Frequency and Clinical Outcomes of Infective Endocarditis: A Single Large Cardiac Center Experience from Pakistan

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This single center study was designed to assess the frequency, causative organisms, antibiotic resistance, and clinical outcomes of IE in patients treated at a tertiary care cardiac center in Pakistan. Methods A retrospective observational study was conducted at a large tertiary care cardiology center in Peshawar, Pakistan from July 2021 to July 2023. Data was collected from hospital records, including demographic, clinical, and laboratory parameters. Statistical analysis was performed using Stata version 14.2. Results Among 84 patients, 41.7% of the patients were male with a mean population age of 49.17 ± 18.55 years, and an average BMI of 27.72 ± 4.37 kg/m². Furthermore, 47.6% patients were hypertensive whereas 36.9% had diabetes. Streptococcus Viridans (25%) was the most common organism isolated, followed closely by Staphylococcus aureus at 22.6%. Interestingly, 32.1% of the patients had negative cultures. Antibiotic resistance was observed in 46.4% of cases, and Major Adverse Cardiovascular Events (MACE) occurred in 56%. Acute kidney injury was observed in 48.8% of the patients. Discussion IE presents diverse etiologies and outcomes, necessitating targeted management strategies to improve prognosis. Infective Endocarditis Antibiotic Resistance MACE Blood Culture Clinical Outcomes Retrospective Study Figures Figure 1 Figure 2 Introduction Infective endocarditis (IE) is a potentially deadly disease process resulting from infection and inflammation of the endocardial surface that most often involves the cardiac valves.(1) The recent years have seen the advent of better diagnostic and therapeutic strategies, yet, infective endocarditis has continued to pose a global burden owing to its high morbidity and mortality. IE is considered the 4th commonest life-threatening infection, after pneumonia, sepsis and intra-abdominal infections. (2) The epidemiological data from developed countries estimate the incidence to be about 3 to 7 cases per 100000 person years with increasing trend seen in the recent decades (3). IE remains a complex disease with heterogeneous presentations making it challenging to diagnose and treat. Infective endocarditis (IE) is an infection of the endocardium, typically the heart valve's lining. Usually, those affected have preexisting valvular abnormalities or history of intravenous drug use. The clinical manifestations can range from low-grade fever and fatigue to heart failure, septic embolism, and stroke (4). The pathogenesis involves microbial colonization of damaged endocardial surfaces. This subsequently results in the formation of what is known as vegetations, which consist of debris from fibrin, platelets, and microorganisms. These vegetations may break off and cause blockages. This can lead to other symptoms like infarctions and abscesses. Historically, infective endocarditis was seen mostly in people with rheumatic heart disease, especially in developing countries. Nonetheless, with the advances of cardiac surgery and the widespread use of invasive procedures, there is a significant shift in its epidemiology.(6) Endocarditis of prosthetic valves and health-care associated infections related to intravascular devices and immunosuppressive therapy have come to the fore as important causes in developed countries.(7) The rising incidences of IE occurring in a prosthetic valve, bioprosthetic implants and valve repair surgery highlight the changing risk factors in modern hospital practice.(8) Microbiologically Streptococcus viridans and Staphylococcus aureus continue to be the most common organism involved. Although Streptococcus species are typically implicated in subacute presentations associated with dental and oral infections, Staphylococcus aureus is more aggressive and is usually implicated in healthcare-associated infections and intravenous drug use. (9) In recent times, the emergence of multi-drug-resistant organisms like enterococcus and gram-negative bacilli has made treatment more difficult. Due to the changing patterns of microorganisms, we need continuous monitoring and amendments in the antibiotic policy. (10) Despite getting better diagnostic tools (like echocardiography and blood culture techniques) and the treatment (e.g., valve replacement surgery and prolonged intravenous antibiotics), mortality due to IE remains very high. (11) The studies show in-hospital mortality between 15% and 30% (more than 30% in patients with prosthetic valve endocarditis, and further can be in patients with heart failure and septic emboli). A delayed diagnosis, relevant bad empirical therapy, and excessive presence of multidrug resistant organisms is often associated with poor prognosis. (12) In Pakistan, the burden of IE remains poorly characterized with limited epidemiological data available. Untreated tooth infection, rheumatic heart disease, and low socioeconomic status are some of the predisposing factors that complicate prevention and control efforts in the region. Also, not having clear national guidelines on how to diagnose and treat IE results in uncertainty in diagnosis and treatment which can affect how patients respond in general. (13) The Modified Duke Criteria is the hallmark for diagnosis of IE as it combines clinical, microbiological and echocardiographic evidence. However, in resource poor settings, Ultra-sound based and other investigation facilities may not be enough. Consequently, the need exists to study the performance of these criteria in local population and see if any adjustment, modification or other addition can improve things. Given the lack of data on microbiological profile and resistance pattern and clinical outcome of Infected Endocarditis in Pakistan, thus study aims to fulfil this gap. As patients treated at a tertiary cardiac center will be analyzed in this research, it attempts to assess the disease burden, emerging scenarios, and the development of context-specific management strategies. The epidemiology of IE may differ substantially between developed and developing countries due to disparities in socioeconomic status, access to healthcare, and underlying conditions. In Pakistan, for instance, IE patients largely consist of those have pre-existing rheumatic heart disease (RHD) owing to high incidence of rheumatic fever (RF). The assessment of the bacterial patterns and antibiotic susceptibility profile is essential for standard evidence-based guidelines and treatment. Also, evaluation of the clinical outcomes (MACE) will suggest the prognosis and the scope of the improvement. Methods 2.1: Study Design and Setting: This was a retrospective observational study conducted at the Department of Cardiology of a large tertiary care cardiology center in Peshawar, Pakistan. The data collection period spanned two years, from July 2021 to July 2023. The study focused on evaluating the frequency, causative organisms, antibiotic resistance, and clinical outcomes of infective endocarditis (IE) in patients admitted to the tertiary care cardiac center. 2.2: Study Population: Patients included in the study were aged between 20 and 80 years and presented with a diagnosis of IE, confirmed using the Modified Duke’s Criteria. Both male and female patients were eligible for inclusion. Patients with native valve, prosthetic valve, or cardiac device-related infective endocarditis were included. 2:3 Inclusion Criteria: Patients aged 20–80 years. Both male and female patients. Definite and Possible IE cases diagnosed based on Modified Duke’s Criteria. Patients with native valve, prosthetic valve, or cardiac device-related infective endocarditis. 2.4: Exclusion Criteria: Patients who did not provide consent. Patients classified as rejected IE based on Modified Duke’s Criteria. Patients without available blood culture reports. 2.5: Sampling Technique: A non-probability consecutive sampling technique was employed. All eligible patients who met the inclusion criteria and were admitted during the study period were included. 2.6: Data Collection Procedure: Following approval from the Institutional Ethical Review Board, data was retrieved retrospectively from the hospital’s electronic database, the Hospital Management Information System (HMIS). Each patient’s demographic data, clinical presentation, laboratory parameters, microbiology reports, antibiotic regimens, imaging results, treatment responses, and outcomes were recorded using a structured proforma. Patients were contacted over the telephone to obtain consent for participation in the study and to verify clinical information where necessary. Follow-up visits were conducted to assess their clinical status. Data collected included demographic details (age, gender, BMI, and residence), presenting symptoms, comorbidities (diabetes, hypertension, smoking status, history of cancer, immune deficiencies, and previous cerebrovascular accidents), and laboratory investigations (C-reactive protein, total leukocyte count, hemoglobin, platelet count, creatinine, and estimated glomerular filtration rate). The echocardiographic findings, such as vegetation size and presence, were recorded. Details of empirical and culture-guided antibiotic regimens, resistance patterns, and outcomes, including Major Adverse Cardiac Events (MACE), were also documented. 2.7: Operational Definitions: Infective Endocarditis Diagnosis: IE was diagnosed based on Modified Duke’s Criteria and classified as definite, possible, or rejected. Definite cases required two major criteria, one major and three minor criteria, or five minor criteria. Possible cases were one major and one minor criterion or three minor criteria. Major Adverse Cardiovascular Events (MACE): Defined as the occurrence of heart failure, pulmonary edema, myocardial infarction, stroke, or cardiac death during hospitalization. Antibiotic Resistance: Defined as the presence of non-susceptibility to at least one commonly used antibiotic (penicillin, ceftriaxone, vancomycin or gentamicin) for infective endocarditis based on sensitivity testing. Renal Dysfunction: Acute Kidney Injury (AKI) was defined as a rise in creatinine by ≥0.3 mg/dL within 48 hours or ≥1.5 times the baseline within seven days. Vegetation on Echocardiography: Defined as an oscillating intracardiac mass or an area of abnormal echo density attached to a valve, prosthetic material, or endocardial surface. 2.8: Data Analysis Procedure: Data was entered and analyzed using Stata version 14.2. Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distributed data were reported as means with standard deviations where as non-normal distribution was displayed as mean and interquartile range. Categorical variables were expressed as frequencies and percentages. Inferential statistics were applied to identify associations between infective endocarditis and clinical outcomes. The Chi-square test or Fisher’s exact test (for small cell counts) was used to assess associations between categorical variables, such as the presence of infective endocarditis and blood culture organisms, antibiotic resistance, and MACE. A p-value of ≤0.05 was considered statistically significant. Results were presented as tables and figures to highlight descriptive and inferential statistics. 2.9: Ethical Considerations: The study adhered to ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board at MTI-Peshawar Institute of Cardiology prior to data collection. Participants were contacted over the phone, and informed consent was obtained. The purpose of the study, confidentiality, and the voluntary nature of participation was explained to all participants. To ensure privacy, patient data was kept anonymous, and all records were securely stored. Participation was voluntary, and patients retained the right to withdraw at any time without any implications on their treatment or care. 2.10: Study Limitations: Being a retrospective observational study, findings may be subject to information bias due to reliance on previously recorded data. Additionally, incomplete follow-up data and missing laboratory records may have influenced the analysis of outcomes Results A total of 84 patients were recruited to the study. The population comprised 41.7% males and 58.3% females. 47.6% of the patients had pre-existing hypertension, while 36.9% had diabetes. Moreover, 28.6% of the patients were smokers, and 21.4% had a history of cerebrovascular accidents (CVA). Intravenous drug abuse (IVDA) was reported in 15.5% of the population. Around 20.2% of patients had prosthetic heart valves whereas the remaining had native valve disease (Table 1). The mean age of the study participants was 49.17 years with a standard deviation of 18.55 years. The mean BMI was 27.72 ± 4.37 kg/m². The average duration of symptoms among participants was 14.72 ± 8.73 days while the average hospital stay duration was 18.13 ± 7.35 days. Laboratory findings revealed that the mean CRP on arrival was 47.9 ± 28.92 mg/L, total leukocyte count (TLC) was 7846.26 ± 2312.10 cells/µL, and hemoglobin (HB) was 12.22 ± 2.51 g/dL. The mean platelet count on arrival was 297500.54 ± 87484.54 cells/µL. Renal function tests showed a mean creatinine level of 1.21 ± 0.42 mg/dL and an estimated glomerular filtration rate (eGFR) of 91.14 ± 17.82 mL/min/1.73m². (Table 1). Table 1 Population Demographics (n = 84) Variable Frequency (n) Percentage Male 35 41.7% Hypertension 40 47.6% Diabetes 31 36.9% Smoking 24 28.6% Prior CVA 18 21.4% Intravenous drug abuse 13 15.5% Native Valve 67 79.8% Prosthetic valves 17 20.2% Quantitative variables Variable Mean Standard Deviation Age 49.17 18.55 BMI 27.72 4.37 Duration of Symptoms 14.72 8.873 CRP on Arrival 47.90 28.92 TLC on Arrival 7846.26 2312.10 HB on Arrival 12.22 2.51 Platelets on Arrival 297500.54 87484.54 Creatinine on Arrival 1.21 0.42 eGFR on Arrival 91.14 17.82 Duration of Hospital Stay 18.13 7.35 The most common presenting symptom was shortness of breath (40.5%) followed by chest pain (27.4%). Cough and fever had similar frequencies at 16.7% and 15.5% respectively (Table 3). Fever was documented on arrival in 46.4% patients whereas 45.2% patients reported antibiotic use prior to admission. Vegetations were seen on echo of 79.8% patients (Table 2). Table 2 Clinical Characterisitics (n = 84) Variable Frequency (n) Percentage Chest Pain 23 27.4% Cough 14 16.7% Fever 13 15.5% Shortness of Breath 34 40.5% Documented fever on arrival 39 46.4% Received antibiotics on arrival 38 45.2% Vegetation on Echo 67 79.8% The most common site of vegetation was the mitral valve (40.5%) followed by the aortic valve (26.2%). Tricuspid and pulmonic valve involvement was less frequently seen (Fig. 1). Approximately 32.1% of the blood cultures yielded no growth. The distribution of organisms isolated from blood cultures revealed that Streptococcus Viridans was the most frequently identified pathogen, occurring in 25% of cases. Staphylococcus aureus was the second most common organism, being reported in 22.6% of cases. Coagulase-negative staphylococci were observed in 14.3% of the cultures, and Enterococcus was detected in 6%. Antibiotic resistance was observed in 46.4% of cases, while 53.6% were susceptible to antibiotics. Based on the Modified Duke Criteria, 64.3% of cases were classified as definite infective endocarditis, while 35.7% were classified as possible (Table 3). Table 3 Culture and sensitivity results and DUKES criteria probability (n = 84) Organisms in Blood Frequency Percent Culture Negative 27 32.1% Enterococcus 5 6.0% Staphylococcus Aureus 19 22.6% Streptococcus Viridans 21 25.0% Coagulase Negative Staphylococci 12 14.3% Total 84 100.0% Resistance to Antibiotics Frequency Percent Yes 39 46.4% No 45 53.6% Total 84 100.0 Probability of Infective Endocarditis Frequency Percent Definite 54 64.3% Possible 30 35.7% Total 84 100.0% MACE was observed in 56% of the patients, with 23.8% patients dying during admission. Pulmonary edema was observed in 21.4% of the patients, while CVA and peripheral embolism were observed in 6% and 4.8% of the patients, respectively (Fig. 2). Apart from MACE, AKI was observed in 48.8% of the patients during admission (Table 4). Table 4 Complications during hospitalization (n = 84) Variable Frequency (n) Percentage No MACE 37 44.0% Death 20 23.8% Pulmonary Edema 18 21.4% CVA 5 6.0% Peripheral Embolism 4 4.8% Total 84 100% AKI during admission 41 48.8% Antibiotic resistance was most commonly observed in patients with Enterococcus species infection seen in 3/5 cases (60%), followed by Staphylococcus aureus 9/19 (47.37%) and Coagulase-negative Staphylococci cases (41.67%). The least resistance was observed in Streptococcus Viridans species, with 8 of 21 cases showing antibiotic resistance (38%). However, there was no statistically significant difference between the groups in terms of resistance (Table 5). Analysis of MACE and its relation to antibiotic resistance/ Probability on DUKES Criteria failed to show any statistically significant relation (Tables 6 and 7). Table 5 Resistance to antibiotics in positive cultures growths (n = 57) Resistance to Antibiotics Total P value Yes No Organism in Blood Culture Enterococcus 3 2 5 0.846 Staphylococcus Aureus 9 10 19 Streptococcus Viridans 8 13 21 Coagulase negative staphylococci 5 7 12 Total 25 32 57 Table 6 MACE and relation to organisms (n = 84) Organism in Blood Culture Total n (%) P value Enterococcus n (%) Culture Negative n (%) Staphylococcus Aureus n (%) Streptococcus Viridans n (%) Coagulase negative staphylococci n (%) MACE During Hospital Stay No 3 (3.57) 14 (16.67) 6 (7.14) 10 (11.9) 4 (4.76) 37 (44.05) .591 Death 2 (2.38) 6 (7.14) 4 (4.76) 4 (4.76) 4 (4.76) 20 (23.81) Pulmonary Edema 0 (0) 5 (5.95) 7 (8.33) 5 (5.95) 1 (1.19) 18 (21.43) CVA 0 (0) 0 (0) 2 (2.38) 1 (1.19) 2 (2.38) 5 (5.95) Peripheral Embolism 0 (0) 2 (2.38) 0 (0) 1 (1.19) 1 (1.19) 4 (4.76) Total 5 (5.95) 27 (32.14) 19 (22.61) 21 (25) 12 (14.28) 84 (100) Table 7 Relation of MACE to Probability on DUKES criteria (n = 84) Probability on DUKES Criteria Total n (%) P-value Definite n (%) Possible n (%) MACE During Hospital Stay No 24 (28.57) 13 (15.47) 37 (44.05) 0.137 Death 9 (10.71) 11 (13.09) 20 (23.81) Pulmonary Edema 15 (17.86) 3 (3.57) 18 (21.43) CVA 4 (4.76) 1 (1.19) 5 (5.95) Peripheral Embolism 2 (2.38) 2 (2.38) 4 (4.76) Total 54 (64.3) 30 (35.7) 84 (100) Discussion Infective endocarditis is an important cause of serious illness and death all over the world. The goal of this research was to evaluate the clinical profile, microbiological patterns, antibiotic resistance and outcome of infective endocarditis patients at a tertiary care cardiac center in Pakistan. The results provide important information about the characteristics of IE in our studied population. It calls for the need for a region-specific diagnosis and management. (16) The mean age of our study was 49.17 years (SD 18.55 years). Our study gives evidence to support IE in our studied population affected a younger age group in contrast to studies conducted in the western part of the world. As the median age of the infection is reported to be more than 60 years there. (17) The possible explanation for this might be varying socioeconomic conditions, treatment access, etc. Further, the persistent burden of rheumatic heart disease in developing countries and delayed diagnosis and treatment of valvular dysfunction. The relatively younger patient age group highlights the need for early screening programs. (19) The mean BMI was 27.72 ± 4.37kg/m² suggestive of overweight/borderline obese status of our study population. This study corroborates the worldwide rise in metabolic syndromes that may predispose to cardiovascular complications, thus heightening the risk of developing infective endocarditis. High BMI can also reflect the sedentary lifestyle and changing eating habits of the area and needs public health intervention for the risk factor. (20) The laboratory findings displayed raised inflammatory markers and a mean CRP of 47.9 ± 28.92 indicating an inflammatory response at the time of presentation. The average TLC level of 7846.26 ± 2312.10 cells/µL indicates possible infection. Many patients in a study had a mean hemoglobin of 12.22 ± 2.51 g/dL. This can be consistent with the inflammation seen in IE and possibly due to hemolysis. (21) Also, some people were either thrombocytosis or thrombocytopenia. The platelet counts varied from 150,000 to 450,000 cells/µL. Thus, this shows the different responses in the presence of an infection. In some cases, renal dysfunction was noticed with mean creatinine of 1.21 ± 0.42 mg/dL an eGFR of 91.14 ± 17.82 mL/min/1.73m², which shows the need for closely monitoring the renal parameters especially in patients receiving nephrotoxic antibiotics. More over the rates of AKI in our study was 48.8% comparable to previous studies (22,23). Microbiological profile showed that 32.1% of blood cultures were negative for any growth. Among the positive blood cultures, Streptococcus Viridans (25%) was the most commonly isolated organism followed closely by Staphylococcus Aureus (22.6%). Coagulase negative staphylococci and Enterococcus were less frequently isolated. These findings were consistent with current literature especially with existing literature on the Pakistani population. The increased prevalence of negative cultures could be attributed either to poor culture/ laboratory techniques or to an increased prevalence of culture negative organisms. It could also be attributed to the fact that 45.2% of the patients had received some form of antibiotics prior to arrival (24–26) The high rate of antibiotic resistance (46.4%) raises a serious concern regarding empirical therapy and failure of treatment, especially. Clinical management of resistant organisms makes the hospital stay longer and costs the health care more. The study emphasizes that blood culture and sensitivity are essential before initiation of therapy. Also, the results further highlight the need for antibiotic stewardship programs to reduce antibiotic overuse and misuse, which may lead to increasing resistance patterns. (27) MACE (56%), including heart failure, peripheral embolism, stroke, pulmonary edema, and cardiac death, was a common outcome, indicating the severity of the disease pattern. The fact that MACE and infective endocarditis probability or the type of organism isolated were not significant (p = 0.591 and 0.137 respectively) suggests that adverse outcomes are influenced by factors other than the criteria for diagnosis alone; for example, comorbid conditions, late diagnosis, severity of underlying structural heart disease, etc. (28). High complication rates in this study reinforce the need for early intervention using a multi-disciplinary approach by cardiologists, infectious disease specialists, and cardiac surgeons. (29,30) There are many important clinical implications. Because they are diagnosed at a younger age, there needs to be greater awareness and screening programs for IE in various high-risk populations like those with (a) structural heart diseases, (b) prosthetic valves, etc. Also, the high rate of antibiotic resistance underscores the importance of culture-guided therapy and strong antimicrobial stewardship programs. The likelihood of a MACE occurring is high; thus, diagnosis of VTE on time along with a multidisciplinary approach and surgery in selected cases are key. Even this study has limitations despite its strengths. Because it is a retrospective observational study, it is subject to information bias, with missing data likely affecting the results. In addition, the small sample size (n = 84) limits its generalizability. Using hospital notes and phone calls may have caused some clinical outcomes to not be recorded. Finally, we are unable to assess recurrence rates or late complications as there is limited follow-up data. It is recommended for future studies to do a larger multicenter prospective study. Using advanced diagnostic tools like 18F-FDG PET-CT and testing for genetic predisposition may lead to improved diagnosis. Assessing the effects of surgery versus drugs in the long term will help. Similarly, discovering new markers for early identification will help. Also, the public health programs should target improving oral hygiene, routine screening for high-risk individuals, and optimizing pre-procedural prophylaxis. Conclusion In summary, the clinical and microbiological profile of infective endocarditis in a developing country is varied. The results highlight the importance of tailored diagnostic and therapeutic measures to combat the rising antibiotic resistance and unfavorable results. Identifying the organisms early and treating them specifically and monitoring closely can improve prognosis. Future studies should refine the diagnostic criteria, evaluate long-term treatment outcomes and develop region-specific management protocols for this high-risk condition. Abbreviations Infective endocarditis (IE), Major Adverse Cardiovascular Events (MACE), rheumatic heart disease (RHD), rheumatic fever (RF), Hospital Management Information System (HMIS), Acute Kidney Injury (AKI), cerebrovascular accidents (CVA), Intravenous drug abuse (IVDA), total leukocyte count (TLC), hemoglobin (HB), estimated glomerular filtration rate (eGFR) Declarations Ethical approval and consent to participate This study received ethical approval from the Peshawar Institute of Cardiology, Internal Review Board (IRB), approval no. IRC/24/59, on 12 th January,2024. Informed consent was obtained verbally before participation. The consent was audio-recorded in the presence of an independent witness . Consent for publication Not Applicable Clinical trial number Not Applicable Funding Statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References Abe T, Eyituoyo HO, De Allie G, Olanipekun T, Effoe VS, Olaosebikan K, et al. Clinical outcomes in patients with native valve infective endocarditis and diabetes mellitus. WJC. 2021 Jan 26;13(1):11–20. Murdoch DR, Corey GR, Hoen B, Miró JM, Fowler VG, Bayer AS, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009 Mar 9;169(5):463–73. Nunes MCP, Guimarães-Júnior MH, Murta Pinto PHO, Coelho RMP, Souza Barros TL, Faleiro Maia NDPA, et al. Outcomes of infective endocarditis in the current era: Early predictors of a poor prognosis. International Journal of Infectious Diseases. 2018 Mar;68:102–7. Meidrops K, Burkhardt FJ, Osipovs JD, Petrosina E, Groma V, Stradins P. Etiology, Risk Factors and Clinical Outcomes in Infective Endocarditis Patients Requiring Cardiac Surgery. JCM. 2022 Apr 1;11(7):1957. Rizk HH, Elamragy AA, Youssef GS, Meshaal MS, Samir A, ElSharkawy A, et al. Clinical features and outcomes of infective endocarditis in Egypt: an 11-year experience at a tertiary care facility. Egypt Heart J. 2019 Dec;71(1):17. Lanz J, Reardon MJ, Pilgrim T, Stortecky S, Deeb GM, Chetcuti S, et al. Incidence and Outcomes of Infective Endocarditis After Transcatheter or Surgical Aortic Valve Replacement. JAHA. 2021 Oct 5;10(19):e020368. Cresti A. Clinical Features and Mortality Rate of Infective Endocarditis in Intensive Care Unit: A Large-Scale Study and Literature Review. Anatol J Cardiol. 2023;44–54. Dayer MJ, Jones S, Prendergast B, Baddour LM, Lockhart PB, Thornhill MH. Incidence of infective endocarditis in England, 2000–13: a secular trend, interrupted time-series analysis. The Lancet. 2015 Mar;385(9974):1219–28. Cresti A, Chiavarelli M, Scalese M, Nencioni C, Valentini S, Guerrini F, et al. Epidemiological and mortality trends in infective endocarditis, a 17-year population-based prospective study. Cardiovasc Diagn Ther. 2017 Feb;7(1):27–35. Talha KM, Baddour LM, Thornhill MH, Arshad V, Tariq W, Tleyjeh IM, et al. Escalating incidence of infective endocarditis in Europe in the 21st century. Open Heart. 2021 Oct;8(2):e001846. Khanal B, Harish BN, Sethuraman KR, Srinivasan S. Infective Endocarditis: Report of a Prospective Study in an Indian Hospital. Trop Doct. 2002 Apr;32(2):83–5. Khanal B, Harish BN, Sethuraman KR, Srinivasan S. Infective Endocarditis: Report of a Prospective Study in an Indian Hospital. Trop Doct. 2002 Apr;32(2):83–5. Habib G, Lancellotti P, Erba PA, Sadeghpour A, Meshaal M, Sambola A, et al. The ESC-EORP EURO-ENDO (European Infective Endocarditis) registry. European Heart Journal - Quality of Care and Clinical Outcomes. 2019 Jul 1;5(3):202–7. Asai N, Shiota A, Ohashi W, Watanabe H, Shibata Y, Kato H, et al. The SOFA score could predict the severity and prognosis of infective endocarditis. Journal of Infection and Chemotherapy. 2019 Dec;25(12):965–71. on behalf of the CUB-Réa Network, Joffre J, Dumas G, Aegerter P, Dubée V, Bigé N, et al. Epidemiology of infective endocarditis in French intensive care units over the 1997–2014 period—from CUB-Réa Network. Crit Care. 2019 Dec;23(1):143. Nguyen J, Baradi A, Reid D, Jin D, Navani R, Huang K, et al. Characteristics, Outcomes and Prognostic Factors of Infective Endocarditis in the Intensive Care Unit. Heart, Lung and Circulation. 2021;30:S216. Chou DW, Wu SL, Chung KM, Han SC, Cheung BMH. Septic Pulmonary Embolism Requiring Critical Care: Clinicoradiological Spectrum, Causative Pathogens and Outcomes. Clinics. 2016;71(10):562–9. Varela Barca L, Navas Elorza E, Fernández-Hidalgo N, Moya Mur JL, Muriel García A, Fernández-Felix BM, et al. Prognostic factors of mortality after surgery in infective endocarditis: systematic review and meta-analysis. Infection. 2019 Dec;47(6):879–95. Varela L, López-Menéndez J, Redondo A, Fajardo ER, Miguelena J, Centella T, et al. Mortality risk prediction in infective endocarditis surgery: reliability analysis of specific scores†. European Journal of Cardio-Thoracic Surgery. 2018 May 1;53(5):1049–54. Cresti A. Clinical Features and Mortality Rate of Infective Endocarditis in Intensive Care Unit: A Large-Scale Study and Literature Review. Anatol J Cardiol. 2023;44–54. Dayer MJ, Jones S, Prendergast B, Baddour LM, Lockhart PB, Thornhill MH. Incidence of infective endocarditis in England, 2000–13: a secular trend, interrupted time-series analysis. The Lancet. 2015 Mar;385(9974):1219–28. Gagneux-Brunon A, Pouvaret A, Maillard N, Berthelot P, Lutz MF, Cazorla C, Tulane C, Fuzellier JF, Verhoeven PO, Frésard A, Duval X. Acute kidney injury in infective endocarditis: a retrospective analysis. Medecine et Maladies Infectieuses. 2019 Oct 1;49(7):527-33. Von Tokarski F, Lemaignen A, Portais A, Fauchier L, Hennekinne F, Sautenet B, Halimi JM, Legras A, Patat F, Bourguignon T, Mirguet C. Risk factors and outcomes of early acute kidney injury in infective endocarditis: a retrospective cohort study. International Journal of Infectious Diseases. 2020 Oct 1;99:421-7. Tariq M, Alam M, Munir G, Khan MA, Smego Jr RA. Infective endocarditis: a five-year experience at a tertiary care hospital in Pakistan. International journal of infectious diseases. 2004 May 1;8(3):163-70. Ali SS, Qureshi IA, Ayaz A, Arshad A, Farhad A, Jamil B, Sohail MR. Etiology, clinical characteristics, and outcome of infective endocarditis: 10-year experience from a tertiary care center in Pakistan. Monaldi Archives for Chest Disease. 2022 Mar 28;92(4). Siddiqui BK, Tariq M, Jadoon A, Alam M, Murtaza G, Abid B, Sethi MJ, Atiq M, Abrar S, Smego Jr RA. Impact of prior antibiotic use in culture-negative endocarditis: review of 86 cases from southern Pakistan. International journal of infectious diseases. 2009 Sep 1;13(5):606-12. Cresti A, Chiavarelli M, Scalese M, Nencioni C, Valentini S, Guerrini F, et al. Epidemiological and mortality trends in infective endocarditis, a 17-year population-based prospective study. Cardiovasc Diagn Ther. 2017 Feb;7(1):27–35. Talha KM, Baddour LM, Thornhill MH, Arshad V, Tariq W, Tleyjeh IM, et al. Escalating incidence of infective endocarditis in Europe in the 21st century. Open Heart. 2021 Oct;8(2):e001846. Habib G, Lancellotti P, Erba PA, Sadeghpour A, Meshaal M, Sambola A, et al. The ESC-EORP EURO-ENDO (European Infective Endocarditis) registry. European Heart Journal - Quality of Care and Clinical Outcomes. 2019 Jul 1;5(3):202–7. Fowler VG, Durack DT, Selton-Suty C, Athan E, Bayer AS, Chamis AL, et al. The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria. Clinical Infectious Diseases. 2023 Aug 22;77(4):518–26. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Nov, 2025 Read the published version in The Egyptian Heart Journal → Version 1 posted Editorial decision: Revision requested 05 Sep, 2025 Reviews received at journal 03 Sep, 2025 Reviewers agreed at journal 01 Sep, 2025 Reviews received at journal 28 Mar, 2025 Reviewers agreed at journal 18 Mar, 2025 Reviewers invited by journal 14 Feb, 2025 Editor assigned by journal 14 Feb, 2025 Submission checks completed at journal 14 Feb, 2025 First submitted to journal 11 Feb, 2025 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. 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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-6006600","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":416065215,"identity":"990ea744-077b-4eb3-9b85-d00cc4920ae2","order_by":0,"name":"Muhammad Wali Saleem","email":"","orcid":"","institution":"Peshawar Institute of Cardiology","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Wali","lastName":"Saleem","suffix":""},{"id":416065216,"identity":"eac50075-1887-4ca4-b380-3908e1135b19","order_by":1,"name":"Maha Amjad","email":"","orcid":"","institution":"Rehman Medical College","correspondingAuthor":false,"prefix":"","firstName":"Maha","middleName":"","lastName":"Amjad","suffix":""},{"id":416065217,"identity":"b1914f2f-c8b4-4891-8227-e72128f1e9bf","order_by":2,"name":"Ihsan Ullah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIie3PMWvCQBTA8fd4EJcke8jgV7CjoO1XMWStIjh28MrBuVjnZupXcHJOeYNLcBbuS0RcpL2hF0Eogkm6Cb3/co/H/YYH4HLdYzkAn4cOCSjt63VaE0KB7xWhFoQuhPzz0CBCnSNPzeOkx/h6HHxtuiEBlofn2yTajYAzlc4skfF4pR8UAUXZ5jbpFfaWQFCyZhTxeKnREo+CJuKbeUXkd3+pn1oSjyuiYjjppJFEBQoO1DbJLOm/CZ0qQll7S1gQH33zkqy2kvcno4cfC/lZHmoIAIpfs7reNGf+8tnlcrn+Sz/uklN1sLOfmgAAAABJRU5ErkJggg==","orcid":"","institution":"Peshawar Institute of Cardiology","correspondingAuthor":true,"prefix":"","firstName":"Ihsan","middleName":"","lastName":"Ullah","suffix":""},{"id":416065218,"identity":"fb5caacf-8225-4856-b04e-e3fc474e978e","order_by":3,"name":"Rafi Ullah Jan","email":"","orcid":"","institution":"Peshawar Institute of Cardiology","correspondingAuthor":false,"prefix":"","firstName":"Rafi","middleName":"Ullah","lastName":"Jan","suffix":""},{"id":416065219,"identity":"cb1b4830-bc37-48ee-852a-74a1324ca835","order_by":4,"name":"Muhammad Ishaq Khan","email":"","orcid":"","institution":"Peshawar Institute of Cardiology","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Ishaq","lastName":"Khan","suffix":""},{"id":416065220,"identity":"e2f77d2e-a7d8-4957-9f2c-69e17daa876e","order_by":5,"name":"Ummad Israr","email":"","orcid":"","institution":"Peshawar Institute of Cardiology","correspondingAuthor":false,"prefix":"","firstName":"Ummad","middleName":"","lastName":"Israr","suffix":""}],"badges":[],"createdAt":"2025-02-11 10:53:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6006600/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6006600/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s43044-025-00699-z","type":"published","date":"2025-11-10T15:58:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":76582841,"identity":"640c8e86-ffcf-43c9-b706-7045a8cad100","added_by":"auto","created_at":"2025-02-18 15:10:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76621,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraphical representation of most common sites of vegetations.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6006600/v1/76d5a869386f9a87dd3a4edb.png"},{"id":76581138,"identity":"42851c34-c354-42cf-8f07-8b93b7416511","added_by":"auto","created_at":"2025-02-18 15:02:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":84546,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMajor Adverse Cardiovascular Events (MACE) during hospitalization\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6006600/v1/a1a441223d9858f8a645a372.png"},{"id":96105139,"identity":"0bd2e757-71c8-43a7-bdc9-adafc9123f7c","added_by":"auto","created_at":"2025-11-17 16:09:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1109972,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6006600/v1/4526b117-2323-431e-84ba-0745e2f1f17d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Frequency and Clinical Outcomes of Infective Endocarditis: A Single Large Cardiac Center Experience from Pakistan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInfective endocarditis (IE) is a potentially deadly disease process resulting from infection and inflammation of the endocardial surface that most often involves the cardiac valves.(1) The recent years have seen the advent of better diagnostic and therapeutic strategies, yet, infective endocarditis has continued to pose a global burden owing to its high morbidity and mortality. IE is considered the 4th commonest life-threatening infection, after pneumonia, sepsis and intra-abdominal infections. (2) The epidemiological data from developed countries estimate the incidence to be about 3 to 7 cases per 100000 person years with increasing trend seen in the recent decades (3). IE remains a complex disease with heterogeneous presentations making it challenging to diagnose and treat. Infective endocarditis (IE) is an infection of the endocardium, typically the heart valve\u0026apos;s lining. Usually, those affected have preexisting valvular abnormalities or history of intravenous drug use. The clinical manifestations can range from low-grade fever and fatigue to heart failure, septic embolism, and stroke (4). The pathogenesis involves microbial colonization of damaged endocardial surfaces. This subsequently results in the formation of what is known as vegetations, which consist of debris from fibrin, platelets, and microorganisms. These vegetations may break off and cause blockages. This can lead to other symptoms like infarctions and abscesses. \u0026nbsp;Historically, infective endocarditis was seen mostly in people with rheumatic heart disease, especially in developing countries. Nonetheless, with the advances of cardiac surgery and the widespread use of invasive procedures, there is a significant shift in its epidemiology.(6) Endocarditis of prosthetic valves and health-care associated infections related to intravascular devices and immunosuppressive therapy have come to the fore as important causes in developed countries.(7) The rising incidences of IE occurring in a prosthetic valve, bioprosthetic implants and valve repair surgery highlight the changing risk factors in modern hospital practice.(8)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Microbiologically Streptococcus viridans and Staphylococcus aureus continue to be the most common organism involved. \u0026nbsp;Although Streptococcus species are typically implicated in subacute presentations associated with dental and oral infections, Staphylococcus aureus is more aggressive and is usually implicated in healthcare-associated infections and intravenous drug use. (9) In recent times, the emergence of multi-drug-resistant organisms like enterococcus and gram-negative bacilli has made treatment more difficult. Due to the changing patterns of microorganisms, we need continuous monitoring and amendments in the antibiotic policy. (10)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite getting better diagnostic tools (like echocardiography and blood culture techniques) and the treatment (e.g., valve replacement surgery and prolonged intravenous antibiotics), mortality due to IE remains very high. (11) The studies show in-hospital mortality between 15% and 30% (more than 30% in patients with prosthetic valve endocarditis, and further can be in patients with heart failure and septic emboli). A delayed diagnosis, relevant bad empirical therapy, and excessive presence of multidrug resistant organisms is often associated with poor prognosis. (12)\u003c/p\u003e\n\u003cp\u003eIn Pakistan, the burden of IE remains poorly characterized with limited epidemiological data available. Untreated tooth infection, rheumatic heart disease, and low socioeconomic status are some of the predisposing factors that complicate prevention and control efforts in the region. Also, not having clear national guidelines on how to diagnose and treat IE results in uncertainty in diagnosis and treatment which can affect how patients respond in general. (13)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Modified Duke Criteria is the hallmark for diagnosis of IE as it combines clinical, microbiological and echocardiographic evidence. However, in resource poor settings, Ultra-sound based and other investigation facilities may not be enough. Consequently, the need exists to study the performance of these criteria in local population and see if any adjustment, modification or other addition can improve things. Given the lack of data on microbiological profile and resistance pattern and clinical outcome of Infected Endocarditis in Pakistan, thus study aims to fulfil this gap. As patients treated at a tertiary cardiac center will be analyzed in this research, it attempts to assess the disease burden, emerging scenarios, and the development of context-specific management strategies.\u003c/p\u003e\n\u003cp\u003eThe epidemiology of IE may differ substantially between developed and developing countries due to disparities in socioeconomic status, access to healthcare, and underlying conditions. In Pakistan, for instance, IE patients largely consist of those have pre-existing rheumatic heart disease (RHD) owing to high incidence of rheumatic fever (RF).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The assessment of the bacterial patterns and antibiotic susceptibility profile is essential for standard evidence-based guidelines and treatment. Also, evaluation of the clinical outcomes (MACE) will suggest the prognosis and the scope of the improvement.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1: Study Design and Setting:\u0026nbsp;\u003c/strong\u003eThis was a retrospective observational study conducted at the Department of Cardiology of a large tertiary care cardiology center in Peshawar, Pakistan. The data collection period spanned two years, from July 2021 to July 2023. The study focused on evaluating the frequency, causative organisms, antibiotic resistance, and clinical outcomes of infective endocarditis (IE) in patients admitted to the tertiary care cardiac center.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2: Study Population:\u0026nbsp;\u003c/strong\u003ePatients included in the study were aged between 20 and 80 years and presented with a diagnosis of IE, confirmed using the Modified Duke\u0026rsquo;s Criteria. Both male and female patients were eligible for inclusion. Patients with native valve, prosthetic valve, or cardiac device-related infective endocarditis were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2:3 Inclusion Criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003ePatients aged 20\u0026ndash;80 years.\u003c/li\u003e\n \u003cli\u003eBoth male and female patients.\u003c/li\u003e\n \u003cli\u003eDefinite and Possible IE cases diagnosed based on Modified Duke\u0026rsquo;s Criteria.\u003c/li\u003e\n \u003cli\u003ePatients with native valve, prosthetic valve, or cardiac device-related infective endocarditis.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e2.4: Exclusion Criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003ePatients who did not provide consent.\u003c/li\u003e\n \u003cli\u003ePatients classified as rejected IE based on Modified Duke\u0026rsquo;s Criteria.\u003c/li\u003e\n \u003cli\u003ePatients without available blood culture reports.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e2.5: Sampling Technique:\u0026nbsp;\u003c/strong\u003eA non-probability consecutive sampling technique was employed. All eligible patients who met the inclusion criteria and were admitted during the study period were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6: Data Collection Procedure:\u0026nbsp;\u003c/strong\u003eFollowing approval from the Institutional Ethical Review Board, data was retrieved retrospectively from the hospital\u0026rsquo;s electronic database, the Hospital Management Information System (HMIS). Each patient\u0026rsquo;s demographic data, clinical presentation, laboratory parameters, microbiology reports, antibiotic regimens, imaging results, treatment responses, and outcomes were recorded using a structured proforma.\u003c/p\u003e\n\u003cp\u003ePatients were contacted over the telephone to obtain consent for participation in the study and to verify clinical information where necessary. Follow-up visits were conducted to assess their clinical status. Data collected included demographic details (age, gender, BMI, and residence), presenting symptoms, comorbidities (diabetes, hypertension, smoking status, history of cancer, immune deficiencies, and previous cerebrovascular accidents), and laboratory investigations (C-reactive protein, total leukocyte count, hemoglobin, platelet count, creatinine, and estimated glomerular filtration rate).\u003c/p\u003e\n\u003cp\u003eThe echocardiographic findings, such as vegetation size and presence, were recorded. Details of empirical and culture-guided antibiotic regimens, resistance patterns, and outcomes, including Major Adverse Cardiac Events (MACE), were also documented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.7: Operational Definitions:\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eInfective Endocarditis Diagnosis:\u003c/strong\u003e IE was diagnosed based on Modified Duke\u0026rsquo;s Criteria and classified as definite, possible, or rejected. Definite cases required two major criteria, one major and three minor criteria, or five minor criteria. Possible cases were one major and one minor criterion or three minor criteria.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMajor Adverse Cardiovascular Events (MACE):\u003c/strong\u003e Defined as the occurrence of heart failure, pulmonary edema, myocardial infarction, stroke, or cardiac death during hospitalization.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAntibiotic Resistance:\u003c/strong\u003e Defined as the presence of non-susceptibility to at least one commonly used antibiotic (penicillin, ceftriaxone, vancomycin or gentamicin) for infective endocarditis based on sensitivity testing.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eRenal Dysfunction:\u003c/strong\u003e Acute Kidney Injury (AKI) was defined as a rise in creatinine by \u0026ge;0.3 mg/dL within 48 hours or \u0026ge;1.5 times the baseline within seven days.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVegetation on Echocardiography:\u003c/strong\u003e Defined as an oscillating intracardiac mass or an area of abnormal echo density attached to a valve, prosthetic material, or endocardial surface.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e2.8: Data Analysis Procedure:\u0026nbsp;\u003c/strong\u003eData was entered and analyzed using Stata version 14.2. Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distributed data were reported as means with standard deviations where as non-normal distribution was displayed as mean and interquartile range. Categorical variables were expressed as frequencies and percentages.\u003c/p\u003e\n\u003cp\u003eInferential statistics were applied to identify associations between infective endocarditis and clinical outcomes. The Chi-square test or Fisher\u0026rsquo;s exact test (for small cell counts) was used to assess associations between categorical variables, such as the presence of infective endocarditis and blood culture organisms, antibiotic resistance, and MACE.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA p-value of \u0026le;0.05 was considered statistically significant. Results were presented as tables and figures to highlight descriptive and inferential statistics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.9: Ethical Considerations:\u0026nbsp;\u003c/strong\u003eThe study adhered to ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board at MTI-Peshawar Institute of Cardiology prior to data collection. Participants were contacted over the phone, and informed consent was obtained. The purpose of the study, confidentiality, and the voluntary nature of participation was explained to all participants.\u003c/p\u003e\n\u003cp\u003eTo ensure privacy, patient data was kept anonymous, and all records were securely stored. Participation was voluntary, and patients retained the right to withdraw at any time without any implications on their treatment or care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.10: Study Limitations:\u0026nbsp;\u003c/strong\u003eBeing a retrospective observational study, findings may be subject to information bias due to reliance on previously recorded data. Additionally, incomplete follow-up data and missing laboratory records may have influenced the analysis of outcomes\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 84 patients were recruited to the study. The population comprised 41.7% males and 58.3% females. 47.6% of the patients had pre-existing hypertension, while 36.9% had diabetes. Moreover, 28.6% of the patients were smokers, and 21.4% had a history of cerebrovascular accidents (CVA). Intravenous drug abuse (IVDA) was reported in 15.5% of the population. Around 20.2% of patients had prosthetic heart valves whereas the remaining had native valve disease (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eThe mean age of the study participants was 49.17 years with a standard deviation of 18.55 years. The mean BMI was 27.72\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37 kg/m\u0026sup2;. The average duration of symptoms among participants was 14.72\u0026thinsp;\u0026plusmn;\u0026thinsp;8.73 days while the average hospital stay duration was 18.13\u0026thinsp;\u0026plusmn;\u0026thinsp;7.35 days. Laboratory findings revealed that the mean CRP on arrival was 47.9\u0026thinsp;\u0026plusmn;\u0026thinsp;28.92 mg/L, total leukocyte count (TLC) was 7846.26\u0026thinsp;\u0026plusmn;\u0026thinsp;2312.10 cells/\u0026micro;L, and hemoglobin (HB) was 12.22\u0026thinsp;\u0026plusmn;\u0026thinsp;2.51 g/dL. The mean platelet count on arrival was 297500.54\u0026thinsp;\u0026plusmn;\u0026thinsp;87484.54 cells/\u0026micro;L. Renal function tests showed a mean creatinine level of 1.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42 mg/dL and an estimated glomerular filtration rate (eGFR) of 91.14\u0026thinsp;\u0026plusmn;\u0026thinsp;17.82 mL/min/1.73m\u0026sup2;. (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePopulation Demographics (n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior CVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntravenous drug abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNative Valve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProsthetic valves\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eQuantitative variables\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of Symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.873\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP on Arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTLC on Arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7846.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2312.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHB on Arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelets on Arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e297500.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87484.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine on Arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeGFR on Arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of Hospital Stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe most common presenting symptom was shortness of breath (40.5%) followed by chest pain (27.4%). Cough and fever had similar frequencies at 16.7% and 15.5% respectively (Table\u0026nbsp;3). Fever was documented on arrival in 46.4% patients whereas 45.2% patients reported antibiotic use prior to admission. Vegetations were seen on echo of 79.8% patients (Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical Characterisitics (n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCough\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShortness of Breath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDocumented fever on arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceived antibiotics on arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVegetation on Echo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe most common site of vegetation was the mitral valve (40.5%) followed by the aortic valve (26.2%). Tricuspid and pulmonic valve involvement was less frequently seen (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eApproximately 32.1% of the blood cultures yielded no growth. The distribution of organisms isolated from blood cultures revealed that Streptococcus Viridans was the most frequently identified pathogen, occurring in 25% of cases. Staphylococcus aureus was the second most common organism, being reported in 22.6% of cases. Coagulase-negative staphylococci were observed in 14.3% of the cultures, and Enterococcus was detected in 6%. Antibiotic resistance was observed in 46.4% of cases, while 53.6% were susceptible to antibiotics. Based on the Modified Duke Criteria, 64.3% of cases were classified as definite infective endocarditis, while 35.7% were classified as possible (Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCulture and sensitivity results and DUKES criteria probability (n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eOrganisms in Blood\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFrequency\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePercent\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCulture Negative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnterococcus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaphylococcus Aureus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStreptococcus Viridans\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoagulase Negative Staphylococci\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eResistance to Antibiotics\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eFrequency\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ePercent\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eProbability of Infective Endocarditis\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eFrequency\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ePercent\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDefinite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePossible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMACE was observed in 56% of the patients, with 23.8% patients dying during admission. Pulmonary edema was observed in 21.4% of the patients, while CVA and peripheral embolism were observed in 6% and 4.8% of the patients, respectively (Fig.\u0026nbsp;2). Apart from MACE, AKI was observed in 48.8% of the patients during admission (Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications during hospitalization (n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo MACE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary Edema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral Embolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e84\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAKI during admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAntibiotic resistance was most commonly observed in patients with Enterococcus species infection seen in 3/5 cases (60%), followed by Staphylococcus aureus 9/19 (47.37%) and Coagulase-negative Staphylococci cases (41.67%). The least resistance was observed in Streptococcus Viridans species, with 8 of 21 cases showing antibiotic resistance (38%). However, there was no statistically significant difference between the groups in terms of resistance (Table\u0026nbsp;5).\u003c/p\u003e \u003cp\u003eAnalysis of MACE and its relation to antibiotic resistance/ Probability on DUKES Criteria failed to show any statistically significant relation (Tables\u0026nbsp;6 and 7).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResistance to antibiotics in positive cultures growths (n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eResistance to Antibiotics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eOrganism in Blood Culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnterococcus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.846\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStaphylococcus Aureus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e19\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStreptococcus Viridans\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e21\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoagulase negative staphylococci\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e25\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e32\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e57\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMACE and relation to organisms (n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e \u003cp\u003eOrganism in Blood Culture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnterococcus\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCulture Negative\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStaphylococcus Aureus n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStreptococcus Viridans\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCoagulase negative staphylococci n (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eMACE During Hospital Stay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (7.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4 (4.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e37 (44.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e.591\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDeath\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (7.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (4.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (4.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4 (4.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20 (23.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePulmonary Edema\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (5.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (5.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18 (21.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCVA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5 (5.95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePeripheral Embolism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4 (4.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5 (5.95)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e27 (32.14)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e19 (22.61)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e21 (25)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e12 (14.28)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e84 (100)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelation of MACE to Probability on DUKES criteria (n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eProbability on DUKES Criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c8\" namest=\"c7\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefinite n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePossible n (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eMACE During Hospital Stay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (28.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (15.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e37 (44.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"5\" nameend=\"c8\" namest=\"c7\" rowspan=\"6\"\u003e \u003cp\u003e0.137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (10.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (13.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e20 (23.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePulmonary Edema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (17.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (3.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e18 (21.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (4.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e5 (5.95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeripheral Embolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (2.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e4 (4.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e54 (64.3)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e30 (35.7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003e84 (100)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eInfective endocarditis is an important cause of serious illness and death all over the world. The goal of this research was to evaluate the clinical profile, microbiological patterns, antibiotic resistance and outcome of infective endocarditis patients at a tertiary care cardiac center in Pakistan. The results provide important information about the characteristics of IE in our studied population. It calls for the need for a region-specific diagnosis and management. (16) The mean age of our study was 49.17 years (SD 18.55 years). Our study gives evidence to support IE in our studied population affected a younger age group in contrast to studies conducted in the western part of the world. As the median age of the infection is reported to be more than 60 years there. (17) The possible explanation for this might be varying socioeconomic conditions, treatment access, etc. Further, the persistent burden of rheumatic heart disease in developing countries and delayed diagnosis and treatment of valvular dysfunction. The relatively younger patient age group highlights the need for early screening programs. (19) The mean BMI was 27.72\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37kg/m\u0026sup2; suggestive of overweight/borderline obese status of our study population. This study corroborates the worldwide rise in metabolic syndromes that may predispose to cardiovascular complications, thus heightening the risk of developing infective endocarditis. High BMI can also reflect the sedentary lifestyle and changing eating habits of the area and needs public health intervention for the risk factor. (20) The laboratory findings displayed raised inflammatory markers and a mean CRP of 47.9\u0026thinsp;\u0026plusmn;\u0026thinsp;28.92 indicating an inflammatory response at the time of presentation. The average TLC level of 7846.26\u0026thinsp;\u0026plusmn;\u0026thinsp;2312.10 cells/\u0026micro;L indicates possible infection. Many patients in a study had a mean hemoglobin of 12.22\u0026thinsp;\u0026plusmn;\u0026thinsp;2.51 g/dL. This can be consistent with the inflammation seen in IE and possibly due to hemolysis. (21) Also, some people were either thrombocytosis or thrombocytopenia. The platelet counts varied from 150,000 to 450,000 cells/\u0026micro;L. Thus, this shows the different responses in the presence of an infection. In some cases, renal dysfunction was noticed with mean creatinine of 1.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42 mg/dL an eGFR of 91.14\u0026thinsp;\u0026plusmn;\u0026thinsp;17.82 mL/min/1.73m\u0026sup2;, which shows the need for closely monitoring the renal parameters especially in patients receiving nephrotoxic antibiotics. More over the rates of AKI in our study was 48.8% comparable to previous studies (22,23). Microbiological profile showed that 32.1% of blood cultures were negative for any growth. Among the positive blood cultures, Streptococcus Viridans (25%) was the most commonly isolated organism followed closely by Staphylococcus Aureus (22.6%). Coagulase negative staphylococci and Enterococcus were less frequently isolated. These findings were consistent with current literature especially with existing literature on the Pakistani population. The increased prevalence of negative cultures could be attributed either to poor culture/ laboratory techniques or to an increased prevalence of culture negative organisms. It could also be attributed to the fact that 45.2% of the patients had received some form of antibiotics prior to arrival (24\u0026ndash;26) The high rate of antibiotic resistance (46.4%) raises a serious concern regarding empirical therapy and failure of treatment, especially. Clinical management of resistant organisms makes the hospital stay longer and costs the health care more. The study emphasizes that blood culture and sensitivity are essential before initiation of therapy. Also, the results further highlight the need for antibiotic stewardship programs to reduce antibiotic overuse and misuse, which may lead to increasing resistance patterns. (27)\u003c/p\u003e \u003cp\u003eMACE (56%), including heart failure, peripheral embolism, stroke, pulmonary edema, and cardiac death, was a common outcome, indicating the severity of the disease pattern. The fact that MACE and infective endocarditis probability or the type of organism isolated were not significant (p\u0026thinsp;=\u0026thinsp;0.591 and 0.137 respectively) suggests that adverse outcomes are influenced by factors other than the criteria for diagnosis alone; for example, comorbid conditions, late diagnosis, severity of underlying structural heart disease, etc. (28). High complication rates in this study reinforce the need for early intervention using a multi-disciplinary approach by cardiologists, infectious disease specialists, and cardiac surgeons. (29,30)\u003c/p\u003e \u003cp\u003eThere are many important clinical implications. Because they are diagnosed at a younger age, there needs to be greater awareness and screening programs for IE in various high-risk populations like those with (a) structural heart diseases, (b) prosthetic valves, etc. Also, the high rate of antibiotic resistance underscores the importance of culture-guided therapy and strong antimicrobial stewardship programs. The likelihood of a MACE occurring is high; thus, diagnosis of VTE on time along with a multidisciplinary approach and surgery in selected cases are key.\u003c/p\u003e \u003cp\u003eEven this study has limitations despite its strengths. Because it is a retrospective observational study, it is subject to information bias, with missing data likely affecting the results. In addition, the small sample size (n\u0026thinsp;=\u0026thinsp;84) limits its generalizability. Using hospital notes and phone calls may have caused some clinical outcomes to not be recorded. Finally, we are unable to assess recurrence rates or late complications as there is limited follow-up data.\u003c/p\u003e \u003cp\u003eIt is recommended for future studies to do a larger multicenter prospective study. Using advanced diagnostic tools like 18F-FDG PET-CT and testing for genetic predisposition may lead to improved diagnosis. Assessing the effects of surgery versus drugs in the long term will help. Similarly, discovering new markers for early identification will help. Also, the public health programs should target improving oral hygiene, routine screening for high-risk individuals, and optimizing pre-procedural prophylaxis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, the clinical and microbiological profile of infective endocarditis in a developing country is varied. The results highlight the importance of tailored diagnostic and therapeutic measures to combat the rising antibiotic resistance and unfavorable results. Identifying the organisms early and treating them specifically and monitoring closely can improve prognosis. Future studies should refine the diagnostic criteria, evaluate long-term treatment outcomes and develop region-specific management protocols for this high-risk condition.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eInfective endocarditis (IE), Major Adverse Cardiovascular Events (MACE), rheumatic heart disease (RHD), rheumatic fever (RF), Hospital Management Information System (HMIS), Acute Kidney Injury (AKI), cerebrovascular accidents (CVA), Intravenous drug abuse (IVDA), total leukocyte count (TLC), hemoglobin (HB), estimated glomerular filtration rate (eGFR)\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthical approval and consent to participate\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the Peshawar Institute of Cardiology, Internal Review Board (IRB), approval no. IRC/24/59, on 12\u003csup\u003eth\u003c/sup\u003e January,2024.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained verbally before participation. The consent was audio-recorded in the presence of an independent witness\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eClinical trial number\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding Statement\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbe T, Eyituoyo HO, De Allie G, Olanipekun T, Effoe VS, Olaosebikan K, et al. Clinical outcomes in patients with native valve infective endocarditis and diabetes mellitus. WJC. 2021 Jan 26;13(1):11\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eMurdoch DR, Corey GR, Hoen B, Mir\u0026oacute; JM, Fowler VG, Bayer AS, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009 Mar 9;169(5):463\u0026ndash;73. \u003c/li\u003e\n\u003cli\u003eNunes MCP, Guimar\u0026atilde;es-J\u0026uacute;nior MH, Murta Pinto PHO, Coelho RMP, Souza Barros TL, Faleiro Maia NDPA, et al. Outcomes of infective endocarditis in the current era: Early predictors of a poor prognosis. International Journal of Infectious Diseases. 2018 Mar;68:102\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eMeidrops K, Burkhardt FJ, Osipovs JD, Petrosina E, Groma V, Stradins P. Etiology, Risk Factors and Clinical Outcomes in Infective Endocarditis Patients Requiring Cardiac Surgery. JCM. 2022 Apr 1;11(7):1957. \u003c/li\u003e\n\u003cli\u003eRizk HH, Elamragy AA, Youssef GS, Meshaal MS, Samir A, ElSharkawy A, et al. Clinical features and outcomes of infective endocarditis in Egypt: an 11-year experience at a tertiary care facility. Egypt Heart J. 2019 Dec;71(1):17. \u003c/li\u003e\n\u003cli\u003eLanz J, Reardon MJ, Pilgrim T, Stortecky S, Deeb GM, Chetcuti S, et al. Incidence and Outcomes of Infective Endocarditis After Transcatheter or Surgical Aortic Valve Replacement. JAHA. 2021 Oct 5;10(19):e020368. \u003c/li\u003e\n\u003cli\u003eCresti A. Clinical Features and Mortality Rate of Infective Endocarditis in Intensive Care Unit: A Large-Scale Study and Literature Review. Anatol J Cardiol. 2023;44\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eDayer MJ, Jones S, Prendergast B, Baddour LM, Lockhart PB, Thornhill MH. Incidence of infective endocarditis in England, 2000\u0026ndash;13: a secular trend, interrupted time-series analysis. The Lancet. 2015 Mar;385(9974):1219\u0026ndash;28. \u003c/li\u003e\n\u003cli\u003eCresti A, Chiavarelli M, Scalese M, Nencioni C, Valentini S, Guerrini F, et al. Epidemiological and mortality trends in infective endocarditis, a 17-year population-based prospective study. Cardiovasc Diagn Ther. 2017 Feb;7(1):27\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eTalha KM, Baddour LM, Thornhill MH, Arshad V, Tariq W, Tleyjeh IM, et al. Escalating incidence of infective endocarditis in Europe in the 21st century. Open Heart. 2021 Oct;8(2):e001846. \u003c/li\u003e\n\u003cli\u003eKhanal B, Harish BN, Sethuraman KR, Srinivasan S. Infective Endocarditis: Report of a Prospective Study in an Indian Hospital. Trop Doct. 2002 Apr;32(2):83\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eKhanal B, Harish BN, Sethuraman KR, Srinivasan S. Infective Endocarditis: Report of a Prospective Study in an Indian Hospital. Trop Doct. 2002 Apr;32(2):83\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eHabib G, Lancellotti P, Erba PA, Sadeghpour A, Meshaal M, Sambola A, et al. The ESC-EORP EURO-ENDO (European Infective Endocarditis) registry. European Heart Journal - Quality of Care and Clinical Outcomes. 2019 Jul 1;5(3):202\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eAsai N, Shiota A, Ohashi W, Watanabe H, Shibata Y, Kato H, et al. The SOFA score could predict the severity and prognosis of infective endocarditis. Journal of Infection and Chemotherapy. 2019 Dec;25(12):965\u0026ndash;71. \u003c/li\u003e\n\u003cli\u003eon behalf of the CUB-R\u0026eacute;a Network, Joffre J, Dumas G, Aegerter P, Dub\u0026eacute;e V, Big\u0026eacute; N, et al. Epidemiology of infective endocarditis in French intensive care units over the 1997\u0026ndash;2014 period\u0026mdash;from CUB-R\u0026eacute;a Network. Crit Care. 2019 Dec;23(1):143. \u003c/li\u003e\n\u003cli\u003eNguyen J, Baradi A, Reid D, Jin D, Navani R, Huang K, et al. Characteristics, Outcomes and Prognostic Factors of Infective Endocarditis in the Intensive Care Unit. Heart, Lung and Circulation. 2021;30:S216. \u003c/li\u003e\n\u003cli\u003eChou DW, Wu SL, Chung KM, Han SC, Cheung BMH. Septic Pulmonary Embolism Requiring Critical Care: Clinicoradiological Spectrum, Causative Pathogens and Outcomes. Clinics. 2016;71(10):562\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eVarela Barca L, Navas Elorza E, Fern\u0026aacute;ndez-Hidalgo N, Moya Mur JL, Muriel Garc\u0026iacute;a A, Fern\u0026aacute;ndez-Felix BM, et al. Prognostic factors of mortality after surgery in infective endocarditis: systematic review and meta-analysis. Infection. 2019 Dec;47(6):879\u0026ndash;95. \u003c/li\u003e\n\u003cli\u003eVarela L, L\u0026oacute;pez-Men\u0026eacute;ndez J, Redondo A, Fajardo ER, Miguelena J, Centella T, et al. Mortality risk prediction in infective endocarditis surgery: reliability analysis of specific scores\u0026dagger;. European Journal of Cardio-Thoracic Surgery. 2018 May 1;53(5):1049\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eCresti A. Clinical Features and Mortality Rate of Infective Endocarditis in Intensive Care Unit: A Large-Scale Study and Literature Review. Anatol J Cardiol. 2023;44\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eDayer MJ, Jones S, Prendergast B, Baddour LM, Lockhart PB, Thornhill MH. Incidence of infective endocarditis in England, 2000\u0026ndash;13: a secular trend, interrupted time-series analysis. The Lancet. 2015 Mar;385(9974):1219\u0026ndash;28. \u003c/li\u003e\n\u003cli\u003eGagneux-Brunon A, Pouvaret A, Maillard N, Berthelot P, Lutz MF, Cazorla C, Tulane C, Fuzellier JF, Verhoeven PO, Fr\u0026eacute;sard A, Duval X. Acute kidney injury in infective endocarditis: a retrospective analysis. Medecine et Maladies Infectieuses. 2019 Oct 1;49(7):527-33.\u003c/li\u003e\n\u003cli\u003eVon Tokarski F, Lemaignen A, Portais A, Fauchier L, Hennekinne F, Sautenet B, Halimi JM, Legras A, Patat F, Bourguignon T, Mirguet C. Risk factors and outcomes of early acute kidney injury in infective endocarditis: a retrospective cohort study. International Journal of Infectious Diseases. 2020 Oct 1;99:421-7.\u003c/li\u003e\n\u003cli\u003eTariq M, Alam M, Munir G, Khan MA, Smego Jr RA. Infective endocarditis: a five-year experience at a tertiary care hospital in Pakistan. International journal of infectious diseases. 2004 May 1;8(3):163-70.\u003c/li\u003e\n\u003cli\u003eAli SS, Qureshi IA, Ayaz A, Arshad A, Farhad A, Jamil B, Sohail MR. Etiology, clinical characteristics, and outcome of infective endocarditis: 10-year experience from a tertiary care center in Pakistan. Monaldi Archives for Chest Disease. 2022 Mar 28;92(4).\u003c/li\u003e\n\u003cli\u003eSiddiqui BK, Tariq M, Jadoon A, Alam M, Murtaza G, Abid B, Sethi MJ, Atiq M, Abrar S, Smego Jr RA. Impact of prior antibiotic use in culture-negative endocarditis: review of 86 cases from southern Pakistan. International journal of infectious diseases. 2009 Sep 1;13(5):606-12.\u003c/li\u003e\n\u003cli\u003eCresti A, Chiavarelli M, Scalese M, Nencioni C, Valentini S, Guerrini F, et al. Epidemiological and mortality trends in infective endocarditis, a 17-year population-based prospective study. Cardiovasc Diagn Ther. 2017 Feb;7(1):27\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eTalha KM, Baddour LM, Thornhill MH, Arshad V, Tariq W, Tleyjeh IM, et al. Escalating incidence of infective endocarditis in Europe in the 21st century. Open Heart. 2021 Oct;8(2):e001846. \u003c/li\u003e\n\u003cli\u003eHabib G, Lancellotti P, Erba PA, Sadeghpour A, Meshaal M, Sambola A, et al. The ESC-EORP EURO-ENDO (European Infective Endocarditis) registry. European Heart Journal - Quality of Care and Clinical Outcomes. 2019 Jul 1;5(3):202\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eFowler VG, Durack DT, Selton-Suty C, Athan E, Bayer AS, Chamis AL, et al. The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria. Clinical Infectious Diseases. 2023 Aug 22;77(4):518\u0026ndash;26. \u003c/li\u003e\n\u003c/ol\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":"the-egyptian-heart-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tehj","sideBox":"Learn more about [The Egyptian Heart Journal](https://tehj.springeropen.com)","snPcode":"43044","submissionUrl":"https://submission.springernature.com/new-submission/43044/3","title":"The Egyptian Heart Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Infective Endocarditis, Antibiotic Resistance, MACE, Blood Culture, Clinical Outcomes, Retrospective Study","lastPublishedDoi":"10.21203/rs.3.rs-6006600/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6006600/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInfective endocarditis (IE) is a potentially fatal condition with high morbidity and mortality. This single center study was designed to assess the frequency, causative organisms, antibiotic resistance, and clinical outcomes of IE in patients treated at a tertiary care cardiac center in Pakistan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective observational study was conducted at a large tertiary care cardiology center in Peshawar, Pakistan from July 2021 to July 2023. Data was collected from hospital records, including demographic, clinical, and laboratory parameters. Statistical analysis was performed using Stata version 14.2.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 84 patients, 41.7% of the patients were male with a mean population age of 49.17\u0026thinsp;\u0026plusmn;\u0026thinsp;18.55 years, and an average BMI of 27.72\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37 kg/m\u0026sup2;. Furthermore, 47.6% patients were hypertensive whereas 36.9% had diabetes. Streptococcus Viridans (25%) was the most common organism isolated, followed closely by Staphylococcus aureus at 22.6%. Interestingly, 32.1% of the patients had negative cultures. Antibiotic resistance was observed in 46.4% of cases, and Major Adverse Cardiovascular Events (MACE) occurred in 56%. Acute kidney injury was observed in 48.8% of the patients.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eIE presents diverse etiologies and outcomes, necessitating targeted management strategies to improve prognosis.\u003c/p\u003e","manuscriptTitle":"Frequency and Clinical Outcomes of Infective Endocarditis: A Single Large Cardiac Center Experience from Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-18 15:02:33","doi":"10.21203/rs.3.rs-6006600/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-05T17:36:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-03T06:55:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170169389758877994945931105620241839441","date":"2025-09-02T03:49:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-29T03:00:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65985466976589542945213820407745931433","date":"2025-03-18T09:55:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-15T01:46:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-14T11:51:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-02-14T11:48:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Heart Journal","date":"2025-02-11T10:51:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-heart-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tehj","sideBox":"Learn more about [The Egyptian Heart Journal](https://tehj.springeropen.com)","snPcode":"43044","submissionUrl":"https://submission.springernature.com/new-submission/43044/3","title":"The Egyptian Heart Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d99e0efd-a0d0-4a04-8648-036447a5764e","owner":[],"postedDate":"February 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:03:35+00:00","versionOfRecord":{"articleIdentity":"rs-6006600","link":"https://doi.org/10.1186/s43044-025-00699-z","journal":{"identity":"the-egyptian-heart-journal","isVorOnly":false,"title":"The Egyptian Heart Journal"},"publishedOn":"2025-11-10 15:58:31","publishedOnDateReadable":"November 10th, 2025"},"versionCreatedAt":"2025-02-18 15:02:33","video":"","vorDoi":"10.1186/s43044-025-00699-z","vorDoiUrl":"https://doi.org/10.1186/s43044-025-00699-z","workflowStages":[]},"version":"v1","identity":"rs-6006600","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6006600","identity":"rs-6006600","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}