Infective Endocarditis in Septic Shock: Results From an Observational Multicenter Study

Introduction Infective endocarditis (IE) in patients with septic shock poses diagnostic challenges due to overlapping systemic effects and comorbidities, making early recognition crucial for improving outcomes. This study aimed to characterize the clinical features, diagnostic findings, and outcomes of IE in septic shock to inform better early recognition and management strategies in emergency and critical care settings. Methodology A multicenter observational study was conducted across three tertiary care hospitals in Pakistan over two years, involving 300 patients presenting with septic shock and confirmed IE. Adults aged 18 years or older who met the Sepsis-3 criteria and were diagnosed with IE using the modified Duke criteria were included. Data collected included demographics, clinical characteristics, imaging results, blood cultures, inflammatory markers, treatment plans, and outcomes (e.g., mortality, embolic events, ICU admission). Multivariate analysis identified independent predictors of adverse outcomes, adjusting for confounders such as age and comorbidities. Missing data were addressed using multiple imputations, which allows for the creation of several plausible datasets to account for uncertainty and minimize bias. This method was selected over simpler approaches, such as mean or median imputation, to enhance the robustness of our findings. Results The mean age was 55.20 ± 14.70 years, the incidence of echocardiographic positivity was 96.33% (n=289), and blood culture positivity was 92.67% (n=278). At admission, patients exhibited varying degrees of septic shock severity based on hemodynamic instability, with hypotension (83.33%) being a prominent feature. Fever (90%) and dyspnea (60%) were among the most frequently reported symptoms. Diagnostic challenges were encountered in 12% of cases, where initial differential diagnoses excluded IE but were later revised based on echocardiographic and microbiological confirmation. Pathogens predominantly included Staphylococcus aureus (50%) and Streptococcus species (30%), with polymicrobial infections noted in 8% of cases. Complications included embolic events (33%), heart failure (28%), renal dysfunction (25%), and neurological involvement such as stroke (10%). ICU admission was required in 50% (n=150) of cases, and in-hospital mortality occurred in 17% (n=51). Predictors of adverse outcomes included older age (AOR: 1.05, 95% CI: 1.02-1.08, p=0.001), prior cardiovascular disease (AOR: 2.14, 95% CI: 1.12-4.08, p=0.021), echocardiographic positivity (AOR: 2.43, 95% CI: 1.36-4.34, p<0.001), blood culture positivity (AOR: 2.50, 95% CI: 1.43-4.34, p<0.001), embolic events (AOR: 3.10, 95% CI: 1.86-5.14, p<0.001), and elevated inflammatory markers (AOR: 2.34, 95% CI: 1.43-3.83, p<0.001).  Conclusion This study reveals that early identification of IE in patients with septic shock is essential for improving outcomes. Key findings include the high diagnostic value of echocardiography and blood cultures in confirming IE, with prior cardiovascular disease emerging as a significant predictor of adverse outcomes. Embolic events and elevated inflammatory markers also played critical roles in predicting patient prognosis. A focused approach to early diagnosis, particularly through these key diagnostic tools, is crucial for timely intervention. Prioritizing these factors in clinical practice can help improve patient outcomes, especially in emergency and resource-limited settings.