HIV and Endocarditis—Two Strikes and Some Are Out
Abstract & Commentary
Synopsis: One-eighth of endocarditis cases occurred in HIV-infected patients, most of whom were injection drug users.
Source: Cicalini S, et al. Infective endocarditis in patients with human immunodeficiency virus infection. J Infect. 2001; 42:267-271.
This report, centered in Rome, involved 54 centers throughout Italy from which Cicalini and colleagues collected 895 cases that satisfied the Duke criteria for a definite diagnosis of infective endocarditis (IE), and from that group extracted those cases in patients with HIV infection. In 105 patients with HIV and IE, there were 108 episodes: 77 were males and 28 were females. Most patients (94%) were injection drug users (IDU) and about 11% had at least 1 previous episode. The duration of IDU was only 6 years.
Causative organisms were Staphylococcus aureus in 55%, coagulase-negative staphylococci in 6%, viridian streptococci in 11%, enterococci and Gram-negative bacilli both in 3.7%, Candida albicans in 1.8%, with polymicrobial infection in 5.6%.
The right-sided valves were involved in 53.7%, left- sided valves in 34%, and both sides in 11%. Tricuspid valve involvement was present in 56 cases, statistically more prevalent than for other valves. More than 1 valve was infected in 17.6% of cases.
About 94% (95/101) were treated medically, 6% surgically. Eighteen of 101 (17.8%) died, most in the medically treated group. Nearly 82% of the patients had cardiovascular complications including congestive heart failure, septic pulmonary empoli, stroke, or other systemic emboli.
Comment by Joseph F. John, MD
In this massive review from Italy, about one-eighth of cases of IE were in the setting of HIV infection. The important epidemiologic factors involve the predominance of IDU and the high rate of S aureus infection. A left-sided vegetation was more likely associated with death than a right-sided lesion. One firm message here is that clinicians should consider surgery in those IE/HIV patients who are febrile.
It is well known that nasal carriage of S aureus is more likely in certain groups of patients, HIV-infected patients among them. Earlier studies have shown that nasal carriage of S aureus in HIV patients is associated with subsequent invasive disease. Since IE poses a major risk for HIV patients, especially those who inject drugs, it may not be unreasonable to reduce the risk somewhat by intermittent decolonization of the nares of those patients who are heavy carriers of S aureus—a clinical trial dealing with this issue would be welcome. In fact, Cicalini et al intimate that there is a need to develop "public health strategies" to deal with this problem. It has been more than a decade since Nahass and colleagues brought attention to the risk for IE in HIV, but little has changed in our understanding, therapy, or prevention of this dreaded disease.1
Reference
1. Nahass RG, et al. Infective endocarditis in intravenous drug users: A comparison of human immunodeficiency virus type 1-negative and positive patients. J Infect Dis. 1990;162:967-970.
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