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Neurologic complications and outcomes of infective endocarditis in critically ill patients: The ENDOcardite en REAnimation prospective multicenter study*

Sonneville, Romain MD; Mirabel, Mariana MD; Hajage, David MD; Tubach, Florence MD, PhD; Vignon, Philippe MD, PhD; Perez, Pierre MD; Lavoué, Sylvain MD; Kouatchet, Achille MD; Pajot, Olivier MD; Dessap, Armand Mekontso MD, PhD; Tonnelier, Jean-Marie MD; Bollaert, Pierre-Edouard MD, PhD; Frat, Jean-Pierre MD; Navellou, Jean-Christophe MD; Hyvernat, Hervé MD; Hssain, Ali Ait MD; Tabah, Alexis MD; Trouillet, Jean-Louis MD; Wolff, Michel MD

doi: 10.1097/CCM.0b013e3182120b41
Neurologic Critical Care

Objective: To describe the clinical spectrum of infective endocarditis in critically ill patients and assess the impact of neurologic complications on outcomes.

Design: Prospective multicenter observational study conducted from April 2007 to October 2008.

Setting: Thirty-three intensive care units in 23 university-affiliated and 10 general French hospitals.

Patients: Two hundred twenty-five patients with definite IE were studied. Factors associated with neurologic complications and predictors of 3-month mortality were identified by logistic regression analysis. Functional outcomes of patients with neurologic complications were evaluated with the modified Rankin Scale.

Interventions: None.

Measurements and Main Results: Among 198 patients with definite left-sided infective endocarditis, 108 (55%) experienced at least one neurologic complication. These complications were ischemic stroke (n = 79), cerebral hemorrhage (n = 53), meningitis or meningeal reaction (n = 41), brain abscess (n = 14), and mycotic aneurysm (n = 10). Factors independently associated with neurologic complications were (subhazard ratio [95% confidence interval]): Staphylococcus aureus infective endocarditis (1.45 [1.02–2.05]), mitral valve infective endocarditis (1.54 [1.07–2.21]), and nonneurologic embolic events (1.51 [1.09–2.09]). In contrast, health care-associated infective endocarditis had a protective effect (0.46 [0.27–0.77]). Multivariate analysis identified three variables associated with 3-month mortality (odds ratio [95% confidence interval]): neurologic failure, as defined as a Glasgow Coma Scale <10 (7.41 [2.89–18.96]), S. aureus infective endocarditis (3.26 [1.53–6.94]), and severe comorbidities before admission as defined as a Charlson score >2 (3.16 [1.47–6.77]). Among the 106 patients with neurologic complications assessed at follow-up (3.9 [3–8.5] months), 31 (29%) had a modified Rankin Scale score ≤3 (ability to walk without assistance), nine (9%) a modified Rankin Scale score of 4 or 5 (severe disability), and 66 (62%) a modified Rankin Scale score of 6 (death).

Conclusions: Neurologic events are the most frequent complications in infective endocarditis patients requiring intensive care unit admission. They contribute to a severe prognosis, leaving less than one-third of patients alive with functional independence. Neurologic failure at intensive care unit admission represents a major determinant of mortality regardless of the underlying neurologic complication.

From the Service de Réanimation Médicale et des Maladies Infectieuses (RS, MW), Département d'Epidémiologie, Biostatistiques et Recherche Clinique et INSERM CIE 801 (DH, FT), Université Paris 7–Denis Diderot, Hôpital Bichat–Claude Bernard, Assistance Publique–Hôpitaux de Paris (AP–HP), Paris, France; Service de Réanimation Médicale, Institut de Cardiologie (MM, J-LT), Université Paris 6–Pierre et Marie Curie, Hôpital Pitié–Salpêtrière, Assistance Publique–Hôpitaux de Paris (AP–HP), Paris, France; Service de Réanimation Polyvalente et CIC-P 0801 (PV), Université de Limoges, CHU de Limoges, Limoges, France; Service de Réanimation Médicale (PP), CHU Nancy–Hôpital Brabois adultes, Vandoeuvre- les-Nancy, France; Service des Maladies Infectieuses et Réanimation Médicale (SL), Hôpital Pontchaillou, CHU de Rennes, France; Service de Réanimation Médicale et de Médecine Hyperbare (AK), CHU d'Angers, Angers, France; Service de Réanimation Polyvalente (OP), CH Victor Dupouy, Argenteuil, France; Service de Réanimation Médicale (AMD), CHU Henri Mondor, Créteil, France; Service de Réanimation Médicale (J-MT), CHU de la Cavale Blanche, Brest, France; Service de Réanimation Médicale (P-EB), CHU de Nancy–Hôpital Central, Nancy, France; Service de Réanimation Médicale (J-PF), CHU de Poitiers, Poitiers, France; Service de Réanimation (J-CN), CHU–Hôpital Jean Minjoz, Besançon, France; Service de Réanimation (HH), CHU Sophia Antipolis, Hôpital Archet Nice, France; Unité de Réanimation Médicale (AAH), Pôle REUNNIRH, Hôpital Gabriel Montpied, Clermont-Ferrand, France; and Service de Réanimation Médicale (AT), CHU Albert Michallon, Grenoble, France.

This work was supported by a grant from the Société De Réanimation De Langue Française (SRLF).

J.-L.T. and M.W. contributed equally.

R.S. and M.M. received a grant from the Société de Réanimation de Langue Française. The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: romain.sonneville@bch.aphp.fr

Members of the ENDOcardite en REAnimation Study Group: R. Sonneville and M. Wolff, Service de Réanimation Médicale et Infectieuse, CHU Bichat–Claude-Bernard, Paris, France; M. Mirabel and J.–L. Trouillet, Service de Réanimation Médicale, CHU La Pitié–Salpétrière, Paris, France; A. Mekontso-Dessap, Service de Réanimation Médicale, CHU Henri Mondor, Créteil, France; A. Tabah and J.-F. Timsit, Service de Réanimation Médicale, CHU de Grenoble, Grenoble, France; K. Chergui, Service de Réanimation Polyvalente, CH Sud Francilien, Corbeil-Essonnes, France; A. Alvarez, Service de Réanimation Polyvalente, CH Delafontaine, Saint-Denis, France; O. Pajot, Service de Réanimation Polyvalente, CH Victor Dupouy, Argenteuil, France; F. Bruneel, Service de Réanimation Médico-Chirurgicale, CH André Mignot, Le Chesnay, France; J. P. Frat, Service de Réanimation Médicale, CHU de Poitiers, Poitiers, France; J. C. Navellou, Service de Réanimation, CHU, Hôpital Jean-Minjoz, Besançon, France; P.-E. Bollaert, Service de Réanimation Médicale, CHU de Nancy Hôpital Central, Nancy, France; J. Allardet-Servent, Service de Réanimation Médicale, CHU de Marseille–Hôpital Sainte Marguerite, Marseille, France; G. Prat and J.M. Tonnelier, Service de Réanimation Médicale, CHU de la Cavale Blanche, Brest, France; A. Kouatchet, Service de Réanimation Médicale et de Médecine Hyperbare, CHU d'Angers, Angers, France; J. Baudot, Service de Réanimation Polyvalente, CH de Nevers, Nevers, France; A. Rabbat, Service de Réanimation Médicale et Respiratoire, CHU Hôtel-Dieu, Paris, France; I. Coquet, Service de Réanimation Médicale, CHU Saint-Louis, Paris, France; E. Maury, Service de Réanimation Médicale, CHU Saint-Antoine, Paris, France; C. Lamer, Service de Réanimation Polyvalente, Institut Montsouris, Paris, France; A. Novara, Service de Réanimation Médicale, CHU HEGP, Paris, France; P. Fangio, Service de Réanimation Médico-Chirurgicale, CH de Poissy, Poissy, France; B. Megarbane, service de Réanimation Médicale et Toxicologique, CHU Lariboisière, Paris, France; D. Prat, Service de Réanimation Médicale Polyvalente, CHU Antoine-Béclère, Clamart, France; A. Ouchenir, Service de Réanimation Polyvalente, CH Louis Pasteur, Chartres, France; S. Lavoué, Service des Maladies Infectieuses et Réanimation Médicale, Hopital Pontchaillou, CHU de Rennes, Rennes, France; A. Ait Hssain, Service de Réanimation Médico-Chirurgicale, CHU Gabriel Montpied, Clermont-Ferrand, France; P. Vignon, Service de Réanimation Polyvalente, CIC-P 0801 et Université de Limoges, Limoges, France; H. Hyvernat, Réanimation Médicale, CHU de Nice Sophia Antipolis, Nice, France; C. Richard, Service de Réanimation Médicale, CHU de Bicêtre, Le Kremlin-Bicêtre, France; A. Perez and B. Levy, Service de Réanimation Médicale, CHU Nancy–Hôpital Brabois adultes, Vandoeuvre-les-Nancy, France; A. Mahrez, Service de Réanimation Médico-Chirurgicale, CH Simone Veil, Eaubonne, France; J. Charpentier, Service de Réanimation Médicale, CHU Cochin–Saint-Vincent de Paul, Paris, France; D. Combaux, Service de Réanimation Médico-Chirurgicale, CH de Compègne, Compiègne, France; and M. Misset, Service de Réanimation, Hôpital Saint-Joseph, Paris.

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