title: Neurologic complications and outcomes of infective endocarditis in critically ill patients: the ENDOcardite en REAnimation prospective multicenter study.
abstract: OBJECTIVE
  To describe the clinical spectrum of infective endocarditis in critically ill patients and assess the impact of neurologic complications on outcomes.
  
  
  METHODS
  Prospective multicenter observational study conducted from April 2007 to October 2008.
  
  
  METHODS
  Thirty-three intensive care units in 23 university-affiliated and 10 general French hospitals.
  
  
  METHODS
  Two hundred twenty-five patients with definite IE were studied. Factors associated with neurologic complications and predictors of 3-month mortality were identified by logistic regression analysis. Functional outcomes of patients with neurologic complications were evaluated with the modified Rankin Scale.
  
  
  METHODS
  None.
  
  
  RESULTS
  Among 198 patients with definite left-sided infective endocarditis, 108 (55%) experienced at least one neurologic complication. These complications were ischemic stroke (n = 79), cerebral hemorrhage (n = 53), meningitis or meningeal reaction (n = 41), brain abscess (n = 14), and mycotic aneurysm (n = 10). Factors independently associated with neurologic complications were (subhazard ratio [95% confidence interval]): Staphylococcus aureus infective endocarditis (1.45 [1.02-2.05]), mitral valve infective endocarditis (1.54 [1.07-2.21]), and nonneurologic embolic events (1.51 [1.09-2.09]). In contrast, health care-associated infective endocarditis had a protective effect (0.46 [0.27-0.77]). Multivariate analysis identified three variables associated with 3-month mortality (odds ratio [95% confidence interval]): neurologic failure, as defined as a Glasgow Coma Scale <10 (7.41 [2.89-18.96]), S. aureus infective endocarditis (3.26 [1.53-6.94]), and severe comorbidities before admission as defined as a Charlson score >2 (3.16 [1.47-6.77]). Among the 106 patients with neurologic complications assessed at follow-up (3.9 [3-8.5] months), 31 (29%) had a modified Rankin Scale score ≤3 (ability to walk without assistance), nine (9%) a modified Rankin Scale score of 4 or 5 (severe disability), and 66 (62%) a modified Rankin Scale score of 6 (death).
  
  
  CONCLUSIONS
  Neurologic events are the most frequent complications in infective endocarditis patients requiring intensive care unit admission. They contribute to a severe prognosis, leaving less than one-third of patients alive with functional independence. Neurologic failure at intensive care unit admission represents a major determinant of mortality regardless of the underlying neurologic complication.
authors.affiliation: Service de Réanimation Médicale et des Maladies Infectieuses, Université Paris 7-Denis Diderot, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France. romain.sonneville@bch.aphp.fr
authors.forename: Romain
authors.initials: R
authors.lastname: Sonneville
authors.forename: Mariana
authors.initials: M
authors.lastname: Mirabel
authors.forename: David
authors.initials: D
authors.lastname: Hajage
authors.forename: Florence
authors.initials: F
authors.lastname: Tubach
authors.forename: Philippe
authors.initials: P
authors.lastname: Vignon
authors.forename: Pierre
authors.initials: P
authors.lastname: Perez
authors.forename: Sylvain
authors.initials: S
authors.lastname: Lavoué
authors.forename: Achille
authors.initials: A
authors.lastname: Kouatchet
authors.forename: Olivier
authors.initials: O
authors.lastname: Pajot
authors.forename: Armand
authors.initials: A
authors.lastname: Mekontso Dessap
authors.forename: Jean-Marie
authors.initials: JM
authors.lastname: Tonnelier
authors.forename: Pierre-Edouard
authors.initials: PE
authors.lastname: Bollaert
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Frat
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Navellou
authors.forename: Hervé
authors.initials: H
authors.lastname: Hyvernat
authors.forename: Ali Ait
authors.initials: AA
authors.lastname: Hssain
authors.forename: Alexis
authors.initials: A
authors.lastname: Tabah
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Trouillet
authors.forename: Michel
authors.initials: M
authors.lastname: Wolff
mesh_terms: D000368:Aged; D015331:Cohort Studies; D016638:Critical Illness; D004696:Endocarditis / Q000150:complications* / Q000401:mortality / Q000628:therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000453:epidemiology* / Q000382:microbiology*; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome