title: Infective endocarditis in Turkey: aetiology, clinical features, and analysis of risk factors for mortality in 325 cases.
abstract: OBJECTIVE
  In order to define the current characteristics of infective endocarditis (IE) in Turkey, we evaluated IE cases over a 14-year period in a tertiary referral hospital.
  
  
  METHODS
  All adult patients who were hospitalized in our hospital with a diagnosis of IE between 2000 and 2013 were included in the study. Modified Duke criteria were used for diagnosis. The Chi-square test, Student's t-test, Mann-Whitney U-test, Cox and logistic regression analysis were used for the statistical analysis.
  
  
  RESULTS
  There were 325 IE cases during the study period. The mean age of the patients was 47 years. Causative microorganisms were identified in 253 patients (77.8%) and included staphylococci (36%), streptococci (19%), enterococci (7%), and Brucella spp (5%). A streptococcal aetiology was associated with younger age (<40 years) (p=0.001), underlying chronic rheumatic heart disease (CRHD) (odds ratio (OR) 3.89) or a congenital heart defect (OR 4.04), community acquisition (OR 17.93), and native valve (OR 3.68). A staphylococcal aetiology was associated with healthcare acquisition (OR 2.26) or pacemaker lead-associated endocarditis (OR 6.63) and an admission creatinine level of >1.2mg/dl (OR 2.15). Older age (>50 year) (OR 3.93), patients with perivalvular abscess (OR 9.18), being on dialysis (OR 6.22), and late prosthetic valve endocarditis (OR 3.15) were independent risk factors for enterococcal IE. Independent risk factors for mortality in IE cases were the following: being on dialysis (hazard ratio (HR) 4.13), presence of coronary artery heart disease (HR 2.09), central nervous system emboli (HR 2.33), and congestive heart failure (HR 2.15). Higher haemoglobin (HR 0.87) and platelet (HR 0.996) levels and surgical interventions for IE (HR 0. 33) were found to be protective factors against mortality.
  
  
  CONCLUSIONS
  In Turkey, IE occurs in relatively young patients and Brucella spp should always be taken into consideration as a cause of this infection. We should first consider streptococci as the causative agents of IE in young patients, those with CRHD or congenital heart valve disease, and cases of community-acquired IE. Staphylococci should be considered first in the case of pacemaker lead IE, when there are high levels of creatinine, and in cases of healthcare-associated IE. Enterococci could be the most probable causative agent of IE particularly in patients aged >50 years, those on dialysis, those with late prosthetic valve IE, and those with a perivalvular abscess. The early diagnosis and treatment of IE before complications develop is crucial because the mortality rate is high among cases with serious complications. The prevention of bacteraemia with the measures available among chronic haemodialysis patients should be a priority because of the higher mortality rate of subsequent IE among this group of patients.
authors.affiliation: Istanbul University, Istanbul Medical Faculty, Infectious Disease and Clinical Microbiology Department, Istanbul, Turkey. Electronic address: serapsimsekyavuz@gmail.com.
authors.forename: Serap
authors.initials: S
authors.lastname: Şimşek-Yavuz
authors.affiliation: Siyami Ersek Thoracic and Cardiovascular Surgery Hospital, Infectious Disease and Clinical Microbiology Department, Istanbul, Turkey.
authors.forename: Ayfer
authors.initials: A
authors.lastname: Şensoy
authors.affiliation: Siyami Ersek Thoracic and Cardiovascular Surgery Hospital, Cardiology Department, Istanbul, Turkey.
authors.forename: Hulya
authors.initials: H
authors.lastname: Kaşıkçıoğlu
authors.affiliation: Siyami Ersek Thoracic and Cardiovascular Surgery Hospital, Infectious Disease and Clinical Microbiology Department, Istanbul, Turkey.
authors.forename: Sabahat
authors.initials: S
authors.lastname: Çeken
authors.affiliation: Siyami Ersek Thoracic and Cardiovascular Surgery Hospital, Infectious Disease and Clinical Microbiology Department, Istanbul, Turkey.
authors.forename: Denef
authors.initials: D
authors.lastname: Deniz
authors.affiliation: Kartal Lutfi Kırdar Research and Education Hospital, Cardiology Department, Istanbul, Turkey.
authors.forename: Atilla
authors.initials: A
authors.lastname: Yavuz
authors.affiliation: Basaksehir State Hospital, Infectious Disease and Clinical Microbiology Department, Istanbul, Turkey.
authors.forename: Funda
authors.initials: F
authors.lastname: Koçak
authors.affiliation: Istanbul University, Cerrahpasa Medical Faculty, Microbiology Department, Istanbul, Turkey.
authors.forename: Kenan
authors.initials: K
authors.lastname: Midilli
authors.affiliation: Siyami Ersek Thoracic and Cardiovascular Surgery Hospital, Cardiology Department, Istanbul, Turkey.
authors.forename: Mehmet
authors.initials: M
authors.lastname: Eren
authors.affiliation: Siyami Ersek Thoracic and Cardiovascular Surgery Hospital, Cardiovascular Surgery Department, Istanbul, Turkey.
authors.forename: İbrahim
authors.initials: İ
authors.lastname: Yekeler
mesh_terms: D000328:Adult; D000368:Aged; D004697:Endocarditis, Bacterial / Q000175:diagnosis / Q000209:etiology / Q000382:microbiology* / Q000401:mortality*; D016983:Enterococcus / Q000302:isolation & purification; D005260:Female; D016908:Gram-Positive Bacterial Infections / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D013203:Staphylococcal Infections / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality; D013210:Staphylococcus / Q000302:isolation & purification; D013290:Streptococcal Infections / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality; D013291:Streptococcus / Q000302:isolation & purification; D014421:Turkey / Q000453:epidemiology
keywords: Aetiology; Infective endocarditis; Mortality risk factors