THE ROLE OF RISK FACTORS (“CARMELI SCORE”) AND INFECTIVEENDOCARDITIS CLASSIFICATION IN THE ASSESSMENT OFAPPROPRIATE EMPIRICAL THERAPY

Adriana Slavcovici ¹, A. Streinu-Cercel ², Doina Ţăţulescu ³, Amanda Rădulescu ⁴, Simona Mera ¹, C. Marcu ¹, D. Vesbianu ⁵, Adriana Topan ^1
1 Assistant Professor, PhD MD, University of Medicine and Pharmacy “Iuliu Haţieganu” Cluj-Napoca, University Hospital of Infectious Diseases Cluj-Napoca
² Professor, PhD MD, University of Medicine and Pharmacy “Carol Davila” Bucharest, “Prof. dr. Matei Balş”
National Institute of Infectious Diseases Bucharest
³ Professor, PhD MD, University of Medicine and Pharmacy “Iuliu Haţieganu” Cluj-Napoca, University Hospital of Infectious Diseases Cluj-Napoca
⁴ Associated Professor, PhD MD, University of Medicine and Pharmacy “Iuliu Haţieganu” Cluj-Napoca, Department of Epidemiology, University Hospital of Infectious Diseases Cluj-Napoca
⁵ Assistant Professor, Drexel University, Hahnemann Hospital, Philadelphia, PA 19102 USA

Abstract

Introduction: Invasive medical procedures, increasing life span, immunosenescence and antibiotic use have changed the epidemiological and bacteriological profile of infective endocarditis (IE) with direct consequences in the assessment of appropriate empirical therapy. Objective: The aim of the study was to classify IE according to predictive factors for drug resistant or multidrug resistant microorganisms in order to establish the appropriate therapeutic options. The study represents an attempt to apply Carmeli’s risk stratification (used for the management of severe infections) in IE.Materials and methods: We performed a retrospective study comprising of 270 consecutive episodes of IE admitted in the University Hospital of Infectious Diseases Cluj-Napoca during 1998-2008. The diagnosis of IE was established upon modified Duke criteria. Risk factors were ranked with 1, 2 or 3 points according to Carmeli’s risk stratifica- tion including: the degree of contact between the patient and the health care system (invasive procedures – present or absent), prior antibiotic treatments and patient characteristics (age, comorbidities, immune status). The highest final score allowed us to classify IE in three strata: IE with score 1, 2 or 3. For each risk category we evaluated the etiology and resistance patterns.Results: Using Carmeli scoring system we found 111 (41%) IE score 1 (community acquired IE), 87 (32%) IE with score 2 (IE associated to health care assistance or community acquired but with increased prediction of multidrug resistance), 72 (27%) IE stratified with “Carmeli score” 3 (usually nosocomial IE). Blood cultures were positive in 50.5% of score 1 IE and the identified strains were: 41% oral streptococci, 30.4% staphylococci (9% MRSA), 7% enterococci. Among score 2 we found 63% IE with positive blood culture: 23.6% staphylococci (16.4% meti-R), 29% oral streptococci, 9% other streptococcal strains, 21.8% Enterococcus spp and 18% Gram negative rods. Among score 3 IE we found 80.5% positive blood cultures. The identified strains were: 46.50% staphylococci (13.8% MRSA), 19% Enterococcus spp., 7% Streptococcus spp. (other oral streptococci), 10.3% Gram negative rods mostly resistant to the classical antibiotics. Multidrug resistant strains had a significantly higher prevalence in score 2 and 3 IE (21.8% and 25.8% respectively, p=0.007). We found significant correlations between the IE with score 2 and 3 and prosthetic valves, enterococcal or staphylococcal etiology and MDR. Conclusions: We found significant differences in the etiology and resistance patterns in risk stratified IE classified entially valuable in the assessment of the appropriate empirical therapy.