Sex Differences in Infective Endocarditis

Sex-specific differences in infective endocarditis: A systematic review and meta-analysis of clinical profiles and management outcomes

Background

Infective endocarditis (IE) presents significant morbidity and mortality, with potential sex differences in clinical profile and outcomes. This is the first meta-analysis that aims to compare the clinical profile and outcomes of IE between males and females.

Methods

We conducted a meta-analysis of nine studies evaluating the clinical profile and outcomes of IE in males versus females extracted from PubMed, EMBASE, SCOPUS, and Cochrane databases up to 1st of Jan 2024.

Results

Our meta-analysis revealed notable sex differences in the incidence and complications of IE. Males exhibited a higher incidence of aortic valve IE (RR 1.57, 95 % CI [1.31, 1.88]), surgical indications for IE (RR 1.38, [1.12, 1.70]), Streptococci infection (RR 1.36, [1.04, 1.77]), intracardiac abscess (RR 1.22, [1.05, 1.42]), and Enterococci IE (RR 1.44, [1.28, 1.61]). In contrast, females had a higher incidence of mitral valve IE (RR 0.79, [0.67, 0.94]) and a higher in-hospital mortality rate (RR 0.84, [0.74, 0.96]). No significant sex differences were found in the incidence of valve vegetations, tricuspid valve IE, embolization, and Staphylococcus IE. In-hospital stay was longer in male patients, however, with borderline significance (RR 3.15, [-0.16, 6.45], p = 0.06). In patients who underwent surgery for IE, mortality rates were significantly lower in male patients (RR: 0.67 [0.59, 0.76], p < 0.01).

Conclusions

Compared to females, males exhibit higher rates of aortic valve IE, intracardiac abscess, streptococci IE, enterococci IE and IE-related surgery indication. In contrast, females have higher rates of mitral valve IE and in-hospital mortality.

Longitudinal Outcomes Following Mitral Valve Repair for Infective Endocarditis

Mitral valve repair is the ideal approach in managing mitral valve infective endocarditis for patients requiring surgery. However, viable repair is influenced by the extent of valve destruction and there can be technical challenges in reconstruction following debridement. Overall, data describing long-term outcomes following mitral repair of infective endocarditis are scarce. We, therefore, assessed the late outcomes of 101 consecutive patients who underwent mitral valve repair for IE at the University of Ottawa Heart Institute from 2001 to 2021. The 5- and 10-year survival rate was 80.8 ± 4.7% and 61.2 ± 9.2%, respectively. Among these 101 patients, 7 ultimately required mitral valve reoperation at a median of 5 years after their initial operation. These patients were of a mean age of 35.9 ± 7.3 years (range 22-44 years) at the time of their initial operation. The 5- and 10-year freedom from mitral valve reoperation was 93.6 ± 3.4% and 87.7 ± 5.2%, respectively. Overall, mitral valve repair can be an effective method for treating infective endocarditis with a favourable freedom from reoperation and mortality over the long term.

Similar Outcomes in Males and Females Undergoing Surgery for Infective Endocarditis

Background: Sex-based differences in mortality have been previously observed in patients with surgically treated infective endocarditis. We sought to evaluate the risk factors leading to this difference. Methods: A retrospective cohort from three centers in Israel comprising 376 surgically treated patients, comparing short- and long-term mortality rates and risk factors between female and male patients. Results: Compared to male patients, female patients had higher rates of hypertension (62% vs. 48%), higher rates of Gram-negative infections (20% vs. 11%), and more mitral valve replacement (55% vs. 42%). Diabetes and age were the most significant predictors for mortality and did not differ between female and male patients. In-hospital mortality rates did not differ between female and male patients (29% vs. 26%), and the difference in long-term mortality was not statistically significant (46% vs. 36% p = 0.088). Conclusions: No statistical difference was observed in short- and long-term mortality between female and male patients, most likely due to a lack of difference in the rates of important risk factors such as diabetes and age. Mortality rates decreased in the last 10 years, and a good prognosis is observed for patients surviving the initial 30 days after surgery.

Infective endocarditis

First described more than 350 years ago, infective endocarditis represents a global health concern characterised by infections affecting the native or prosthetic heart valves, the mural endocardium, a septal defect, or an indwelling cardiac device. Over recent decades, shifts in causation and epidemiology have been observed. Echocardiography remains pivotal in the diagnosis of infective endocarditis, with alternative imaging modalities gaining significance. Multidisciplinary management requiring expertise of cardiologists, cardiovascular surgeons, infectious disease specialists, microbiologists, radiologists and neurologists, is imperative. Current recommendations for clinical management often rely on observational studies, given the limited number of well conducted randomised controlled trials studying infective endocarditis due to the rarity of the disease. In this Seminar, we provide a comprehensive overview of optimal clinical practices in infective endocarditis, highlighting key aspects of pathophysiology, pathogens, diagnosis, management, prevention, and multidisciplinary approaches, providing updates on recent research findings and addressing remaining controversies in diagnostic accuracy, prevention strategies, and optimal treatment.

Sex differences in infective endocarditis: a Danish nationwide study

PURPOSE

Sex differences in infective endocarditis (IE) are reported, but patient characteristics are sparse and conflicting findings on the association between sex and short-term outcomes demand further research. We aimed to characterize sex differences in IE in terms of patient characteristics, frailty, microbiology, socioeconomic status, management and outcome on a nationwide scale.

METHODS

Between 2010 and 2020, we used Danish national registries to characterize patients with IE according to sex using ICD codes and microbiological lab reports. Frailty was assessed with the Hospital Frailty Risk Score. Mortality was reported with Kaplan-Meier estimates. Logistic regression and Cox regression were used for adjusted analyses.

RESULTS

We included 6259 patients with IE with 2047 (32.7%) female patients and 4212 (67.3%) male patients. Female patients were older (median age 75.0 years (64.3-82.2) vs. 71.7 (61.7-78.9)) and more frail (Intermediate frailty: 36.5% vs. 33.1%, High frailty: 11.4% vs. 9.2%). Staphylococcus aureus-IE were most common in both sexes (34.6% vs. 28.8%), but fewer female patients had Enterococcus-IE (10.5% vs. 18.1%). Female patients were less surgically treated (14.0% vs. 21.2%). Female sex was associated with increased in-hospital mortality (adj. OR 1.33, 95% CI 1.16-1.52), but no statistically significant difference in associated 1- and 5-year mortality from hospital discharge were identified (adj. HR 1.09, 95% CI 0.95-1.24 and 1.02, 95% CI 0.92-1.12, respectively).

CONCLUSION

Female sex is associated with increased in-hospital mortality, but not in long-term mortality as compared with male patients. Female patients have a lower prevalence of Enterococcus-IE and rates of surgery. Further research is needed to understand these differences.

Sex differences and outcomes in surgical infective endocarditis

BACKGROUND

Cardiac surgery for infective endocarditis (IE) is associated with significant hospital mortality, and female sex may be associated with worse outcomes. However, the impact of sex on the presenting characteristics, management, and outcomes of patients operated on for acute infective endocarditis (IE) has not been adequately studied.

OBJECTIVES

The goal of our study was to analyse differences in management and outcome of IE between women and men who undergo surgery.

METHODS

Clinical data of 717 patients undergoing cardiac surgery for IE between December 2005 and December 2019 were prospectively collected. Sex-related postoperative outcomes including in-hospital mortality were recorded. Univariable and multivariable analyses were performed to identify potential sex-related determinant of in-hospital mortality.

RESULTS

In all, 532 male patients (74.2%) and 185 female patients (25.8%) underwent surgery for IE. At baseline, women had more frequent mitral regurgitation with 63 patients (34.1%) than men with 135 patients (25.4%) (P = 0.002). Female sex was associated with higher in-hospital mortality (23.2% versus 17.3%, P = 0.049). However, multivariable analysis revealed age (P < 0.01), antibiotics < 7 days before surgery (P = 0.01) and staphylococcal IE (P < 0.01) but not female sex (P = 0.99) as independent determinants of hospital mortality.

CONCLUSIONS

In this study of patients operated-on for IE, female sex was associated with more severe manifestations of IE and significantly higher in-hospital mortality. However, after multivariable analysis, initial presentation, but not sex, seemed to determine clinical outcomes.

Sex Differences in Infective Endocarditis: A Systematic Review

Despite the advancement in medicine, there is still a lack of understanding of the sex disparities in disease onset, progression, treatment, and outcome. In some life-threatening acute conditions, despite most patients with these illnesses being males, females have a significantly higher chance of mortality. This can be due to the differences in disease progression or healthcare disparities in managing the illness between the sexes. Treatment of illnesses tends to be more conservative for women without an explanation, but this disparity is due to the healthcare provider. Infective endocarditis (IE) is an acute life-threatening condition where bacteria latch onto and seed damaged endocardium, with some preliminary information reporting differences between the sexes. This paper aims to evaluate the sex disparities in the incidence, age, comorbidities, etiology, risk factors, manifestations, treatment, and outcomes of IE. From 2003-2023, 21584 articles were found that focused on the sex differences in IE and, through PRISMA guidelines, were narrowed down to 34 publications. There are significant differences between the sexes in IE, such as a significantly higher incidence of IE in males, who also tend to be older and have their native aortic valves involved, compared to younger females who have their mitral valve involved. Comorbidities also vary between the sexes; females tend to have atrial fibrillation, chronic kidney disease, psychiatric disorders, and taking immunosuppressants compared to males who suffer from chronic liver disease, underlying valve disease, and peripheral artery disease, contributing to the ease of developing IE. While the most common microorganism leading to IE is Staphylococcus aureus, females were more likely to have culture-negative IE, and men were more likely to be infected with Streptococcus viridans. Major manifestations in IE are fever and vegetation along the closure of the valves in the heart, where females were more likely to have vegetation on the mitral and aortic valves. At the same time, males were more likely to have it on the tricuspid valve. On par with sex disparities in health, females usually took longer to seek medical help than males despite the advancement of symptoms and deterioration. Females were also treated conservatively through antibiotic management, whereas males were more likely to advance to surgical treatment, leading to a longer hospital stay. While there was no true difference in the in-hospital mortality rate, the 30-day and 1-year mortality were significantly increased in females. These differences provide a range of starting points for various research to further educate physicians on sex disparities, such as why males have a higher incidence of infective endocarditis and determining whether it's hormones and basic metabolites, possibly limiting those who develop the infection. Another important point is treating females with IE; the antibiotic doses are standard, but whether they advance to surgical treatment is mostly up to the provider. Some providers deny surgical treatment despite all indications, but it could also be females denying surgery as they tend to leave against medical advice. This review is crucial in developing the next steps to sex disparity in IE, which may lead to better outcomes for males and females.

Differences in Sex and the Incidence and In-Hospital Mortality among People Admitted for Infective Endocarditis in Spain, 2016-2020

(1) Background: A description of the trends and outcomes during hospitalization for infective endocarditis (IE) according to sex. (2) Methods: Using Spanish national hospital discharge data (2016−2020), we built Poisson regression models to compare the age-adjusted time trends for the incidence rate. We used propensity score matching (PSM) to compare the clinical characteristics and the in-hospital mortality (IHM) between men and women hospitalized with IE. (3) Results: We identified 10,459 hospitalizations for IE (33.26% women). The incidence of IE remained stable during this five-year period. The age-adjusted incidence of IE was two-fold higher among men vs. women (IRR = 2.08; 95%CI 2.0−2.17). Before PSM, women with IE were significantly older than men (70.25 vs. 66.24 years; p < 0.001) and had lower comorbidity according to the Charlson comorbidity index (mean 1.38 vs. 1.43; p = 0.019). After PSM, the IHM among women admitted for IE remained >3 points higher than that among men (19.52% vs. 15.98%; p < 0.001). (4) Conclusions: The incidence of IE was two-fold higher among men than among women. IHM was significantly higher among women after accounting for the potential confounders.

Sex-related disparities in the incidence and outcomes of infective endocarditis according to type 2 diabetes mellitus status in Spain, 2016-2020

BACKGROUND

We performed a study to assess sex-differences in incidence (2016-2020), clinical characteristics, use of therapeutic procedures, and in-hospital outcomes in patients with infective endocarditis (IE) according to T2DM status.

METHODS

Ours was a retrospective cohort study using data from the Spanish National Hospital Discharge Database. We estimated the incidence of hospitalizations for IE in men and women aged ≥ 40 years with and without T2DM. Propensity score matching (PSM) and multivariable logistic regression were used to compare subgroups according to sex and the presence of T2DM.

RESULTS

From 2016 to 2020, IE was coded in 9,958 patients (66.79% men). T2DM was diagnosed in 2,668 (26.79%). The incidence of IE increased significantly from 15.29 cases per 100,000 persons with T2DM in 2016 to 17.69 in 2020 (p < 0.001). However, this increment was significant only among men with T2DM (19.47 cases per 100,000 in 2016 vs. 22.84 in 2020; p = 0.003). The age-adjusted incidence of IE was significantly higher in people with T2DM (both sexes) than in those without T2DM (IRR, 2.86; 95% CI, 2.74-2.99). The incidence of IE was higher in men with T2DM than in women with T2DM (adjusted IRR, 1.85; 95% CI, 1.54-3.31). After PSM, in-hospital mortality (IHM) was higher among T2DM women than matched T2DM men (22.65% vs. 18.0%; p = 0.018). The presence of T2DM was not associated with IHM in men or women.

CONCLUSIONS

T2DM is associated with a higher incidence of hospitalization for IE. Findings for T2DM patients who had experienced IE differed by sex, with higher incidence rates and lower IHM in men than in women. T2DM was not associated to IHM in IE in men or in women.

Sex Differences in Characteristics of Patients with Infective Endocarditis: A Multicenter Study

Infectious diseases like infective endocarditis (IE) may manifest or progress differently between sexes. This study sought to identify the differences in demographic and clinical characteristics among male and female patients with IE. Data were obtained from a newly developed registry comprising all adult patients with first IE admission at the four major tertiary cardiovascular centers in West Virginia, USA during 2014−2018. Patient characteristics were compared between males and females using Chi-square test, Fisher’s exact test, and Wilcoxon rank-sum test. A secondary analysis was restricted to IE patients with drug use only. Among 780 unique patients (390 males, 390 females), significantly more women (a) were younger than males (median age 34.9 vs. 41.4, p < 0.001); (b) reported drug use (77.7% vs. 64.1%, p < 0.001); (c) had tricuspid valve endocarditis (46.4% vs. 30.8%, p < 0.001); and (d) were discharged against medical advice (20% vs. 9.5%, p < 0.001). These differences persisted even within the subgroup of patients with drug use-associated IE. In a state with one of the highest incidences of drug use and overdose deaths, the significantly higher incident IE cases in younger women and higher proportion of women leaving treatment against medical advice are striking. Differential characteristics between male and female patients are important to inform strategies for specialized treatment and care.

Sex-Specific Risk Factors for Short- and Long-Term Outcomes after Surgery in Patients with Infective Endocarditis

(1) Background: Surgery for infective endocarditis (IE) is associated with considerable mortality and it is controversial whether the female gender is predictive for a worse outcome. This large single-center study investigated the impact of sex on outcomes after surgery for IE. (2) Methods: 413 patients (25.4% female) were included into this retrospective observational study. Univariate and multivariable analyses identified sex-specific risk factors for 30 day and late mortality. Survival was estimated by the Kaplan-Meier-method. (3) Results: Women presented more often with mitral valve infection (p = 0.039). Men presented more frequently with previous endocarditis (p = 0.045), coronary heart disease (p = 0.033), and aortic valve infection (p = 0.005). Blood transfusion occurred more frequently intraoperatively in women (p < 0.001), but postoperatively in men (p = 0.015) and men had a longer postoperative stay (p = 0.046). Women showed a higher 30 day mortality than men (p = 0.007) and female gender was predictive for 30 day mortality (OR 2.090). Late survival showed no sex-specific difference (p = 0.853), and the female gender was not an independent predictor for late mortality (p = 0.718). Risk factors for early and late mortality showed distinct sex-specific differences such as increased preoperative CRP level in women and culture-negative IE in men.

Native and Prosthetic Valve Staphylococcus capitis Endocarditis: A Review of the Literature

Infective endocarditis (IE) is a rare but serious disease. Coagulase-negative staphylococci (CoNS) are among the least prevalent causes of IE. Staphylococcus capitis, a species of CoNS, although described in the literature before has only been seen in a few cases. Even with such few cases, complications and mortality have still been demonstrated. In our review, we look at the epidemiology, diagnosis, management, and literature prevalence of CoNS in native and prosthetic valve IE.