Severe Liver Failure Is Strongest Independent Risk Factor for Mortality in Infectious Endocarditis

The strongest risk factor for mortality related to infectious endocarditis (IE) was severe liver failure, according to research in the European Journal of Gastroenterology & Hepatology.

To investigate the characteristics and predictors of mortality from IE in those with liver cirrhosis (LC), 101 patients with LC and 101 control patients with IE were matched for age, date of IE diagnosis, sex, and diabetes. They were retrospectively selected from 23 liver units between 2000 and 2013.

The mean age of participants was similar for the LC and control groups: 60.8±10.5 and 60.6±11.5 years, respectively. A previous history of cardiomyopathy was found in 24.8% of patients with LC compared with 37.6% of control patients (P =.07).

In both groups, the proportions of patients dying after cardiac surgery were similar, at 9.7% for LC vs 8.7% for control patients. In-hospital mortality was significantly higher for patients diagnosed as Child-Pugh C compared with for control patients (61.4% vs 23%; P <.001), and Child-Pugh scores above C10 were the best predictor of in-hospital mortality.

Similar mortality rates were not observed for Child-Pugh A and B patients, however (33.3% and 25.0%, respectively). Independent predictive factors for in-hospital mortality in the LC group were Child-Pugh score (odds ratio, 1.5; 95% CI, 1.2-2.0; P =.002) and history of decompensation (odds ratio, 3.1; 95% CI, 1.1-9.0; P =.003).

The rareness of IE in patients with LC meant a prospective study could not be conducted. Also, the length of the study and the impossibility of matching control patients with patients with LC based on the medical center likely influenced microbiological data, clinical practice, and outcome. Further, analyses dedicated to surgical treatment were not possible because of the small numbers of patients with LC undergoing cardiac surgery and the retrospective design.

Investigators conclude that patients with cirrhosis are at higher risk for death in case of IE than the control patients. Also, severe liver failure, represented by Child-Pugh score above C10, and history of decompensation were the strongest independent risk factors for mortality when IE occurred in patients with LC.

Investigators recommend that “the use of aminosides and rifamycin should be reassessed in patients with cirrhosis with IE,” mainly because of the potential influences on outcome that choices of antibiotics may have.

Further studies are still required to evaluate the true effects and complications of antibiotics on outcome. Finally, the investigators do not believe cirrhosis should be a contraindication for cardiac surgery, especially for patients with the best prognoses.

Reference

Allaire M, Cadranel JD, Bureau C, et al. Severe liver failure rather than cirrhosis is associated with mortality in patients with infectious endocarditis: a retrospective case-control study [published online May 3, 2018]. Eur J Gastroenterol Hepatol. doi: 10.1097/MEG.0000000000001155