Infective endocarditis: fever, chills and heart murmurs were common.

Clinical bottom line (level 4)

  1. Infective endocarditis was uncommon in patients with S. aureus bacteraemia (3%).
  2. A heart murmur followed by heart failure were the commonest physical findings in patients with infective endocarditis. Patients commonly reported fever and chills.
  3. Patients often had a raised white cell count and ESR.
  4. Patients aged over 60 were at increased risk of dying (NNH = 3 at unknown) .
Espersen et al: Archives of Internal Medicine 1986; 146: 1118-1121
Expires July 2003

The study

Case series with ?objective ?blinded outcomes, not adjusted for confounding factors, not validated in an independent set of patients.

Setting: 3518 cases of bacteraemia in Denmark, 1976 to 1981

119 patients (aged range 1 month to 85 years; median 63 years, 51% female) staphylococcus aureus endocarditis fulfilling von Reyn criteria

Excluded if
  • missing relevant information
  • missing records




    • ? followed for duration of hospitalisation
    Outcomes studied:
  • infective endocarditis in patients with S. aureus bacteraemia
  • cardiac murmur
  • heart failure
  • CNS involvement
  • skin infection
  • petechiae/ splinters/ Janeway lesions
  • rales
  • hepatomegaly
  • joint effusion
  • splenomegaly
  • conjunctival haemorrhages
  • fever at onset
  • chills at onset
  • cerebral symptoms at onset headache, mental state changes
  • pain at onset
  • dyspnoea at onset
  • coughing at onset
  • nausea/vomiting at onset
  • anorexia/weight loss at onset
  • diarrhoea at onset
  • abnormal chest x-ray
  • abnormal leukocyte count
  • abnormal differential count
  • abnormal haemoglobin
  • abnormal ESR
  • abnormal serum creatinine
  • abnormal liver function
  • abnormal urinalysis- red blood cells
  • abnormal urinalysis- white blood cells
  • abnormal urinalysis- casts
  • mortality- 0-20 years old
  • mortality- 21-40 years old
  • mortality- 41-60 years old
  • mortality- 61-80 years old
  • mortality- 81+ years old
  • total mortality

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    infective endocarditis in patients with S. aureus bacteraemia duration of hospitalisation 119/3518 3.4%
    (2.8% to 4.0%)
    cardiac murmur duration of hospitalisation 80/117 68%
    (60% to 77%)
    heart failure duration of hospitalisation 52/117 44%
    (35% to 53%)
    CNS involvement duration of hospitalisation 39/117 33%
    (25% to 42%)
    skin infection duration of hospitalisation 32/117 27%
    (19% to 35%)
    petechiae/ splinters/ Janeway lesions duration of hospitalisation 31/117 27%
    (19% to 35%)
    rales duration of hospitalisation 23/117 20%
    (13% to 27%)
    hepatomegaly duration of hospitalisation 23/117 20%
    (13% to 27%)
    joint effusion duration of hospitalisation 8/117 6.8%
    (2.3% to 11%)
    splenomegaly duration of hospitalisation 4/117 3.4%
    (0.1% to 6.7%)
    conjunctival haemorrhages duration of hospitalisation 4/117 3.4%
    (0.1% to 6.7%)
    fever at onset duration of hospitalisation 118/118 100%
    (97% to 100%)
    chills at onset duration of hospitalisation 80/118 68%
    (59% to 76%)
    cerebral symptoms at onset duration of hospitalisation 62/118 53%
    (44% to 62%)
    pain at onset duration of hospitalisation 52/118 44%
    (35% to 53%)
    dyspnoea at onset duration of hospitalisation 46/118 39%
    (30% to 48%)
    coughing at onset duration of hospitalisation 32/118 27%
    (19% to 35%)
    nausea/vomiting at onset duration of hospitalisation 29/118 25%
    (17% to 32%)
    anorexia/weight loss at onset duration of hospitalisation 20/118 17%
    (10% to 24%)
    diarrhoea at onset duration of hospitalisation 4/118 3.4%
    (0.1% to 6.7%)
    abnormal chest x-ray duration of hospitalisation 53/113 47%
    (38% to 56%)
    abnormal leukocyte count duration of hospitalisation 62/102 60%
    (51% to 67%)
    abnormal differential count duration of hospitalisation 63/86 73%
    (64% to 83%)
    abnormal haemoglobin duration of hospitalisation 36/109 33%
    (24% to 42%)
    abnormal ESR duration of hospitalisation 68/92 74%
    (65% to 83%)
    abnormal serum creatinine duration of hospitalisation 54/109 50%
    (40% to 59%)
    abnormal liver function duration of hospitalisation 46/103 45%
    (35% to 54%)
    abnormal urinalysis- red blood cells duration of hospitalisation 41/99 41%
    (31% to 51%)
    abnormal urinalysis- white blood cells duration of hospitalisation 34/98 35%
    (25% to 44%)
    abnormal urinalysis- casts duration of hospitalisation 19/98 19%
    (12% to 27%)
    mortality- 0-20 years old duration of hospitalisation 2/10 20%
    (0% to 45%)
    mortality- 21-40 years old duration of hospitalisation 6/17 35%
    (13% to 58%)
    mortality- 41-60 years old duration of hospitalisation 20/28 71%
    (55% to 88%)
    mortality- 61-80 years old duration of hospitalisation 43/50 86%
    (76% to 96%)
    mortality- 81+ years old duration of hospitalisation 13/14 93%
    (79% to 100%)
    total mortality duration of hospitalisation 84/119 71%
    (62% to 79%)

    prognostic factor for
    total mortality     		time to outcome unadjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    aged >60 duration of hospitalisation 1.72
    (1.30 to 2.26)     		3
    (2 to 6)

    • The diagnosis of endocarditis was not suspected clinically in 65 patients (55%), but was demonstrated only at autopsy.
    • The number of drug addicts was 13, of which 11 had tricuspid endocarditis.
    • Cardiac surgery was performed in only four patients.

    Citation

    1. Espersen F, et al: Staphylococcus aureus endocarditis. Archives of Internal Medicine 1986; 146: 1118-1121
    Search Terms: endocarditis and staphylococcus
    Contributor: Carl Heneghan, Sumit Dhingra and Chris Ball, July 2000
    Reviewer:

    Clinical Question.
    Patient suspected endocarditis
    Intervention or Exposure clinical features
    Outcome prevalence