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BMC Infectious Diseases

, 19:937 | Cite as

The clinical features and prognosis of infective endocarditis in the elderly from 2007 to 2016 in a tertiary hospital in China

  • Zhenzhu Wu
  • Yi Chen
  • Tingting Xiao
  • Tianshui Niu
  • Qingyi Shi
  • Yonghong XiaoEmail author
Open Access
Research article
  • 121 Downloads
Part of the following topical collections:
  1. Bacterial and fungal diseases

Abstract

Background

Infective endocarditis (IE) especially in the elderly is a serious disease, with a worse prognosis.

Methods

A retrospective cohort study was conducted. A total of 405 patients with definite IE were divided into three groups: 205 patients under 50 years old, 141 patients between 50 and 64 years old and 59 patients over 65 years old.

Results

For older patients, clinical symptoms such as fever, anemia, and heart murmur were as common as the younger patients. IE in old patients had more frequent nosocomial origin (P = 0.007) and tended to be more frequent with bad oral hygiene (p = 0.008). The most frequent isolated pathogens in the old groups was streptococci and coagulase-negative staphylococci. The old patients had a lower operation rate (40.7% vs 58.9% vs 62.4%, P = 0.012) and higher in-hospital mortality (20.3% vs 10.6% vs 8.8%, P = 0.044) compared with the younger patients. Surgical treatment was a significant predictor of one-year mortality even after adjusting for the confounders (HR = 2.45, 95% CI 1.027–10.598, P = 0.009). The one-year survival rate was higher for older patients with surgical intervention than those without (95.8% vs 68.6%, P = 0.007).

Conclusions

Older patients with IE presented with more comorbidities, bad oral hygiene, more nosocomial origin and a more severe prognosis than younger patients. Streptococci was the most frequent micro-organisms in this group. Surgery were underused in old patients and those with surgical treatment had better prognosis.

Keywords

Infective endocarditis Older patients Risk factors Surgical treatment 

Abbreviations

CI

Confidence interval

HR

Hazard ratio

IE

Infective endocarditis

IQR

Interquartile range

OR

Odds ratios

SD

Standard deviation

TEE

Transesophageal echocardiography

TTE

Transthoracic echocardiography

Background

Infective endocarditis (IE) is a severe disease with a high burden of mortality and morbidity [1]. Over the past few decades, with the increase in life span and invasive procedures, IE has become more and more frequent in the elderly [2, 3]. The increasing age of patients with IE will become the major determinant of disease characteristics in the future. Therefore, it is significantly important to explore the clinical features of old patients with IE at present.

According to the published researches, IE in the elderly is a different disease, with a higher mortality [2, 3]. The most frequent causative organism as reported previously is Staphylococcus aureus and methicillin-resistant Staphylococcus aureus has a high infection rate in older patients [2, 3]. Previous reports show that clinical presentations of IE in the elderly are often nonspecific and atypical, which often lead to the delay in diagnosis and treatment for this unique population [4, 5, 6]. And the proportion of patients undergoing surgical treatment is lower in older patients compared with the younger because of the increased risk caused by aging [7].

However, most of the reports derive from developed countries, and studies exploring the clinical features of older patients with IE in developing countries are scarce. The aim of this article is to investigate the clinical features and prognosis of IE in the elderly from a tertiary teaching hospital in east China.

Methods

Patient selection and study design

The study was conducted in the First Affiliated Hospital of Zhejiang University, Hangzhou, China. Patients with definite IE from January 1, 2007 to December 31, 2016 were reviewed. All patients were identified according to the modified Duke criteria [8] and patients under 16 years old were excluded. Patients with IE who were admitted to the hospital more than once during the study period were considered as one case. All the patients included were separated into three groups according to their age: 205 patients under 50 years old, 141 patients between 50 and 64 years old and 59 patients over 65 years old. Then, patients over 65 years old were divided into the survival group and the mortality group according to their one-year outcome.

The analysis strategies were as the follows: (1) To analyze the clinical features of IE in the elderly, a comparison between the three groups was conducted; (2) to explore the prognostic risk factors of one-year mortality for older patients and a comparison between the survival group and mortality group was conducted; (3) to evaluate the effect of surgical treatment on older patients, and analysis of the one-year survival rate between patients with antibiotic therapy combined with surgical intervention and patients with antibiotic treatment alone.

Clinical parameters and definition

The data was obtained from the Electronic Medical Record. The following data were recorded: age, gender, underlying diseases general, IV drug addiction, dental condition and interventions, length of hospitalization, clinical, laboratory and microbiological data, vegetation location, complications of IE, treatments (included antibiotics and surgical intervention), and outcomes.

The modified Duke criteria, which were used to evaluate our patients, involve two major criteria: (1) the presence of at least two positive blood cultures with typical organisms consistent with IE, and (2) evidence of endocardial involvement, primarily diagnosed using echocardiography; and several minor criteria such as predisposing cardiac condition or injection drug abuse, fever >38°C, vascular phenomena (arterial embolism, septic pulmonary infarction, intracranial hemorrhage, Janeway lesions) or immunologic phenomena (Osler nodes, Roth spots, glomerulonephritis), and serological evidence of organisms consistent with IE. To be enrolled in this study as definite IE, patients had to meet one of the following criteria: (1) the major two criteria; (2) one major and three minor criteria; (3) five minor criteria; or (4) pathological criteria: microorganisms demonstrated by culture or on histological examination of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen; or pathological lesions; vegetation or intracardiac abscess by histological examination showing active endocarditishis.

Surgical indications were based on the European Society of Cardiology (ECS) guidelines: heart failure, uncontrolled infection and prevention of embolism were the main indications of surgery [8, 9].

The main outcome was one-year all-cause mortality. The one-year follow-up data were collected from the patients’ latest visits to our hospital. Transthoracic echocardiogram was performed routinely in all patients. Transesophageal echocardiogram (TEE) was used to detect cases with negative transthoracic echocardiography (TTE) results. Blood culture was performed in all the patients with aerobic, anaerobic and fungal blood cultures, but blood cultures for the HACEK group (Haemophilus spp, Aggregatibacter spp, Cardiobaterium hominis, Eikenella corrodens, and Kingella kingae), and anti-legionella, mycoplasma and bartonella anti-body tests as well as PCR test were not performed when patients had negative blood culture results.

Statistical analysis

The clinical features analysis was performed using Pearson’ s χ2 test or Fisher’ s exact test as appropriate for categorical variables and independent Student’s t-test or Rank sum test was used as appropriate for continuous variables. Cox univariate and multivariate survival analysis was performed to discover the predictors of one-year all-cause mortality. A Kaplan-Meier analysis was used to determine the one-year survival. All tests were 2-tailed, and P < 0.05 was considered statistically significant. All analyses were performed using the SPSS version 23 statistical software.

Results

Patient enrollment

Between January 2007 and December 2016, there were 405 patients (male: 64.4%, age: 16–86) included in our study. Of these patients, 205 patients were in the < 50 years group, 141 patients in the 50–64 years group and 59 patients in the ≥65 years group. During the follow-up, 92.8% (378 of 407) of patients taking part in the study completed a median follow-up of one year after infective endocarditis diagnosis.

The clinical characteristics of IE in the three groups

The clinical characteristics of IE in the three groups are summarized in Table 1.
Table 1

Clinical characteristics of patients with infective endocarditis

Variables % or Mean ±SD

<50 years old

n = 205

(50.6%)

50-64 years old

n = 141

(34.8%)

≥65 years old

n = 59

(14.6%)

P value

Clinical data

 Male

127 (62.0)

93 (66.0)

41 (69.5)

.508

 Age

35 ± 9

57 ± 4

72 ± 5

P<0.001

 Hospital stay

24 ±19

28 ±27

23 ±19

.295

 Duration of symptoms before echocardiography

30 ± 37

24 ± 27

24 ± 34

.174

 Duration of symptoms before diagnosis

42 ± 39

42 ± 44

42 ± 58

.991

 Time interval from diagnosis to surgery

23.5 (8–55.5)

16 (6.5–54)

30 (11.5–64)

.322

 Time interval from embolism to diagnosis

4 ± 3

13 ± 17

11 ± 10

.001

 Time interval from cerebral embolism to diagnosis

4 ± 2

16 ± 21

13 ± 12

.006*

IE localization

 Native valve

191 (93.2)

128 (90.8)

49 (83.1)

.059

 Mitral

61 (30.0)

44 (31.2)

15 (25.4)

 

 Aortic

54 (26.3)

56 (40.0)

18 (30.5)

 

 Mitro-aortic

31 (15.1)

17 (12.1)

8 (13.5)

 

 Right valves

23 (11.2)

2 (1.4)

4 (6.8)

 

 Prosthetic valve

13 (6.3)

10 (7.1)

8 (13.6)

.176

 Mitral

4 (2.0)

4 (2.8)

3 (5.1)

 

Aortic

5 (2.4)

4 (2.8)

3 (5.1)

 

Mitro-aortic

1 (0.5)

0

1 (1.7)

 

 Pacemaker

1 (0.5)

3 (2.1)

2 (3.4)

.191

 Community origin

187 (91.2)

124 (87.9)

47 (79.7)

.050

 Nosocomial origin

3 (1.5)

6 (4.3)

6 (10.2)

.007

Comorbidities

Predisposing cardiac conditions

 Rheumatic heart disease

28 (13.7)

30 (21.3)

11 (18.6)

.169

 Congenital heart disease

71 (34.6)

23 (16.3)

10 (16.9)

P<0.001

 Previous cardiac surgery

16 (7.8)

14 (9.9)

14 (23.7)

.002

 Degenerative heart disease

1 (0.5)

6 (4.3)

6 (10.2)

.001

 Chronic pulmonary disease

1 (0.5)

3 (2.1)

2 (3.4)

.191

 History of cancer

3 (1.5)

6 (4.3)

2 (3.4)

.275

 Hemodialysis

3 (1.5)

7 (5.0)

4 (6.8)

.069

 Liver cirrhosis

2 (1.0)

1 (0.7)

1 (1.7)

.813

 Hypertension

14 (6.8)

43 (30.5)

25 (42.4)

P<0.001

 Diabetes

2 (1.0)

25 (17.7)

10 (16.9)

P<0.001

 Intravenous drug abuse

2 (1.0)

0

1 (1.7)

.250

 Immunodepression

17 (8.3)

12 (8.5)

4 (6.8)

.915

 Bad oral hygiene

57 (27.8)

45 (31.9)

29 (49.2)

.008

Symptoms and signs

 Fever

186 (90.7)

125 (88.7)

53 (89.8)

.820

 Anemia

116 (56.6)

68 (48.2)

38 (64.4)

.085

 Osler nodule

5 (2.4)

1 (0.7)

1 (1.7)

.439

 Janeway lesions or nailbed bleeding

3 (1.5)

1 (0.7)

0

.601

 New or changing heart murmur

172 (83.9)

110 (78.0)

45 (76.3)

.253

 Hepatomegaly

10 (4.9)

9 (6.4)

2 (3.4)

.658

 Splenomegaly

68 (33.2)

28 (19.9)

13 (22.0)

.015

Echocardiographic data

 Vegetation length

   

.029

 <10 mm

35 (17.1)

36 (25.5)

18 (30.5)

 

  ≥ 10 mm

146 (71.2)

83 (58.9)

30 (50.8)

 

 No vegetation

24 (11.7)

22 (15.6)

11 (18.6)

 

 Vegetation mobility

84 (41.0)

47 (33.3)

26 (44.1)

.238

 Moderate or severe valve regurgitation

29 (14.2)

17 (12.4)

12 (20.3)

.547

 Moderate or severe valve stenosis

11 (5.4)

27 (19.7)

5 (8.5)

.001

 Abscess

25 (12.2)

17 (12.1)

8 (13.6)

.953

 Annular abscess

13 (6.4)

10 (7.1)

7 (11.9)

.365

 Pseudoaneurysm

18 (8.8)

7 (5.0)

2 (3.4)

.207

 Valvular perforation

32 (15.8)

27 (19.1)

13 (22.0)

.480

Microbiology

 Streptococci

53 (25.9)

34 (24.1)

13 (22.0)

.819

 Streptococcus viridans

22 (10.7)

9 (6.4)

3 (5.1)

.219

 Staphylococci

40 (19.5)

28 (19.9)

11 (18.6)

.981

Staphylococcus aureus

17 (8.3)

9 (6.4)

2 (3.4)

.405

 Coagulase-negative staphylococci

23 (11.2)

19 (13.5)

9 (15.3)

.660

 Enterococci

2 (1.0)

2 (1.4)

1 (1.7)

 

 Fungi

0

2 (1.4)

1 (1.7)

 

 Polymicrobial

1 (0.5)

1 (0.7)

0

 

Complications

 Heart failure

101 (49.3)

76 (53.9)

37 (62.7)

.181

 Total emboli

57 (27.8)

45 (31.9)

23 (39.0)

.247

 Emboli under treatment

60 (29.3)

35 (24.8)

12 (20.3)

.339

 Intracranial infection

12 (5.9)

4 (2.8)

1 (1.7)

.227

 Cerebral emboli

31 (15.1)

29 (20.6)

14 (23.7)

.219

 Cerebral hemorrhage,

14 (6.8)

7 (5.0)

2 (3.4)

.544

 Arrhythmia

24 (11.7)

33 (23.4)

23 (39.0)

P<0.001

 Atrial fibrillation

15 (7.3)

29 (20.6)

20 (33.9)

P<0.001

 Apparition of atrioventricular block

4 (2.0)

4 (2.8)

4 (6.8)

.155

 Hepatic insufficiency

43 (21.0)

22 (15.6)

6 (10.2)

.119

 Renal insufficiency

34 (16.6)

29 (20.6)

18 (30.5)

.061

Surgery and mortality

 Surgical indication

204 (99.5)

140 (99.3)

57 (96.6)

.142

 Surgery indicated and performed

128 (62.4)

83 (58.9)

24 (40.7)

.012

Reason of no surgery

 Medical treatment

61 (80.3)

46 (80.7)

23 (69.7)

 

 Death before surgery

12 (15.8)

11 (19.3)

10 (30.3)

.216

 Patient’s refusal

3 (3.9)

0

0

 

 In-hospital mortality

16 (7.8)

15 (10.6)

12 (20.3)

.023**

 One-year mortality

18 (8.8)

15 (10.6)

12 (20.3)

.044

Cause of death

   

.124

 Heart failure

0

5 (33.3)

3 (25.0)

 

 Sepsis

10 (55.6)

6 (40.0)

5 (41.7)

 

 Cerebral hemorrhage Brain palsy

6 (33.3)

1 (6.7)

2 (16.7)

 

 Life-threatening arrhythmias

1 (5.6)

1 (6.7)

1 (8.3)

 

 Others

1 (5.6)

2 (13.3)

1 (8.3)

 

IQR interquartile range, IE Infective endocarditis

*p = 0.051: < 50 years group vs ≥65 years group p = 0.526:50–64 years group vs ≥65 years group

** p = 0.006 < 50 years group vs ≥65 years group p = 0.067 50–64 years group vs ≥65 years group

There was no statistically significant difference between the age groups in terms of the length of hospital stay, duration of symptoms before echocardiography, duration of symptoms before diagnosis, time interval from diagnosis to surgery and time interval from cerebral embolism to diagnosis. Prosthetic valve IE was more common in older patients and native valve IE was more common in younger patients but there were no statistically difference. Old patients with IE had more frequent nosocomial origin (P = 0.007).

It was more common for old IE patients to have previous cardiac surgery (P = 0.001) and degenerative heart disease (P = 0.001) but less common in congenital heart disease (P<0.001). There was no statistically significant difference between the age groups in terms of fever, anemia, heart murmur, extracardiac IE signs (Osler’s nodes, Janeway lesions and nailbed bleeding) and hepatomegaly. However, splenomegaly was less frequent in old patients. Old patients tend to be more frequent with a bad oral hygiene (p = 0.008).

The most frequent isolated pathogens in the old groups was streptococci and coagulase-negative staphylococci. Staphylococcus aureus tended to be less frequent with age but it presented no statistically difference. Concerning complications, no difference was observed between groups in heart failure, emboli under treatment, intracranial infection, cerebral emboli, cerebral hemorrhage, hepatic insufficiency and renal insufficiency, except atrial fibrillation, which was more frequent in old subjects.

In-hospital mortality rates were 7.8% (< 50 years group), 10.6% (50–65 years group) and 15.7% (≥65 years group) (p = 0.023). In-hospital mortality was high in the ≥65 years group than in the< 50 years group (p = 0.006). In the ≥65 years group, the predominant cause of deaths were sepsis (41.7%) and heart failure (25.0%).

According to the ESC guidelines, surgery was theoretically indicated in 99.5, 99.3 and 96.6%, but was ultimately performed in 62.4,58.9 and 40.7% in the < 50 years, 50–64 years and ≥ 65 years groups, respectively. The main reason for elder patients not operated was the choice of medical treatment after considering the high comorbidities, high operative risk or multidisciplinary decision. Owing to death before surgery tended to be more frequent with age (15.8 to 19.3% and 30.3%) but there was no statistically difference.

The risk factors for one-year mortality in old patients

A one-year cox survival analysis was performed for the ≥65 years group. The results were show in Tables 2 and 3. Significant variables included man, hemodialysis, renal insufficiency, pulmonary arterial hypertension, Pitt score ≥ 4, vegetation length>30 mm and surgical treatment were risk factors for one-year mortality. Surgical treatment [HR = 2.45, 95% CI 1.027–10.598, P = 0.009) was a significant predictor of one-year mortality even after adjusting for confounder. The Kaplan–Meier survival curves revealed that cumulative one-year survival rate was significantly higher in old patients when surgery operated than those not (95.8% vs 68.6%, P = 0.007) (Fig. 1).
Table 2

Cox univariate analysis of one-year mortality in patients ≥65 year old with infective endocarditis

Variables% or Mean ±SD

Survival

n = 47

Mortality

n = 12

P value

Clinical data

 Male

35 (74.5)

6 (50.0)

.267

 Length of hospital stay

25 ± 21

16 ± 10

.052

 Symptoms before echocardiography

26 ± 37

16 ± 17

.355

 Duration of symptoms

before diagnosis, median (IQR),days

24.0 (12.0–42.0)

29.0 (10.3–54.8)

.799

 Time interval from emboli to diagnosis

12 ± 10

11 ± 11

.868

 Time interval from cerebral emboli to diagnosis

15 ± 13

12 ± 12

.724

IE localization

 Native valve

40 (85.1)

9 (75.0)

.518

 Prosthetic valve

6 (12.8)

2 (16.7)

.862

 Community origin

42 (89.4)

5 (41.7)

P<0.001

 Nosocomial origin

2 (4.3)

4 (33.3)

P<0.001

Comorbidities

 With predisposing cardiac disease

29 (61.7)

6 (50.0)

.457

 Rheumatic heart disease

8 (17.0)

3 (25.0)

.752

 Congenital heart disease

9 (19.1)

1 (8.3)

.482

 Previous cardiac surgery

10 (21.3)

4 (33.3)

.475

 Degenerative heart disease

6 (12.8)

0

.466

 Chronic pulmonary disease

1 (2.1)

1 (8.3)

.343

 Cancer

2 (4.3)

0

.690

 Hemodialysis

1 (2.1)

3 (25.0)

.007

 Liver cirrhosis

  

.713

 Hypertension

18 (38.3)

7 (58.3)

.272

 Diabetes

7 (14.9)

3 (25.0)

.565

 Immunodepression

0

4 (33.3)

P<0.001

 Bad oral hygiene

22 (46.8)

7 (58.3)

.713

Symptoms and signs

 Anemia

31 (66.0)

7 (58.3)

.425

 Fever

44 (93.6)

9 (75.0)

.046

 Splenomegaly

11 (23.4)

2 (16.7)

.491

 Hepatomegaly

1 (2.1)

1 (8.3)

.516

 New or changing heart murmur

39 (83.0)

6 (50.0)

.021

Complications

 Heart failure

25 (53.2)

12 (100.0)

.106

 Total emboli

16 (34.0)

7 (58.3)

.143

 Emboli under treatment

8 (17.0)

4 (33.3)

.295

 Intracranial infection

1 (2.1)

0

.713

 Cerebral emboli

8 (17.0)

6 (50.0)

.053

 Cerebral hemorrhage

1 (2.1)

1 (8.3)

.404

 Arrhythmia

16 (34.0)

7 (58.3)

.202

 Renal insufficiency

9 (19.1)

9 (75.0)

.001

 Hepatic insufficiency

3 (6.4)

3 (25.0)

.092

 Pulmonary arterial hypertension

15 (31.9)

8 (66.7)

.037

 Moderate or severe valve regurgitation

10 (21.3)

2 (16.7)

.570

 Moderate or severe valve stenosis

4 (8.5)

1 (8.3)

.912

 Annular abscess

5 (10.6)

2 (16.7)

.564

 Pseudoaneurysm

1 (2.1)

1 (8.3)

.289

 Valvular perforation

10 (21.3)

3 (25.0)

.781

 Pitt score ≥ 4

1 (2.1)

5 (41.7)

.001

 Vegetation length

  

.062

≤10 mm

25 (53.2)

4 (33.3)

 

>10 mm<20 mm

19 (40.4)

5 (41.7)

 

≥20 mm ≤ 30 mm

3 (6.4)

1 (8.3)

 

>30 mm

0

2 (16.7)

.039

Microbiology

  

.050

 Streptococci

12 (48.0)

1 (16.7)

.268

 Staphylococci

8 (32.0)

3 (50.0)

.679

 Staphylococcus aureus

0

2 (33.3)

.039

 Enterococci

1 (4.0)

0

 

 Fungi

0

1 (16.7)

 

 Surgical treatment

23 (48.9)

1 (8.3)

.018

Table 3

Cox multivariate analysis of one-year mortality for patients ≥65 year old with infective endocarditis

Variables

P value

HR

95% CI

Male

.025

3.751

1.183–11.891

Hemodialysis

.007

6.146

1.633–23.124

Renal insufficiency

.001

8.684

2.327–32.407

Pulmonary arterial hypertension

.037

3.627

1.083–12.153

Pitt score ≥ 4

<.001

10.589

3.284–34.147

Vegetation length>30 mm

.009

10.600

1.796–62.569

Surgical treatment

.009

2.45

1.027–10.598

IQR interquartile range, HR hazard ratio, CI confidence interval

Fig. 1

Figure One-year survival analysis for patients≥65 years old The Kaplan–Meier survival curves revealed that cumulative one-year survival rate was higher in old patients with surgical intervention than that in patients without surgical intervention (95.8% vs 68.6%, P = 0.007)

Discussion

This study represents a large cohort of IE from a single center. It showed that older patients with IE had common clinical symptoms, more nosocomial origin, worse oral hygiene than younger patients. The most frequent isolated pathogens in the old groups was Streptococci. Moreover, they presented more comorbidities, more atrial fibrillation as well as more severe prognosis than younger patients. Surgical therapy was less performed in older patients although the theoretical indications for surgery was clear. Those with surgical therapy had better outcome.

The clinical characteristics of older patients with infective endocarditis

According to the published researches, the clinical features in older patients were few and untypical, which often led to a delay in the diagnosis of IE [5, 10, 11]. While, Jean et al. [12] found older people had a more severe clinical status than younger patients, which lead to the early diagnosis. However, the clinical presentations in old patients was not significantly different as compared with the younger patients in our study. And the time to diagnosis was not significantly different compared with the younger patients.

In accordance with previous studies, clinical characteristics varied with aging [12, 13, 14, 15]. Older patients were more frail, which often lead to more cardiovascular and general comorbidities and complications than younger patients. In our study, the older patients presented more predisposing factors (like previous cardiac surgery history, degenerative heart disease, hypertension, diabetes and so on) contrary to younger patients who frequently presented congenital heart disease. For IE patients, comorbidities and complications increased with ageing, just like the general population.

Different to the published researches, streptococci was the most frequent isolated pathogens in the old groups in our study. This might be owing to the large number of native valve IE and community-acquired IE in old patients. According to the published researches, streptococci was more prevalent among patients with a native valve and community-acquired IE [16]. What’s more, the bad oral hygiene among old patients might be another important reason. The microtrauma caused by these everyday activities (like oral hygiene habits) has been identified to induce oral streptococcal bacteraemia [17]. Therefore, a better control for individual oral hygiene and dental status for old patients was important in reducing oral streptococcal infective endocarditis.

In our study, we found the in-hospital mortality rate and one-year mortality rate in older patients was much higher than the younger patients, which was consistent with previous reports [3, 14, 15, 18, 19]. As reported previously, older adults were prone to require complex care needs and suffer from multiple comorbidities, which made them vulnerable to health-associated exposure and poor outcomes [14, 20, 21, 22]. Besides, the lower operative rate in older patients compared with the younger in our cohort may be another important reason for the higher mortality in older patients [7, 13, 14].

The in-hospital mortality and one-year mortality were lower in older patients in our study compared with previous studies [5, 14, 18]. Léopold Oliver et al. reported that one-year mortality was higher in the ≥80-year-old group (37.3%) than in the < 65-year-old group (13%) and the 65–80-year-old group (19.7%), indicating that the mortality rate increased with aging [13]. The few number of very old patients in our study (there were only 5 patients who were over 80 years old) may be an important reason. And a larger cohort for older IE patients was suggest in our region in the future.

Surgical therapy and prognosis for patients≥65 year old with infective endocarditis

Previous studies reported that older age, renal failure, prosthetic valve endocarditis, neurological deficit, and cerebral emboli were independent risk factors for one-year mortality in older patients [4, 15]. In our study we found the independent risk factors for one-year mortality were man, hemodialysis, renal insufficiency, Pitt score ≥ 4,vegetation length>30 mm and surgical treatment. These events have been confirmed previously to be risk factors for mortality in IE patients [8, 23, 24].

We observed that elder patients with surgical therapy had a lower mortality rate compared with patients not operated during the one-year follow-up. Other recent reports also reached the same conclusion [13]. Surgery was performed less frequent in older patients in our study, although the rate of patients with theoretical indications of surgery was not significantly different compared with the younger. This phenomenon was frequently presented in previous reports [3, 25, 26]. The main consideration may be the increasing risks during the perioperative period owing to the decline in organ function and the presence of comorbidities associated with aging. These factors made the choice of surgical treatment for elderly patients more difficult.

But these considerations could not prevent the old patients with surgical indications from suitable treatments in-time. There are many frailty scores to assess the physical condition of older patients, and some scores showed good reliability in the assessment of mortality independently of age [20]. Some studies have recently proven the utility of these scores for the evaluation of IE-related stroke and prognosis evaluation before cardiac surgery [27]. Therefore, surgery is appropriate in selected old patients with IE. And we suggest a more global patient evaluation and cooperation among multiple specialists to improve IE management in older populations.

Limitations

There are several limitations in our study. First, it was performed in a referral teaching hospital where most patients were transferred from other medical centers leading to long-term disease and negative blood culture results. Therefore, these results should not be generalized to other patient groups. Second, as a retrospective study, the long-term follow-up was not possible and 29 patients were lost during the one-year follow-up. Finally, the study covered a long period of time in order to keep the enough sample sizes. Changes in treatment regimens and causative organisms could affect the patient prognosis during this period. Therefore, a multiple-center prospective cohort studies conducted in our region was suggested.

Conclusions

In conclusion, older patients with IE presents more comorbidities, bad oral hygiene, more nosocomial origin and a more severe prognosis than younger patients. Streptococci was the most frequent micro-organisms in this group. Surgery were underused in older patients and those with surgical treatment presented better long-term prognosis.

Notes

Acknowledgements

We are very grateful to the staffs in the Medical record room in the First Affiliated Hospital of Zhejiang University for their support and assistance.

Authors’ contributions

ZZW designed the study and created study protocols, ZZW and YC performed the data collection, data analysis and drafts the manuscript. YHX supervised the study development, helped to review the manuscript and made critical revision to the paper. TTX TSN and QYS performed data collection and helped to review the manuscript. All authors read and approved the final manuscript.

Funding

This work was partially supported by grants from the Key Research and Development Program of Zhejiang Province (No. 2015C03032). The funder was not involved in the design of the study, data collection, analysis and interpretation of the data and in writing the manuscript.

Ethics approval and consent to participate

Ethics approval for this study was submitted and approved through Research Ethics Committee of the First Affiliated Hospital, College of Medicine, Zhejiang University. The consent to participate is not applicable because the study design is a retrospective data collection. The Research Ethics Committee of the Hospital was responsible for administrative permissions to access the raw data.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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© The Author(s). 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  • Zhenzhu Wu
    • 1
  • Yi Chen
    • 1
  • Tingting Xiao
    • 1
  • Tianshui Niu
    • 1
  • Qingyi Shi
    • 1
  • Yonghong Xiao
    • 1
    Email author
  1. 1.State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of MedicineZhejiang UniversityHangzhouChina

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