 19/38(50%). 30/38(79%) of IE due to GNB were caused by microorganisms susceptible to most microbial agents. Risk factors associated to mortality were found in patients indwelling central venous catheter (OR=5,93, CI=1,29-27,3, p=0,017), with chronic kidney disease (p=0,049, CI=1,20-19,1 e OR=4,8) and performed hemodialysis (OR=16,2 CI=1,78-147, p=0,008). IE due to GNB rates were similar to previous studies. Pseudomonas aeruginosa is a classical opportunistic pathogen and well-known for its tendency to colonize surfaces in a biofilm. These characteristics might also explain the reason why health care-related infection was more often found. Prosthetic valve and intracardiac devices were more affected characterized by a high mortality rate.
Description
Palavras-chave
Endocardite infecciosa, Bacilo Gram-negativo, não-HACEK, Infecção nosocomial, Cateter venoso central, Infective endocarditis, Gram-negative bacilli, non-HACEK, Health care-associated infection, Central venous catheter
Citação
Sousa LP. Endocardite infecciosa por bactérias gram-negativas não-HACEK: estudo multicêntrico. Dissertação [Mestrado Profissional em Ciências Cardiovasculares]. Instituto Nacional de Cardiologia; 2021.