The Infectious Tricuspid Endocarditis in ICU: Clinical Features, Management and Outcome

Abstract

Introduction Since the outbreak scourge of intravenous drug addiction in Tunisia, we are witnessing the emergence of cases of infectious tricuspid endocarditis (ITE). This pathology should be studied because it requires specifc medical and surgical management. The aim of the study was to describe the clinical features, management and outcome of ITE in intensive care unit. Patients and methods This was a retrospective study from January 2009 to December 2014. We enrolled patients who were hospitalized in intensive care unit and had ITE. We recorded baseline characteristics, management and outcome. Results During the study period, we collected 10 cases of ITE making an incidence rate of 3 cases for 1000 patient admissions. They were divided into 8 men and 2 women. The median age was of 37.5 years. The main reasons of ICU admission was acute respiratory failure (80%), among them 5 required mechanical ventilation. Hemodynamic failure was present in 3 cases. The median SAPS II was of 33 [19-90]. The median APACHE II was of 17 [7-53]. Different contributing factors were identifed: intravenous drug abuse (6 patients), a central venous catheter (1 patient) and a pacemaker (1 patient). All patients underwent transesophageal echocardiography showing one or several vegetations on native tricuspid valve. No associated left endocarditis was found. Blood cultures were positive in 8 cases of which 5 contained 2 different micro-organisms. The identifed micro-organisms were: Meticillin Resistant Staphylococcus aureus (n = 6), Meticillin Sensitive Staphylococcus aureus (n = 3), coagulase-negative staphylococcus (n = 2), Enterobacter cloacae (n = 1), and candida famata (n = 1). Occurring complications were hospital-acquired infections (n = 5), septic pulmonary embolism (n = 4), withdrawal syndrome (5 cases), acute renal failure (n = 2) and atrioventricular block (n = 2). Medical treatment consisted of a double antibiotic treatment. Surgical treatment was required in 7 patients: tricuspid valve replacement by bioprosthesis (6 cases) and valvuloplasty (1 case). The average length of stay was of 31.3 days [2-56]. ITE had recurred on bioprotheses in two patients after intravenous drug resumption; they underwent surgery again and one of them died. In hospital mortality was of 30%. The outcome was favorable in 7 patients. Conclusion The ITE in ICU is a severe disease with frequent complications and in hospital mortality reaches 30%. The most frequent incriminated micro-organism is Meticillin Resistant Staphylococcus aureus. It often requires medical and surgical treatment. Intravenous drug addiction remains the most common cause and worsens the prognosis by the risk of recurrence.