Nosocomial endocarditis in the intensive care unit:: An analysis of 22 cases

Objectives: To review the intensive care unit experience of patients with admitted or acquired nosocomial endocarditis (NE) defined according to the Duke criteria. Design: Prospective, cohort study, Setting: University teaching hospital. Patients: We reviewed the records of 22 patients documented with NE during a 6-yr period from 1992 to 1997, Interventions: None. Measurements and Main Results: Twenty-two patients (9 women/13 men) aged 38-83 yrs (mean 65 +/- 9 yrs) had a NE (prevalence of 5 per 1,000 admissions). For six patients, NE was the reason for the admission to the intensive care unit. For 17 patients, the time elapsed between admission and diagnosis of ME was 39 +/- 25 days. Sixteen patients were predisposed to infection and seven had underlying heart conditions that put them at risk for acute endocarditis: three prosthetic valves, two valvular diseases, and two cardiac pacemakers, In 21 cases (one unknown portal of entry), NE was the consequence of bacteremia related to a medical or surgical procedure: 11 intravascular devices, eight surgical wounds, one tracheal procedure, and one leg ulceration. The bacteriologic agents detected in blood cultures were: staphylococci (n = 17), Strepfococcus (n = 2), Pseudomonas aeruginoss (n = 2), and Candida (n = 2), Fourteen patients underwent echocardiography according to cardiac signs (cardiac failure, new cardiac murmur, or embolic event), For the eight remainders, echocardiography was performed systematically because of fever and positive blood cultures. The lesions detected by 21 transthoracic and 17 transesophageal echocardiographs were the following: vegetations (n = 19), myocardial abscesses (n = 5), and valvular perforation (n = 1), On 16 surgical indications, only five patients underwent surgery because the others were in too poor of a condition. The overall mortality was 68% (n = 15) and was directly associated with NE in 36% of cases (n = 8), Seven patients (28%) were discharged 34 days after the diagnosis of endocarditis, Conclusions: NE is a frequent nosocomial infection that occurs late during hospitalization. Persistent fever with positive blood cultures is sufficient symptomology to promptly perform an echocardiogram, The poor prognosis is related to the poor condition of those patients who cannot be referred for surgical treatment.