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Incidence and risk of developing fungal prosthetic valve endocarditis after nosocomial candidemia
R M Nasser1, G R Melgar, D L Longworth
1Department of Infectious Disease, Cleveland Clinic Foundation, Ohio 44195, USA.
Purpose:
To determine the incidence of prosthetic valve endocarditis (PVE) in fungemic patients with prosthetic heart valves (PHV), estimate risk of subsequent PVE, and describe risk factors and diagnostic and therapeutic management issues in such patients.
Patients And Methods:
This is a retrospective chart review in a 1,100-bed tertiary referral center with an active cardiothoracic surgical service. Forty-four patients with PHVs developed nosocomial fungemia between January 1985 and April 1995.
Results:
Of 44 patients, 33 never developed evidence of PVE (group 1), 7 (16%) had evidence of PVE at the time of candidemia (group 2), and 4 (9%) developed PVE a mean of 232 days after candidemia (group 3). Predisposing factors including intravascular lines, prior antibiotic therapy, and an identifiable portal of entry for fungemia were common in group 1 but not group 2. Candidemia occurred significantly later after PHV surgery in group 2 (mean 270 days) as compared to groups 1 and 3 (means 48 and 15.5 days, respectively; P = 0.02). Ten of 11 patients with Candida PVE (group 2 and 3) were treated with amphotericin B and valve replacement. Three relapses after combined therapy were documented in two patients. Mortality was significantly higher for patients without Candida PVE (group 1) as compared to patients with Candida PVE (groups 2 and 3) at 1 month (53% vs 9%), 2 months (69% vs 20%) and 1 year (83% vs 25%) after candidemia.
Conclusions:
Patients with prosthetic heart valves who develop nosocomial candidemia are at notable risk of either having or developing Candida PVE months or years later. Late onset candidemia and lack of an identifiable portal of entry should heighten concern about Candida PVE in such patients.
Insights
Patients with prosthetic heart valves (PHV) who develop candidemia face a significant risk of prosthetic valve endocarditis (PVE). Early diagnosis and treatment, including amphotericin B and valve replacement, are crucial for improving outcomes in these high-risk patients.
Area of Science:
- Infectious Diseases
- Cardiology
- Medical Mycology
Background:
- Nosocomial candidemia poses a serious threat to patients with prosthetic heart valves (PHV).
- Understanding the incidence and risk factors for prosthetic valve endocarditis (PVE) in this population is critical for patient management.
Purpose of the Study:
- To determine the incidence of PVE in fungemic patients with PHV.
- To estimate the risk of subsequent PVE.
- To describe risk factors and management strategies for PVE in patients with PHV.
Main Methods:
- Retrospective chart review of 44 patients with PHVs who developed nosocomial fungemia.
- Analysis of PVE development, risk factors, and treatment outcomes.
- Comparison of patient groups based on PVE development.
Main Results:
- Of 44 patients, 11 (25%) developed PVE, with 7 at diagnosis and 4 later.
- Late candidemia after PHV surgery was associated with PVE.
- Mortality was significantly higher in patients without PVE compared to those with PVE.
Conclusions:
- Patients with PHV and candidemia are at notable risk of developing PVE, even years later.
- Late-onset candidemia and lack of an identifiable entry portal warrant heightened suspicion for PVE.
- Combined therapy with amphotericin B and valve replacement is indicated, though relapses can occur.