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Influence of Human Immunodeficiency Virus 1 Infection and Degree of Immunosuppression in the Clinical Characteristics and Outcome of Infective Endocarditis in Intravenous Drug Users
Esteban Ribera, MD;
José M. Miró, MD;
Emilia Cortés, MD;
Ana Cruceta, MD;
Jordi Merce, MD;
Francesc Marco, MD;
Ana Planes, MD;
Joan Carles Paré, MD;
Asunción Moreno, MD;
Imma Ocaña, MD;
José M. Gatell, MD;
Albert Pahissa, MD
Arch Intern Med. 1998;158:2043-2050.
Background Immunosuppression caused by human immunodeficiency virus 1 (HIV) infection appears to modify the clinical characteristics and to increase the severity of several bacterial infections. The impact of HIV infection and the degree of immunosuppression on the clinical characteristics and outcome of infective endocarditis (IE) in intravenous (IV) drug users has not been well characterized.
Methods Prospective cohort study among 292 consecutive IV drug users with IE diagnosed in 2 academic institutional hospitals in Barcelona, Spain, from January 1, 1984, to October 31, 1995. Serostatus of HIV infection was documented in 283 patients. We measured demographics, clinical and biological data, cause, echocardiographic findings, HIV serostatus and classification, CD4 cell count, complications, and mortality.
Results Among the 283 episodes of IE, 216 (76.3%) were in HIV-infected patients and 67 (23.7%) in non–HIV-infected patients. Rate of IE per 1000 admissions ranged from 0.17 to 0.82 per year, peaking in 1989. Characteristics of IE independently associated with HIV infection were right-side involvement (odds ratio [OR], 7.6; 95% confidence interval [CI], 3.5-16.7), a micro-organism different from viridans streptococci (OR, 2.5; 95% CI, 1.1-5.9), duration of drug abuse longer than 5 years (OR, 5.0; 95% CI, 2.4-10.3), and white blood cell count of no more than 10x109/L (OR, 2.2; 95% CI, 1.1-4.2). There were no significant differences in mortality due to IE according to HIV serostatus. Among the 216 patients with HIV infection, the variables independently associated with worse outcome were CD4 cell count lower than 0.200x109/L and left-sided or mixed IE.
Conclusions Although there is a difference in clinical presentation in IE in IV drug users, outcome was similar according to their HIV status. However, among HIV-infected patients, severe immunosuppression and mixed or left-side valvular involvement were strong risk factors for mortality.
From the Infectious Diseases Service (Drs Ribera, Cortés, Ocaña, and Pahissa), Cardiology Service (Dr Merce), and Microbiology and Parasitology Service (Dr Planes), Hospital Vall d'Hebron, Universidad Autónoma de Barcelona, and the Infectious Diseases Service (Drs Miró, Cruceta, Moreno, and Gatell), Microbiology and Parasitology Service (Dr Marco), and Cardiology Service (Dr Paré), Hospital Clínic i Provincial, Universidad de Barcelona, Barcelona, Spain.
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