Incidence and Risk of Developing Fungal Prosthetic Valve Endocarditis after Nosocomial Candidemia

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Abstract

PURPOSE: To determine the incidence of prosthetic valve endocarditis (PVE) in fungemic patients with prosthetic heart valves (PHV), estimate the 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.

Section snippets

Background

The Cleveland Clinic Foundation (CCF) is a 1,100-bed tertiary referral center with an active cardiothoracic surgical service. The Cardiac Valve Information Registry at CCF is a computerized database that contains information on all open-heart operations performed since 1970. Between 1985 and 1995, 6,661 patients underwent PHV replacement.

Case Definition

A case-patient was defined as any patient with a PHV implant hospitalized at the CCF with one or more blood culture growing yeast between January 1985 and

Results

From January 1, 1985, to April 1, 1995, 53 patients with fungemia in the presence of a prosthetic heart valve were identified. Nine patients were excluded; three had missing charts and in six patients the pathogens were not considered nosocomial (Cryptococcus [3], Histoplasma capsulatum [1], Chaetomium [1], and Saccharomyces [1]). Thus, 44 patients were included in the analysis. Thirty-three (75%) had fungemia without evidence of endocarditis (group 1, no PVE) and seven (16%) had evidence of

Discussion

Incidence rates of bloodstream infections attributable to Candida species have been increasing. The National Nosocomial Infection Survey found a 487% increase in Candida bloodstream infections in large teaching hospitals during the 10-year period 1980 to 1989. [2]A recent review of bloodstream infections in a 900-bed hospital found a 12-fold increase in rates of candidemia during the 12-year study period, mainly due to C. albicans.[3]Thus, the scenario of a patient with a PHV who becomes

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