Infective endocarditis: strokes, toxic confusion and meningitis manifestations were common.

Clinical bottom line (level 4)

  1. Mortality was high in patients with S. Aureus infective endocarditis (~60%).
  2. A quarter had neurological manifestations (50% with a stroke, 25% with toxic confusion, 20% with meningitis).
  3. Patients with neurological manifestations were at increased risk of dying (NNH = 6 at unknown) .
Roder et al: American Journal of Medicine 1997; 102: 379-386
Expires July 2003

The study

Retrospective cohort study with objective outcomes, not adjusted for confounding factors, not validated in an independent set of patients.

Setting: 63 acute hospitals, Denmark, 1982 to 1991

260 patients (aged range 20 to 97 years; mean 68, 56% male) Staphylococcus aureus endocarditis defined by Duke criteria

Excluded if
  • drug addicts
  • no medical records were obtained
  • insufficient information




    • ?100% followed for ?3 months
    Outcomes studied:
  • neurological manifestations
  • mortality
  • thromboembolic event
  • hemiparesis
  • aphasia
  • cranial nerve deficit
  • rigidity
  • conjugated gaze deviation
  • ataxia
  • retinal emboli
  • meningitis
  • toxic confusion

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    neurological manifestations ?3 months 91/260 24%
    (18% to 29%)
    mortality ?3 months 162/260 62%
    (56% to 68%)
    thromboembolic event ?3 months 52/91 57%
    (47% to 67%)
    hemiparesis ?3 months 41/91 45%
    (35% to 55%)
    aphasia ?3 months 8/91 9%
    (3% to 15%)
    cranial nerve deficit ?3 months 6/91 7%
    (1% to 12%)
    rigidity ?3 months 4/91 4%
    (0% to 8%)
    conjugated gaze deviation ?3 months 3/91 3%
    (0% to 7%)
    ataxia ?3 months 2/91 2%
    (0% to 5%)
    retinal emboli ?3 months 2/91 2%
    (0% to 5%)
    meningitis ?3 months 20/91 20%
    (13% to 30%)
    toxic confusion ?3 months 22/91 24%
    (13% to 30%)

    prognostic factor for
    mortality     		time to outcome unadjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    neurologic manifestation ?3 months 1.31
    (1.09 to 1.57)     		6
    (3 to 19)

    prognostic factor outcome present outcome absent unadjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    neurologic manifestation 67 24 1.31
    (1.09 to 1.57)     		6
    (3 to 19)
    no neurologic manifestation 95 74

    • 67% of patients with neurological manifestations had them present at admission (95% CI: 57% to 77%).
    • Community-acquired infection, n=173 (67%); nosocomial acquired infection, n=87 (33%).
    • The risk of recurrent embolism was low.
    • Complications occurred in 91 patients (35%); most frequently caused by cerebral embolism with cerebral infarction.

    Citation

    1. Roder BL, et al: Neurologic manifestations in Staphylococcus aureus endocarditis: a review of 260 bacteraemic cases in nondrug addicts. American Journal of Medicine 1997; 102: 379-386
    Search Terms: explode 'infective, endocarditis and neurologic'
    Contributor: Carl Heneghan, Sumit Dhingra and Chris Ball, July 2000
    Reviewer:

    Clinical Question.
    Patient infective endocarditis
    Intervention or Exposure clinical features, neurological manifestations, stroke
    Outcome mortality, prevalence