ENDOCARDITIS IN AN URBAN HOSPITAL IN THE 1990S

Objectives: To analyze the clinical characteristics and outcome of 159 consecutive patients with endocarditis who presented to an inner-city hospital from 1990 onward and to elucidate the most current problems and advances in the management of endocarditis. Methods: One hundred e ighty-two consecutive cases (in 159 patients) met diagnostic criteria for endocarditis, including histopathologic evidence or multiple posit ive blood cultures without another primary source, and appropriate sig ns or symptoms. Transthoracic echocardiography was performed for 171 c ases, and 36 patients underwent transesophageal echocardiography. Resu lts: Sixty-seven percent of the patients were known drug users: more t han 80% of these were positive for human immunodeficiency virus. Fever . malaise. and fatigue occurred in moro than 95%, but other signs were neither sensitive nor specific, and classic microvascular phenomena w ere uncommon. Blood cultures were positive in 96%; all 7 patients with negative cultures had received prior antibiotic therapy. Staphylococc us aureus was the most common organism, and a significant increase in S aureus infections was noted for tricuspid endocarditis (chi(2)=71.07 , P=.003). The mitral (n=51) and tricuspid (n=49) valves were the most common si res of infection. Underlying heart disease was only identif ied in one fourth of the cases. Transesophageal echocardiography ident ified vegetation in 34 of 36 studies, 16 of which had negative transth oracic echoes, Five of 6 patients with documented abscesses died withi n 7 months. A systemic embolism occurred in nearly a third (n=51) of t he cases. Large vegetations (>20 mm) were significantly correlated wit h an increased frequency of embolization (chi(2)=6.77, P=.009), but ve getation mobility was not. Cardiac surgery was performed in 24 patient s; there were 2 perioperative deaths. Conclusions: The changing clinic al spectrum of endocarditis exemplified in our series has important im plications for diagnosis and management. Close attention to appropriat e risk factors can contribute to optimal management of those factors a nd improve prognosis.