Epidemiology, Outcomes and Prognosis of Infective Endocarditis in Northern Morocco

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Our study aims to describe the epidemiology and management aspects of endocarditis in northern Morocco and compare it with international management guidelines. Materials and Methods: This is a retrospective study involving all patients hospitalized in the cardiology department of the University Hospital of Tangier for infective endocarditis over a period of 4 years and 7 months, from May 2019 to February 2024. Results: 80 patients were hospitalized for IE during the study period. The average age of the patients was 46 years, with an even sex ratio. IE concerned native valves in 77% of cases, mechanical prostheses in 19% of cases, and on bio prostheses in 4%. The average diagnostic delay was 25 days. Blood cultures were negative in 59% of cases. The predominant infective microorganism was the bacteria Staphylococcus (65.6%). Imaging results showed vegetations in 76.3% of cases, predominantly on the mitral valve (39.3%), followed by the aortic valve (21.3%). The main complications included heart failure (51.2%), peripheral arterial embolisms (22.5%) and splenic infarction (17.5%) Management wise, the most commonly used antibiotic therapy was a combination of ceftriaxone and gentamicin. Clinical and biological improvement was observed in 70% of cases, with a mortality rate of 12.5%. Twelve patients underwent urgent surgery (41.7%). Conclusion: Our study highlights the challenges in managing infective endocarditis in northern Morocco. The prognosis of infective endocarditis can be improved through multidisciplinary management within the implementation of an Endocarditis Team. infective endocarditis valve blood culture complications antibiotic surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 HIGHLIGHTS Infective endocarditis is a rare but severe disease. Guidelines are updated frequently to perfect the assessment and management of this condition. Complications of IE should be assessed systematically to improve prognosis Our study proves that the epidemiological data in the guidelines concerning countries where rheumatic heart disease is endemic is similar and compatible with our results. a INTRODUCTION Infective endocarditis (IE) refers to lesions of cardiac valve endocardium by virulent microorganisms, most often bacterial, and concerns much less commonly the heart wall (parietal endocardium), intracardiac prosthesis (IE on prostheses) and devices. It is a rare and serious condition, with significant morbidity and mortality. Its diagnosis is based on a set of clinical and paraclinical arguments. Guidelines have been updated recently by different international committees, such as the 2023 European Society of Cardiology (ESC) guidelines. Diagnosis of IE distinguishes different parameters for native valves, valvular prostheses, and intracardiac devices. Among IE on native valves, the left heart is most frequently affected, and rarely the right heart is affected. 1 The epidemiology of IE is changing, with usual patients with degenerative valve disease being added to those with prosthetic valves and intracardiac devices, and the microbiology is also changing during the past decade. Treatment is based on prolonged antibiotic therapy adapted to the identified responsible organism, and requires thorough assessment of IE complications The management of IE must be collaborative, involving the cardiologist, infective disease specialist, cardiovascular surgeon, and sometimes vascular surgeon, intensivist, microbiologist, and possibly other specialists. The objective of our study is to evaluate the epidemiological, clinical, biological, and prognostic aspects of infective endocarditis in the cardiology setting in Northern Morocco, and to compare our results with the data from the literature and current recommendations. MATERIAL AND METHODS This is a retrospective descriptive study including all patients hospitalized in the cardiology department over a period of 4 years and 7 months, from 2019 to 2024. All patients diagnosed with infective endocarditis during this period were included without any exclusion criteria. A total of 80 cases of confirmed infective endocarditis were identified according to the Modified Duke Criteria of the 2023 ESC guidelines for the management of endocarditis. Patient information was collected from medical records and inscribed using a data collection form. Anonymity and confidentiality of the collected data were strictly maintained. The variables studied in the data collection form include: Epidemiological and socioeconomic data, clinical and paraclinical aspects, (laboratory tests, radiology), complications, follow-up, medical and surgical management and mortality. The data was analysed using "IBM SPSS Statistics 27" statistics software. No artificial intelligence (AI) was utilized in the process. RESULTS 1) Anamnestic data: The average age of our study group was 46 years [12;78]. The sex ratio was even, with 40 female patients and 40 males. Background risk factors favouring IE are shown in Figure 1. Rheumatic fever and childhood recurrent pharyngitis were the most common elements. The average diagnostic delay is 25 days. The revelation onset is subacute in 65% of cases, acute in 16.3% of cases and chronic in 18.8% of patients. (Figure 2) 2) Clinical characteristics: Symptoms: The symptoms investigated in our study are: dyspnoea, chest pain, palpitations, joint pain, and malaise, and infective history signs (fever, cough, urinary burning, and digestive symptoms). Poor general condition is defined by the coexistence of at least 2 elements of the following: Fatigue, weight loss and appetite loss. The results are summarized in (Table 1) . Almost all patients had fever and poor general condition on admission. Physical exam elements: The average systolic blood pressure is 112 mm Hg, and the diastolic blood pressure is 65 mm Hg. The average heart rate is 92 beats per minute. Heart failure congestive signs were present in 51,2% of cases, distributed as following (Figure 3) : left-sided signs (22.5%), global (both left and right signs) 23.8%, and isolated right-sided (5%). Heart auscultation revealed a regular heart rhythm in 73.8% of patients, with a murmur present in 77.5% of patients (regardless of location). 66,3% of cases presented with bad dental status. Extra cardiac manifestations: Extra cardiac signs and phenomena can be classified as following: -Vascular phenomena (arterial emboli, peripheral infarcts (kidney, spleen, pulmonary)) -Neurological phenomena (intracranial haemorrhage, cerebral mycotic aneurysms) -Cutaneous phenomena (Janeway lesions, Osler's nodes, purpura) -Ocular phenomena (Roth's spots, conjunctival haemorrhage) -Splenomegaly, glomerulonephritis Results are listed in (Table 2) 3) Diagnosis and types: Types of IE: 77% had infective endocarditis on native heart valves, whereas 19% of the cases concerned mechanical valve protheses, and only 4% of bio prothesis IE were found. (Figure 4a) Amongst patients with native valves, the mitral valve is the most affected, followed by the aortic valve. No cases of pulmonary valve IE were reported during the study period. (Figure 4b) Echocardiogram findings: Transthoracic echocardiography (TTE) was performed on all patients. Transoesophageal echocardiography (TEE) was performed in 61.3% of patients. Vegetations were found in 76.3% of cases. The average size was 9.85 mm, with a maximum size of 33 mm and a minimum size of 2 mm. They were located on the mitral valve in 39.3% of patients, aortic valve in 21.3% of cases, mitro-aortic in 18% of patients, tricuspid in 9.8% of patients, pulmonary in 3.3% of patients. They were identified in prosthetic valves in 6.6% of patients. The mobile aspect of vegetations was observed in 93.1% of cases. Valvular and paravalvular abscess was found in 11.3% of cases in our study. Other destructive lesions were identified: 8 patients had chordae tendineae rupture, and 10 patients had valve perforation. We also observed mycotic valvular aneurysm in 2.5% of patients. Prosthesis detachment was diagnosed in 4.9% of cases. Lastly, pericardial effusion was present in 10.1% of patients As for other echocardiographic parameters, LV dysfunction is reported in 37.5%, LV dilation in 25%, LA dilation in 42.5%, intra-LA thrombus in 10%, ascending aorta dilation in 5%, pulmonary hypertension (HTAP) in 65%, IVC dilation and decreased compliance in 16.3% of cases. 4) Microbiological data: Blood cultures were sampled for all our study patients. Consequently, they were positive in 41.3% of cases. the isolated pathogens are as following (Figure 5) : Staphylococcus (65.6%) (Staph. Aureus (40.6%), coagulase-negative Staphylococcus (25%)), Oral Streptococcus (9%), Lactococcus lactis (6.3%) and Enterococcus (6.3%) 5) Therapeutical management: Antibiotics: All patients received intravenous antibiotic therapy. Empirical management was indicated initially, then was adjusted according to the antibiogram after blood culture results. Main initial treatment consisted of a combination of 2 bactericidal antibiotics for an average duration of 4 weeks. The double therapy combinations used in our study are as follows (Figure 6) : Surgical management: All patients benefited from surgical management. The degree of urgency of surgical management is defined following the 2023 ESC guidelines: Very urgent (5%), Urgent (10%) and non-urgent (85%). The characteristics of the very urgent-urgent group is detailed in Table III . 6) Evolution and prognosis: Clinical and biological improvement was observed in 70% of cases, and no improvement was seen in 17.5% of cases. Death occurred in 12.5% of cases. (Figure 7). Complications of infective endocarditis were observed and listed in Figure 8 . Heart failure is the most common complication (51%), followed by peripheral arterial embolization (23%) and splenic infarct (18,5 %). As for patients managed with urgent surgery, outcomes were as follows: 1 patient out 4 improved after surgery for hemodynamic indication, 2 out 3 for embolic indication, and 1 our 3 for infective indication. DISCUSSION I-EPIDEMIOLOGY: Our study shows that IE predominantly affects younger individuals with an average age of 46 years. A similar observation is made in Cameroon, as mentioned in the study by Jérôme Boombhi et al., 2 with an average age of 44 years, and in Algeria, the study by Bennata et al. 3 reports an average age of 40.5. However, the series by Toyoda et al. reports an average age of 62. 4 In France, as mentioned previously, infective endocarditis is increasingly affecting elderly individuals, with the average age rising from 58 to 62 years between 1991 and 2008. In our study, infective endocarditis is equally common in men and women. In the series by Toyoda et al., 59% of endocarditis cases were in women. 4 However, a male predominance was noted in the series by Fedeli et al. (62%). 5 Recent dental care (7.5%) and acute rheumatic fever (10%) are the main risk factors for infective endocarditis according to our study. In the study by Boombhi et al, rheumatic valvular disease represents the main cause of infective endocarditis followed by degenerative valvular heart disease. 2 Similarly, in the study by Bennata et al., rheumatic heart disease account for 70% of cases. 3 Additionally, 33% of patients have a history of rheumatic heart disease according to Blanchard et al. 6 In contrast, in the Toyoda series conducted in New York, recent valve surgery and the presence of intracardiac material are major risk factors for infective endocarditis. 4 Infective endocarditis on native valves is more common than on prosthetic valves according to our study (77% vs. 23%). This aligns with most series. II-DIAGNOSIS: A- Amnestic and clinical aspects: Anamnesis interrogation must be thorough to detect risk factors for infectious endocarditis. Infectious endocarditis can be acute, rapidly progressive, subacute, or even chronic. The average treatment time in our study is 25 days. In a study conducted in Rabat by S. Harrak, the average time required for diagnosis is 77 days. 7 Infectious endocarditis can be diagnosed based on symptoms such as fever, joint pain, general malaise (anorexia, asthenia, weight loss), or cardiac signs such as dyspnoea, chest pain, and palpitations. In our study, fever is present in 90% of cases, while in the series by Duval, 86% of patients are febrile. 8 Boombhi's study shows that all patients have fever. 2 In our series, general malaise is found in 87.5% of patients. Splenomegaly associated with general malaise was present in 11% of cases in the study by Montassier conducted in France. 9 Symptoms found in our patients include dyspnoea in 65% of cases, cough in 23.8% of cases, and chest pain in 8.8% of cases. Heart failure is found in 51.2% of cases, in Fedeli's study HF is found in 13%, 5 in Duval's study HF is found in 33.8%, 8 and represents 26% in Benatta's study. 3 in a Tunisian study HF presents 41.5%. 10 (10) In our study series, cardiac auscultation revealed that 77.5% of patients had a murmur. In 73.8% of patients, the rhythm is regular. B-Extra cardiac manifestations: Vascular phenomena are found in 2.5% of cases. Neurological signs in 10% of cases. A lone purpura is noted in 6.3% of cases. Purpura was associated with Osler’s nodes in 1.3% of cases. Ocular phenomena represent 1.3% of cases. Splenomegaly in 12.5% of cases. In Montassier's study, Osler's nodes are found in 5% of cases, Janeway lesions in 5% of cases, conjunctival purpura in 5% of cases, Roth's spots in 5% of cases, and neurological manifestations in 5-20% of cases. 9 C-Echocardiography: In addition to blood cultures, echocardiography is the second major criterion for the diagnosis of IE. It plays a crucial role in for diagnosis, prognosis, and treatment monitoring. Vegetation is present in 76.3% of cases in our study, while in the study by S. Harrak, 7 it is present in 95% of cases. It predominantly occurs at the mitral level in our study, with a percentage of 39.3%, but according to the study by S. Harrak, 7 vegetation predominates at the aortic level with a percentage of 46%, followed by the mitral level with a percentage of 28%. Myocardial abscess is present in 11.3% of cases in our study, according to S. Harrak 7 , it is present in 25% of cases. As for other destructive lesions 10% of patients had chordal rupture and 12.5% had perforation, while in the study by S. Harrak, 7 60% of patients had perforation and 43% had chordal rupture. Mycotic aneurysm is present in 2.5% of patients. Prosthesis detachment is reported in 3.8% of cases, in the Harrak study, 7 it was reported in one patient. Echocardiography assesses the impact of underlying valvopathies by the following data in our study: S.Harrak found that LV dysfunction is reported in 32%, LV dilation in 64%, LA dilation in 70%, intra-LA thrombus in 6%, ascending aorta dilation in 25%, pulmonary hypertension (HTAP) in 88%, IVC dilation and decreased compliance in 36%. 7 III-MICROBIOLOGY: A- Positivity of blood cultures: Haemocultures were positive in 29% of cases in our study. However, in industrialized countries, the proportion of negative blood cultures ranges from 5 to 15%, while the proportion of positive blood cultures is approximately 85%. 1,2 This issue arises in almost all underdeveloped countries. B- Microbiology: In our work, the predominant pathogen responsible for infectious endocarditis is Staphylococcus, accounting for 65.6% of cases. This is consistent with the series by Fadeli, 5 with a rate of 42%, and that of Nappi, 11 with a staphylococcal rate of 36.3%. However, in the study by Boombhi in Cameroon, streptococcus predominates as the cause of IE (20%), followed by Staphylococcus (10%). 2 Streptococcus is in the second line in 22% of cases, with Lactococcus lactis in 22% of cases, and finally, Enterococcus in 11% of cases. IV-TREATMENT ASPECTS: A-Antibiotics: Since the majority of blood cultures are negative (59%), antibiotic therapy has mostly remained probabilistic, based on patient history, medical records, clinical signs, whether IE is present on a native valve or a prosthesis (early or late). echocardiographic findings, and sensitivity profile to common pathogens. Modification of antibiotics were made based on the antibiogram data when blood culture is positive. According to the study by S. Harrak, 7 the antibiotic empiric protocols were as the following: For native valve IE: Ampicillin + gentamicin: 67% 3rd generation cephalosporins + gentamicin: 32% Vancomycin + gentamicin: 12% Amoxicillin + clavulanic acid + gentamicin: 9% Fluoroquinolones + gentamicin: 8% Flucloxacillin + gentamicin: 3% Penicillin G + gentamicin: 1% For prosthetic valve IE: Early IE on prosthetic valve: Vancomycin + gentamicin: 80% Ampicillin + gentamicin: 20% Late IE on prosthetic valve: Ampicillin + gentamicin: 40% 3rd generation cephalosporins + gentamicin: 40% Amoxicillin + clavulanic acid + gentamicin: 20% B- Surgery: 15% of patients underwent early urgent surgery. Among these patients, 41.7% of indications were embolic, 33% were for hemodynamic indications, and 25% were for infectious indications. In the series by S. Harrak, 7% of patients underwent early surgery, and the main indication was mostly hemodynamic. 7 V-PROGNOSIS: A-Mortality: According to studies, in-hospital mortality is approximately 15 to 25%, 6-month mortality is 30%, and 5-year mortality is around 40%. These data hardly change over time. This is probably due to the epidemiological developments of IE, with more frequent nosocomial-origin infections affecting older patients with multiple comorbidities. 1,2 The mortality rate in our series is 12.5%. B-Prognostic factors: In our study, the prognostic factors found in patients who did not improve or died are: Patient characteristics: Age between 30 and 50 years Male gender Presence of IE complications: Heart failure (60%) Peripheral arterial embolism (29.2%) Septic shock (25%) Splenic infarction (25%) Cardiogenic shock (16.7%) Echocardiographic data: Vegetation size >10 mm (46%) Valvular prosthesis (21%) Altered left ventricular ejection fraction (54%) Pulmonary arterial hypertension (54%) VI-SUMMARY CHART: Following the results of our study, we summarize the characteristics of our population in Table IV. LIMITS OF THE STUDY: -Retrospective data collection CONCLUSION IE is a serious condition with significant morbidity and mortality. Unfortunately, its frequency has not decreased in recent years. In our study, the epidemiological profile shows minimal change regarding the predominance of Staphylococcus as the responsible germ for IE, reflecting the minimal decrease in IE on rheumatic valves. Its complications are numerous and fatal, and sometimes early valve surgery is necessary in cases of indication to improve prognosis. Disease prevention is a crucial step that requires a more serious application of prevention rules as well as better diagnostic and therapeutic management of the patient at the first symptoms of endocarditis to reduce the frequency and severity of the disease. In our context, there are several difficulties to face in order to improve the prognosis of patients with IE, such as diagnostic delay, difficulty in identifying the portal of entry, frequency of negative blood cultures, and incomplete extension assessment. Its diagnosis remains challenging and represents a challenge for all practitioners. Its management requires multidisciplinary collaboration within an Endocarditis Team. Declarations Data Availability: The data will be shared on reasonable request to the corresponding author Funding: None declared. Conflict of interest: None declared Data Availability: At reasonable request from editor Human Ethics and Consent to Participate declarations: Ethical Approval: Acquired (Faculty of Medicine & Pharmacy of Tangier Ethics Committee) Authors consent for publication: Acquired from all Statement of consent: the authors declare that signed written consent was acquired from the patient. Contributions: Z.R: Methodology B.E and I.S wrote the main manuscript H.B prepared figures and draft corrections All authors reviewed the manuscript References Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561–632. Boombhi J, Menanga A, Hamadou B, Yomba AM. S. Kingue. Infective Endocarditis at the Yaounde General Hospital. J Cardiovasc Med Cardiol 4(3): 058–06. Benatta NF, Batouche DD, Benouaz S, Djazouli MA. Infectious endocarditis: Experience of a cardiology department at Oran university hospital. Ann Cardiol Angeiol. 2019;68(2):94–7. Toyoda N, Chikwe J, Itagaki S, Gelijns AC, Adams DH, Egorova NN. Trends in Infective Endocarditis in California and New York State. JAMA. 2017;317(16):1652–60. Fedeli U, Schievano E, Buonfrate D, Pellizzer G, Spolaore P. Increasing incidence and mortality of infective endocarditis. BMC Infect Dis 2011;11(48). Blanchard V, Pagis B, Richaud R, et al. Infective endocarditis in French Polynesia: Epidemiology, treatments and outcomes. Arch Cardiovasc Dis. 2020;113(4):252–62. Harrak S, Doghmi N, Fellat B, Zarzur J. Cherti. L’endocardite infectieuse au Maroc à travers l’expérience d’un service hospitalier. Ann Cardiol Angeiol. 2019;68(2):87–93. Hoen B, Duval X. Infective endocarditis. N Engl J Med 2013;368: 425 – 33. Montassier E, Batard E, Goffinet N et al. Endocardites infectieuses. Diagnostics infectieux à ne pas manquer. 2014. Letaief A, Boughzala E, Kaabia N, et al. Epidemiology of infective endocarditis in Tunisia: a 10-year multicenter retrospective study. Int J Infect Dis. 2007;11(5):430–3. Nappi F, Martuscelli G, Bellomo F, Avtaar Singh SS, Moon MR. Infective Endocarditis in High-Income Countries. Metabolites ;12(8):682. Tables Table 1: Symptoms at admission Symptoms: Percentage: Dyspnoea 65% Chest pain 8.8% Palpitations 5% Joint Paint 8.8% Poor general condition 87.5% Fever 90% Cough 23.8% Digestive symptoms 8.8% Urinary burning 1.3% Table 2: Extra cardiac manifestations in our population Extra cardiac manifestations Percentage Vascular phenomena 2.5% Neurological phenomena 10% Cutaneous phenomena Purpura: 6,3% Osler’s nodes: 2,3% Ocular phenomena 1.3% Splenomegaly 12.5% Glomerulonephritis 0 % Table 3: Surgical indications and management Urgent surgery indication: Percentage Hemodynamic (Congestive heart failure) 33,3% (4 patients) Embolic complications 41,7% (5 patients) Infective (resistance to medical treatment) 25% (3 patients) Table 4: Patient profile summary chart Characteristics Results Young patients Mean age: 46 years old No sex predominance Sex ratio 1:1 Rheumatic fever 10% Recurrent pharyngitis 12,5% Diagnosis delay Mean : 25 days Initial infection non identified 72,5% Fever 90% Vegetations 76,3% Types of IE MS 10%, MR 10%, MD 6,3% AS 6,3%, AR 3,8%, AD 8,8% Negative blood cultures 59% Heart Failure 51,2% Splenomegaly 12,5% Neurological complications 10% Clinical improvement 70% Death 12,5% Urgent surgery 15% Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Jul, 2024 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 03 Apr, 2024 Submission checks completed at journal 31 Mar, 2024 Editor assigned by journal 31 Mar, 2024 First submitted to journal 10 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4066111","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":285976392,"identity":"0591b5d9-df1d-42bd-a0d2-73612f5201b0","order_by":0,"name":"Badre El 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Abdelmalek Essaadi University","correspondingAuthor":false,"prefix":"","firstName":"Amine","middleName":"","lastName":"Ech-chenbouli","suffix":""},{"id":285976397,"identity":"71684c2f-9b4d-4c1f-91a3-960051347c34","order_by":5,"name":"Zainab Raissouni","email":"","orcid":"","institution":"Mohamed VI University Hospital of Tangier, Abdelmalek Essaadi University","correspondingAuthor":false,"prefix":"","firstName":"Zainab","middleName":"","lastName":"Raissouni","suffix":""}],"badges":[],"createdAt":"2024-03-10 15:45:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4066111/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4066111/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-024-09436-4","type":"published","date":"2024-07-15T01:50:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54044740,"identity":"db52a3a5-ec57-4a2b-baa8-b1d04c9cb117","added_by":"auto","created_at":"2024-04-03 18:49:11","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37634,"visible":true,"origin":"","legend":"\u003cp\u003eBackground risk factors\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4066111/v1/8d71b7d984676ed96f4ab235.jpg"},{"id":54045330,"identity":"9c5b1bd1-3945-4a2e-b3b3-7968af2e1d54","added_by":"auto","created_at":"2024-04-03 19:05:11","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":31379,"visible":true,"origin":"","legend":"\u003cp\u003eOnset type of IE\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4066111/v1/06ff993f6ea7132664924f00.jpg"},{"id":54044742,"identity":"502acd0d-2227-4f52-bc0f-f1fa80186399","added_by":"auto","created_at":"2024-04-03 18:49:11","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":23718,"visible":true,"origin":"","legend":"\u003cp\u003eHeart failure signs and profiles\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4066111/v1/bed92953fec415443543b100.jpg"},{"id":54045133,"identity":"d184f7c4-4c8c-4cbc-b09a-ad8bc7ab5700","added_by":"auto","created_at":"2024-04-03 18:57:11","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":36375,"visible":true,"origin":"","legend":"\u003cp\u003ea: Distribution of IE by native or prosthetic valves\u003c/p\u003e\n\u003cp\u003eb: Heart valves types affected in by IE\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4066111/v1/712c47aafd315e689c7383d0.jpg"},{"id":54044746,"identity":"ef097a79-5abe-43f5-90ba-2f6066def2d2","added_by":"auto","created_at":"2024-04-03 18:49:11","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":51787,"visible":true,"origin":"","legend":"\u003cp\u003eMicrobiological blood culture results\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4066111/v1/d90b1bfea0e2172f6a37d4d6.jpg"},{"id":54044744,"identity":"8f0e9741-229a-481e-b6eb-1319ddc9add1","added_by":"auto","created_at":"2024-04-03 18:49:11","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":112607,"visible":true,"origin":"","legend":"\u003cp\u003eAntibiotherapy in IE\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4066111/v1/f714b0f77f4d3c4f4cbcc266.jpg"},{"id":54044747,"identity":"d9b595b3-c847-496d-a02e-609fd7c21707","added_by":"auto","created_at":"2024-04-03 18:49:11","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":27269,"visible":true,"origin":"","legend":"\u003cp\u003ePrognosis of our population\u003c/p\u003e","description":"","filename":"7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4066111/v1/f6773e264486699711e7311e.jpg"},{"id":54044745,"identity":"f94b3e19-7175-4621-af86-958ec3c1a1b2","added_by":"auto","created_at":"2024-04-03 18:49:11","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":35427,"visible":true,"origin":"","legend":"\u003cp\u003eComplications of IE\u003c/p\u003e","description":"","filename":"8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4066111/v1/9a35ee0c8a093077feca4b3b.jpg"},{"id":60265642,"identity":"46d94e55-6972-4a3b-b110-35b26601983e","added_by":"auto","created_at":"2024-07-15 01:50:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1102712,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4066111/v1/690edefc-d8e0-4345-b21d-3c9c316196df.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Epidemiology, Outcomes and Prognosis of Infective Endocarditis in Northern Morocco","fulltext":[{"header":"HIGHLIGHTS","content":"\u003cul\u003e\n \u003cli\u003eInfective endocarditis is a rare but severe disease. Guidelines are updated frequently to perfect the assessment and management of this condition.\u003c/li\u003e\n \u003cli\u003eComplications of IE should be assessed systematically to improve prognosis\u003c/li\u003e\n \u003cli\u003eOur study proves that the epidemiological data in the guidelines concerning countries where rheumatic heart disease is endemic is similar and compatible with our results.\u003c/li\u003e\n\u003c/ul\u003ea"},{"header":"INTRODUCTION","content":"\u003cp\u003eInfective endocarditis (IE) refers to lesions of cardiac valve endocardium by virulent microorganisms,\u0026nbsp;most often bacterial, and concerns\u0026nbsp;much less commonly the heart wall (parietal endocardium), intracardiac prosthesis (IE on prostheses) and devices.\u003c/p\u003e\n\u003cp\u003eIt is a rare and serious condition, with significant morbidity and mortality. Its diagnosis is based on a set of clinical and paraclinical arguments. Guidelines have been updated recently by different international committees, such as the 2023 European Society of Cardiology (ESC) guidelines. Diagnosis of IE distinguishes different parameters for native valves, valvular prostheses, and intracardiac devices. Among IE on native valves, the left heart is most frequently affected, and rarely the right heart is affected.\u003cstrong\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe epidemiology of IE is changing, with usual patients with degenerative valve disease being added to those with prosthetic valves and intracardiac devices, and the microbiology is also changing during the past decade. Treatment is based on prolonged antibiotic therapy adapted to the identified responsible organism, and requires thorough assessment of IE complications\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The management of IE must be collaborative, involving the cardiologist, infective disease specialist, cardiovascular surgeon, and sometimes vascular surgeon, intensivist, microbiologist, and possibly other specialists.\u003c/p\u003e\n\u003cp\u003eThe objective of our study is to evaluate the epidemiological, clinical, biological, and prognostic aspects of infective endocarditis in the cardiology setting in Northern Morocco, and to compare our results with the data from the literature and current recommendations.\u003c/p\u003e"},{"header":"MATERIAL AND METHODS","content":"\u003cp\u003eThis is a retrospective descriptive study including all patients hospitalized in the cardiology department over a period of 4 years and 7 months, from 2019 to 2024. All patients diagnosed with infective endocarditis during this period were included without any exclusion criteria. A total of 80 cases of confirmed infective endocarditis were identified according to the Modified Duke Criteria of the 2023 ESC guidelines for the management of endocarditis.\u003c/p\u003e\n\u003cp\u003ePatient information was collected from medical records and inscribed using a data collection form. Anonymity and confidentiality of the collected data were strictly maintained. The variables studied in the data collection form include: Epidemiological and socioeconomic data, clinical and paraclinical aspects, (laboratory tests, radiology), complications, follow-up, medical and surgical management and mortality. The data was analysed using \"IBM SPSS Statistics 27\" statistics software. \u0026nbsp;No artificial intelligence (AI) was utilized in the process.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003e1) Anamnestic data:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The average age of our study group was 46 years [12;78]. The sex ratio was even, with 40 female patients and 40 males.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Background risk factors favouring IE are shown in \u003cstrong\u003e\u003cem\u003eFigure 1.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eRheumatic fever and childhood recurrent pharyngitis were the most common elements.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The average diagnostic delay is 25 days. The revelation onset is subacute in 65% of cases, acute in 16.3% of cases and chronic in 18.8% of patients. \u003cstrong\u003e\u003cem\u003e(Figure 2)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2) Clinical characteristics:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eSymptoms:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The symptoms investigated in our study are: dyspnoea, chest pain, palpitations, joint pain, and malaise, and infective history signs (fever, cough, urinary burning, and digestive symptoms). Poor general condition is defined by the coexistence of at least 2 elements of the following: Fatigue, weight loss and appetite loss. The results are summarized in \u003cstrong\u003e(Table 1)\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eAlmost all patients had fever and poor general condition on admission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003ePhysical exam elements:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The average systolic blood pressure is 112 mm Hg, and the diastolic blood pressure is 65 mm Hg. The average heart rate is 92 beats per minute.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Heart failure congestive signs were present in 51,2% of cases, distributed as following \u003cstrong\u003e(Figure 3)\u003c/strong\u003e: left-sided signs (22.5%), global (both left and right signs) 23.8%, and isolated right-sided (5%).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Heart auscultation revealed a regular heart rhythm in 73.8% of patients, with a murmur present in 77.5% of patients (regardless of location). 66,3% of cases presented with bad dental status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eExtra cardiac manifestations:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExtra cardiac signs and phenomena can be classified as following:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e-Vascular phenomena (arterial emboli, peripheral infarcts (kidney, spleen, pulmonary))\u003c/p\u003e\n\u003cp\u003e-Neurological phenomena (intracranial haemorrhage, cerebral mycotic aneurysms)\u003c/p\u003e\n\u003cp\u003e-Cutaneous phenomena (Janeway lesions, Osler\u0026apos;s nodes, purpura)\u003c/p\u003e\n\u003cp\u003e-Ocular phenomena (Roth\u0026apos;s spots, conjunctival haemorrhage)\u003c/p\u003e\n\u003cp\u003e-Splenomegaly, glomerulonephritis\u003c/p\u003e\n\u003cp\u003eResults are listed in \u003cstrong\u003e(Table 2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDiagnosis and types:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eTypes of IE:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;77% had infective endocarditis on native heart valves, whereas 19% of the cases concerned mechanical valve protheses, and only 4% of bio prothesis IE were found. \u003cstrong\u003e\u003cem\u003e(Figure 4a)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmongst patients with native valves, the mitral valve is the most affected, followed by the aortic valve. No cases of pulmonary valve IE were reported during the study period. \u003cstrong\u003e\u003cem\u003e(Figure 4b)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eEchocardiogram findings:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Transthoracic echocardiography (TTE) was performed on all patients. Transoesophageal echocardiography (TEE) was performed in 61.3% of patients.\u003c/p\u003e\n\u003cp\u003eVegetations were found in 76.3% of cases. The average size was 9.85 mm, with a maximum size of 33 mm and a minimum size of 2 mm.\u003c/p\u003e\n\u003cp\u003eThey were located on the mitral valve in 39.3% of patients, aortic valve in 21.3% of cases, mitro-aortic in 18% of patients, tricuspid in 9.8% of patients, pulmonary in 3.3% of patients. They were identified in prosthetic valves in 6.6% of patients. The mobile aspect of vegetations was observed in 93.1% of cases.\u003c/p\u003e\n\u003cp\u003eValvular and paravalvular abscess was found in 11.3% of cases in our study. \u0026nbsp;Other destructive lesions were identified: 8 patients had chordae tendineae rupture, and 10 patients had valve perforation. We also observed mycotic valvular aneurysm in 2.5% of patients.\u003c/p\u003e\n\u003cp\u003eProsthesis detachment was diagnosed in 4.9% of cases. Lastly, pericardial effusion was present in 10.1% of patients\u003c/p\u003e\n\u003cp\u003eAs for other echocardiographic parameters, LV dysfunction is reported in 37.5%, LV dilation in 25%, LA dilation in 42.5%, intra-LA thrombus in 10%, ascending aorta dilation in 5%, pulmonary hypertension (HTAP) in 65%, IVC dilation and decreased compliance in 16.3% of cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4) Microbiological data:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBlood cultures were sampled for all our study patients. Consequently, they were positive in 41.3% of cases.\u003c/p\u003e\n\u003cp\u003ethe isolated pathogens are as following \u003cstrong\u003e(Figure 5)\u003c/strong\u003e: Staphylococcus (65.6%) (Staph. Aureus (40.6%), coagulase-negative Staphylococcus (25%)), Oral Streptococcus (9%), Lactococcus lactis (6.3%) and Enterococcus (6.3%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5) Therapeutical management:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eAntibiotics:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients received intravenous antibiotic therapy. Empirical management was indicated initially, then was adjusted according to the antibiogram after blood culture results.\u003c/p\u003e\n\u003cp\u003eMain initial treatment consisted of a combination of 2 bactericidal antibiotics for an average duration of 4 weeks. The double therapy combinations used in our study are as follows \u003cstrong\u003e\u003cem\u003e(Figure 6)\u003c/em\u003e\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eSurgical management:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients benefited from surgical management. The degree of urgency of surgical management is defined following the 2023 ESC guidelines: Very urgent (5%), Urgent (10%) and non-urgent (85%).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The characteristics of the \u003cem\u003every urgent-urgent\u003c/em\u003e group is detailed in \u003cstrong\u003eTable III\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6) Evolution and prognosis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical and biological improvement was observed in 70% of cases, and no improvement was seen in 17.5% of cases.\u0026nbsp;Death occurred in 12.5% of cases. \u003cstrong\u003e(Figure 7).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Complications of infective endocarditis were observed and listed in \u003cstrong\u003e\u003cem\u003eFigure 8\u003c/em\u003e\u003c/strong\u003e. Heart failure is the most common complication (51%), followed by peripheral arterial embolization (23%)\u0026nbsp;and splenic infarct (18,5\u0026nbsp;%).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;As for patients managed with urgent surgery, outcomes were as follows: 1 patient out 4 improved after surgery for hemodynamic indication, 2 out 3 for embolic indication, and 1 our 3 for infective indication.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eI-EPIDEMIOLOGY:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Our study shows that IE predominantly affects younger individuals with an average age of 46 years. A similar observation is made in Cameroon, as mentioned in the study by J\u0026eacute;r\u0026ocirc;me Boombhi et al.,\u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e with an average age of 44 years, and in Algeria, the study by Bennata et al.\u003cstrong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e reports an average age of 40.5. However, the series by Toyoda et al. reports an average age of 62.\u003cstrong\u003e\u003csup\u003e4\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003eIn France, as mentioned previously, infective endocarditis is increasingly affecting elderly individuals, with the average age rising from 58 to 62 years between 1991 and 2008.\u003c/p\u003e\n\u003cp\u003eIn our study, infective endocarditis is equally common in men and women. In the series by Toyoda et al., 59% of endocarditis cases were in women.\u003cstrong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003e However, a male predominance was noted in the series by Fedeli et al. (62%).\u003cstrong\u003e\u003csup\u003e5\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRecent dental care (7.5%) and acute rheumatic fever (10%) are the main risk factors for infective endocarditis according to our study. In the study by Boombhi et al, rheumatic valvular disease represents the main cause of infective endocarditis followed by degenerative valvular heart disease.\u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e Similarly, in the study by Bennata et al., rheumatic heart disease account for 70% of cases.\u003cstrong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e Additionally, 33% of patients have a history of rheumatic heart disease according to Blanchard et al.\u003cstrong\u003e\u003csup\u003e6\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast, in the Toyoda series conducted in New York, recent valve surgery and the presence of intracardiac material are major risk factors for infective endocarditis.\u003cstrong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInfective endocarditis on native valves is more common than on prosthetic valves according to our study (77% vs. 23%). This aligns with most series.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eII-DIAGNOSIS:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003e\u003cu\u003eA-\u003c/u\u003e\u003c/em\u003e\u003cem\u003e\u003cu\u003eAmnestic and clinical aspects:\u003c/u\u003e\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003e\u0026nbsp;Anamnesis interrogation must be thorough to detect risk factors for infectious endocarditis.\u003c/p\u003e\n\u003cp\u003eInfectious endocarditis can be acute, rapidly progressive, subacute, or even chronic. The average treatment time in our study is 25 days. In a study conducted in Rabat by S. Harrak, the average time required for diagnosis is 77 days.\u003cstrong\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInfectious endocarditis can be diagnosed based on symptoms such as fever, joint pain, general malaise (anorexia, asthenia, weight loss), or cardiac signs such as dyspnoea, chest pain, and palpitations. In our study, fever is present in 90% of cases, while in the series by Duval, 86% of patients are febrile.\u003cstrong\u003e\u003csup\u003e8\u003c/sup\u003e\u003c/strong\u003e Boombhi\u0026apos;s study shows that all patients have fever.\u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our series, general malaise is found in 87.5% of patients. Splenomegaly associated with general malaise was present in 11% of cases in the study by Montassier conducted in France.\u003cstrong\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/strong\u003e Symptoms found in our patients include dyspnoea in 65% of cases, cough in 23.8% of cases, and chest pain in 8.8% of cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Heart failure\u003c/strong\u003e is found in 51.2% of cases, in Fedeli\u0026apos;s study HF is found in 13%,\u003cstrong\u003e\u003csup\u003e5\u003c/sup\u003e\u003c/strong\u003e in Duval\u0026apos;s study HF is found in 33.8%,\u003cstrong\u003e\u003csup\u003e8\u003c/sup\u003e\u003c/strong\u003e and represents 26% in Benatta\u0026apos;s study.\u003cstrong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e in a Tunisian study HF presents 41.5%.\u003cstrong\u003e\u003csup\u003e10\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003e(10)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study series, cardiac auscultation revealed that 77.5% of patients had a murmur. In 73.8% of patients, the rhythm is regular.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003e\u003cu\u003eB-Extra cardiac manifestations:\u003c/u\u003e\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eVascular phenomena are found in 2.5% of cases. Neurological signs in 10% of cases. A lone purpura is noted in 6.3% of cases. Purpura was associated with Osler\u0026rsquo;s nodes in 1.3% of cases. Ocular phenomena represent 1.3% of cases. Splenomegaly in 12.5% of cases. In Montassier\u0026apos;s study, Osler\u0026apos;s nodes are found in 5% of cases, Janeway lesions in 5% of cases, conjunctival purpura in 5% of cases, Roth\u0026apos;s spots in 5% of cases, and neurological manifestations in 5-20% of cases.\u003cstrong\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003e\u003cu\u003eC-Echocardiography:\u003c/u\u003e\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eIn addition to blood cultures, echocardiography is the second major criterion for the diagnosis of IE. It plays a crucial role in for diagnosis, prognosis, and treatment monitoring.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVegetation is present in 76.3% of cases in our study, while in the study by S. Harrak,\u003cstrong\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/strong\u003e it is present in 95% of cases. It predominantly occurs at the mitral level in our study, with a percentage of 39.3%, but according to the study by S. Harrak,\u003cstrong\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/strong\u003e vegetation predominates at the aortic level with a percentage of 46%, followed by the mitral level with a percentage of 28%.\u003c/p\u003e\n\u003cp\u003eMyocardial abscess is present in 11.3% of cases in our study, according to S. Harrak\u003cstrong\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/strong\u003e, it is present in 25% of cases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs for other destructive lesions 10% of patients had chordal rupture and 12.5% had perforation, while in the study by S. Harrak,\u003cstrong\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/strong\u003e 60% of patients had perforation and 43% had chordal rupture. Mycotic aneurysm is present in 2.5% of patients. Prosthesis detachment is reported in 3.8% of cases, in the Harrak study,\u003cstrong\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/strong\u003e it was reported in one patient.\u003c/p\u003e\n\u003cp\u003eEchocardiography assesses the impact of underlying valvopathies by the following data in our study: S.Harrak found that LV dysfunction is reported in 32%, LV dilation in 64%, LA dilation in 70%, intra-LA thrombus in 6%, ascending aorta dilation in 25%, pulmonary hypertension (HTAP) in 88%, IVC dilation and decreased compliance in 36%.\u003cstrong\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eIII-MICROBIOLOGY:\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eA- Positivity of blood cultures:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Haemocultures were positive in 29% of cases in our study. However, in industrialized countries, the proportion of negative blood cultures ranges from 5 to 15%, while the proportion of positive blood cultures is approximately 85%.\u003cstrong\u003e\u003csup\u003e1,2\u003c/sup\u003e\u003c/strong\u003e This issue arises in almost all underdeveloped countries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eB- Microbiology:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In our work, the predominant pathogen responsible for infectious endocarditis is Staphylococcus, accounting for 65.6% of cases. This is consistent with the series by Fadeli,\u003cstrong\u003e\u003csup\u003e5\u003c/sup\u003e\u003c/strong\u003e with a rate of 42%, and that of Nappi,\u003cstrong\u003e\u003csup\u003e11\u003c/sup\u003e\u003c/strong\u003e with a staphylococcal rate of 36.3%. However, in the study by Boombhi in Cameroon, streptococcus predominates as the cause of IE (20%), followed by Staphylococcus (10%).\u003cstrong\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003eStreptococcus is in the second line in 22% of cases, with Lactococcus lactis in 22% of cases, and finally, Enterococcus in 11% of cases.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eIV-TREATMENT ASPECTS:\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eA-Antibiotics:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSince the majority of blood cultures are negative (59%), antibiotic therapy has mostly remained probabilistic, based on patient history, medical records, clinical signs, whether IE is present on a native valve or a prosthesis (early or late). echocardiographic findings, and sensitivity profile to common pathogens.\u003c/p\u003e\n\u003cp\u003eModification of antibiotics were made based on the antibiogram data when blood culture is positive.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;According to the study by S. Harrak,\u003cstrong\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/strong\u003e the antibiotic empiric protocols were as the following:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eFor native valve IE:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAmpicillin + gentamicin: 67%\u003c/p\u003e\n\u003cp\u003e3rd generation cephalosporins + gentamicin: 32%\u003c/p\u003e\n\u003cp\u003eVancomycin + gentamicin: 12%\u003c/p\u003e\n\u003cp\u003eAmoxicillin + clavulanic acid + gentamicin: 9%\u003c/p\u003e\n\u003cp\u003eFluoroquinolones + gentamicin: 8%\u003c/p\u003e\n\u003cp\u003eFlucloxacillin + gentamicin: 3%\u003c/p\u003e\n\u003cp\u003ePenicillin G + gentamicin: 1%\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eFor prosthetic valve IE:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eEarly IE on prosthetic valve:\u003c/p\u003e\n\u003cp\u003eVancomycin + gentamicin: 80%\u003c/p\u003e\n\u003cp\u003eAmpicillin + gentamicin: 20%\u003c/p\u003e\n\u003cp\u003eLate IE on prosthetic valve:\u003c/p\u003e\n\u003cp\u003eAmpicillin + gentamicin: 40%\u003c/p\u003e\n\u003cp\u003e3rd generation cephalosporins + gentamicin: 40%\u003c/p\u003e\n\u003cp\u003eAmoxicillin + clavulanic acid + gentamicin: 20%\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eB- Surgery:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e15% of patients underwent early urgent surgery. Among these patients, 41.7% of indications were embolic, 33% were for hemodynamic indications, and 25% were for infectious indications. In the series by S. Harrak, 7% of patients underwent early surgery, and the main indication was mostly hemodynamic.\u003cstrong\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eV-PROGNOSIS:\u003c/em\u003e\u003c/h2\u003e\n\u003ch2\u003e\u003cem\u003e\u003cu\u003eA-Mortality:\u003c/u\u003e\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eAccording to studies, in-hospital mortality is approximately 15 to 25%, 6-month mortality is 30%, and 5-year mortality is around 40%. These data hardly change over time. This is probably due to the epidemiological developments of IE, with more frequent nosocomial-origin infections affecting older patients with multiple comorbidities.\u003csup\u003e1,2\u003c/sup\u003e The mortality rate in our series is 12.5%.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003e\u003cu\u003eB-Prognostic factors:\u003c/u\u003e\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eIn our study, the prognostic factors found in patients who did not improve or died are:\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003ePatient characteristics:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAge between 30 and 50 years\u003c/p\u003e\n \u003cp\u003eMale gender\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003ePresence of IE complications:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eHeart failure (60%)\u003c/p\u003e\n \u003cp\u003ePeripheral arterial embolism (29.2%)\u003c/p\u003e\n \u003cp\u003eSeptic shock (25%)\u003c/p\u003e\n \u003cp\u003eSplenic infarction (25%)\u003c/p\u003e\n \u003cp\u003eCardiogenic shock (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eEchocardiographic data:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eVegetation size \u0026gt;10 mm (46%)\u003c/p\u003e\n \u003cp\u003eValvular prosthesis (21%)\u003c/p\u003e\n \u003cp\u003eAltered left ventricular ejection fraction (54%)\u003c/p\u003e\n \u003cp\u003ePulmonary arterial hypertension (54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cem\u003eVI-SUMMARY CHART:\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eFollowing the results of our study, we summarize the characteristics of our population in\u003cstrong\u003e\u0026nbsp;Table IV.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLIMITS OF THE STUDY:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-Retrospective data collection\u0026nbsp;\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIE is a serious condition with significant morbidity and mortality. Unfortunately, its frequency has not decreased in recent years. In our study, the epidemiological profile shows minimal change regarding the predominance of Staphylococcus as the responsible germ for IE, reflecting the minimal decrease in IE on rheumatic valves.\u003c/p\u003e\n\u003cp\u003eIts complications are numerous and fatal, and sometimes early valve surgery is necessary in cases of indication to improve prognosis. Disease prevention is a crucial step that requires a more serious application of prevention rules as well as better diagnostic and therapeutic management of the patient at the first symptoms of endocarditis to reduce the frequency and severity of the disease.\u003c/p\u003e\n\u003cp\u003eIn our context, there are several difficulties to face in order to improve the prognosis of patients with IE, such as diagnostic delay, difficulty in identifying the portal of entry, frequency of negative blood cultures, and incomplete extension assessment. Its diagnosis remains challenging and represents a challenge for all practitioners. Its management requires multidisciplinary collaboration within an Endocarditis Team.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data will be shared on reasonable request to the corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eNone declared\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e At reasonable request from editor\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e Acquired (Faculty of Medicine \u0026amp; Pharmacy of Tangier Ethics Committee)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors consent for publication:\u003c/strong\u003e Acquired from all\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement of consent:\u003c/strong\u003e the authors declare that signed written consent was acquired from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZ.R: Methodology\u003c/p\u003e\n\u003cp\u003eB.E and I.S wrote the main manuscript\u003c/p\u003e\n\u003cp\u003eH.B prepared figures and draft corrections\u003c/p\u003e\n\u003cp\u003eAll authors reviewed the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561\u0026ndash;632.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoombhi J, Menanga A, Hamadou B, Yomba AM. S. Kingue. Infective Endocarditis at the Yaounde General Hospital. J Cardiovasc Med Cardiol 4(3): 058\u0026ndash;06.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenatta NF, Batouche DD, Benouaz S, Djazouli MA. Infectious endocarditis: Experience of a cardiology department at Oran university hospital. Ann Cardiol Angeiol. 2019;68(2):94\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToyoda N, Chikwe J, Itagaki S, Gelijns AC, Adams DH, Egorova NN. Trends in Infective Endocarditis in California and New York State. JAMA. 2017;317(16):1652\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFedeli U, Schievano E, Buonfrate D, Pellizzer G, Spolaore P. Increasing incidence and mortality of infective endocarditis. BMC Infect Dis 2011;11(48).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlanchard V, Pagis B, Richaud R, et al. Infective endocarditis in French Polynesia: Epidemiology, treatments and outcomes. Arch Cardiovasc Dis. 2020;113(4):252\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarrak S, Doghmi N, Fellat B, Zarzur J. Cherti. L\u0026rsquo;endocardite infectieuse au Maroc \u0026agrave; travers l\u0026rsquo;exp\u0026eacute;rience d\u0026rsquo;un service hospitalier. Ann Cardiol Angeiol. 2019;68(2):87\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoen B, Duval X. Infective endocarditis. N Engl J Med 2013;368: 425\u0026thinsp;\u0026ndash;\u0026thinsp;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMontassier E, Batard E, Goffinet N et al. Endocardites infectieuses. \u003cem\u003eDiagnostics infectieux \u0026agrave; ne pas manquer.\u003c/em\u003e 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLetaief A, Boughzala E, Kaabia N, et al. Epidemiology of infective endocarditis in Tunisia: a 10-year multicenter retrospective study. Int J Infect Dis. 2007;11(5):430\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNappi F, Martuscelli G, Bellomo F, Avtaar Singh SS, Moon MR. Infective Endocarditis in High-Income Countries. \u003cem\u003eMetabolites\u003c/em\u003e;12(8):682.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Symptoms at admission\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eSymptoms:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003ePercentage:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eDyspnoea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eChest pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e8.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003ePalpitations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eJoint Paint\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e8.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003ePoor general condition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e87.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eCough\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e23.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eDigestive symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e8.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eUrinary burning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Extra cardiac manifestations in our population\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"498\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.803212851405625%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eExtra cardiac manifestations\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.196787148594375%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003ePercentage\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.803212851405625%\" valign=\"top\"\u003e\n \u003cp\u003eVascular phenomena\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.196787148594375%\" valign=\"top\"\u003e\n \u003cp\u003e2.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.803212851405625%\" valign=\"top\"\u003e\n \u003cp\u003eNeurological phenomena\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.196787148594375%\" valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.803212851405625%\" valign=\"top\"\u003e\n \u003cp\u003eCutaneous phenomena\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.196787148594375%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Purpura: 6,3%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Osler\u0026rsquo;s nodes: 2,3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.803212851405625%\" valign=\"top\"\u003e\n \u003cp\u003eOcular phenomena\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.196787148594375%\" valign=\"top\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.803212851405625%\" valign=\"top\"\u003e\n \u003cp\u003eSplenomegaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.196787148594375%\" valign=\"top\"\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.803212851405625%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Glomerulonephritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.196787148594375%\" valign=\"top\"\u003e\n \u003cp\u003e0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Surgical indications and management\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.65656565656566%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eUrgent surgery indication:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.343434343434346%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003ePercentage\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.65656565656566%\"\u003e\n \u003cp\u003eHemodynamic (Congestive heart failure)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.343434343434346%\"\u003e\n \u003cp\u003e33,3%\u0026nbsp;(4\u0026nbsp;patients)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.65656565656566%\"\u003e\n \u003cp\u003eEmbolic complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.343434343434346%\"\u003e\n \u003cp\u003e41,7%\u0026nbsp;(5\u0026nbsp;patients)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.65656565656566%\" valign=\"top\"\u003e\n \u003cp\u003eInfective (resistance to medical treatment)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.343434343434346%\"\u003e\n \u003cp\u003e25% (3 patients)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Patient profile summary chart\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eYoung patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003eMean age: 46 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eNo sex predominance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003eSex ratio 1:1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eRheumatic fever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eRecurrent pharyngitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e12,5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eDiagnosis delay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003eMean : 25\u0026nbsp;days\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eInitial infection non identified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e72,5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eVegetations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e76,3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eTypes of IE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003eMS\u0026nbsp;10%,\u0026nbsp;MR\u0026nbsp;10%,\u0026nbsp;MD\u0026nbsp;6,3%\u003c/p\u003e\n \u003cp\u003eAS 6,3%,\u0026nbsp;AR\u0026nbsp;3,8%, AD\u0026nbsp;8,8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eNegative blood cultures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e59%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eHeart Failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e51,2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eSplenomegaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e12,5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eNeurological complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eClinical improvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e70%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e12,5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.299674267100976%\" valign=\"top\"\u003e\n \u003cp\u003eUrgent surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.700325732899024%\" valign=\"top\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"infective endocarditis, valve, blood culture, complications, antibiotic, surgery","lastPublishedDoi":"10.21203/rs.3.rs-4066111/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4066111/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003eInfective endocarditis is a rare but potentially severe disease, associated with significant morbidity and mortality. Our study aims to describe the epidemiology and management aspects of endocarditis in northern Morocco and compare it with international management guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods:\u003c/strong\u003eThis is a retrospective study involving all patients hospitalized in the cardiology department of the University Hospital of Tangier for infective endocarditis over a period of 4 years and 7 months, from May 2019 to February 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 80 patients were hospitalized for IE during the study period. The average age of the patients was 46 years, with an even sex ratio. IE concerned native valves in 77% of cases, mechanical prostheses in 19% of cases, and on bio prostheses in 4%. The average diagnostic delay was 25 days. Blood cultures were negative in 59% of cases. The predominant infective microorganism was the bacteria Staphylococcus (65.6%).\u003c/p\u003e\n\u003cp\u003eImaging results showed vegetations in 76.3% of cases, predominantly on the mitral valve (39.3%), followed by the aortic valve (21.3%). The main complications included heart failure (51.2%), peripheral arterial embolisms (22.5%) and splenic infarction (17.5%)\u003c/p\u003e\n\u003cp\u003eManagement wise, the most commonly used antibiotic therapy was a combination of ceftriaxone and gentamicin. Clinical and biological improvement was observed in 70% of cases, with a mortality rate of 12.5%. Twelve patients underwent urgent surgery (41.7%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Our study highlights the challenges in managing infective endocarditis in northern Morocco. The prognosis of infective endocarditis can be improved through multidisciplinary management within the implementation of an Endocarditis Team.\u003c/p\u003e","manuscriptTitle":"Epidemiology, Outcomes and Prognosis of Infective Endocarditis in Northern Morocco","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-03 18:49:06","doi":"10.21203/rs.3.rs-4066111/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-03T08:07:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-01T03:16:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-01T03:16:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-03-10T15:22:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fae09a79-da56-4a7a-a552-41baca8d088d","owner":[],"postedDate":"April 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-07-15T01:50:13+00:00","versionOfRecord":{"articleIdentity":"rs-4066111","link":"https://doi.org/10.1186/s12879-024-09436-4","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2024-07-15 01:50:13","publishedOnDateReadable":"July 15th, 2024"},"versionCreatedAt":"2024-04-03 18:49:06","video":"","vorDoi":"10.1186/s12879-024-09436-4","vorDoiUrl":"https://doi.org/10.1186/s12879-024-09436-4","workflowStages":[]},"version":"v1","identity":"rs-4066111","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4066111","identity":"rs-4066111","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}