National Temporal Trend Analysis of Infective Endocarditis among Patients Infected with HIV in Spain (1997-2014): A Retrospective Study

Abstract

Background: People living with human immunodeficiency virus (HIV) (PLWH) form a vulnerable population for the onset of infective endocarditis (IE). We aimed to analyze the epidemiological trend of IE, as well as its microbiological characteristics, in PLWH during the combined antiretroviral therapy era in Spain.

Methods: We performed a retrospective study (1997-2014) in PLWH with data obtained from the Spanish Minimum Basic Data Set. We selected 1800 hospital admissions with an IE diagnosis, which corresponded to 1439 patients.

Results: We found significant downward trends in the periods 1997-1999 and 2008-2014 in the rate of hospital admissions with an IE diagnosis (from 21.8 to 3.8 events per 10,000 patients/year; p < 0.001), IE incidence (from 18.2 to 2.9 events per 10,000 patients/year; p < 0.001), and IE mortality (from 23.9 to 5.5 deaths per 100,000 patient-years; p < 0.001). The most frequent microorganisms involved were staphylococci (50%; 42.7% Staphylococcus aureus and 7.3% coagulase-negative staphylococci (CoNS)), followed by streptococci (9.3%), Gram-negative bacilli (8.3%), enterococci (3%), and fungus (1.4%). During the study period, we found a downward trend in the rates of CoNS (p < 0.001) and an upward trends in streptococci (p = 0.001), Gram-negative bacilli (p < 0.001), enterococci (p = 0.003), and fungus (p < 0.001) related to IE, mainly in 2008-2014. The rate of community-acquired IE showed a significant upward trend (p = 0.001), while the rate of health care-associated IE showed a significant downward trend (p < 0.001).

Conclusions: The rates of hospital admissions, incidence, and mortality related to IE diagnosis in PLWH in Spain decreased from 1997 to 2014, while other changes in clinical characteristics, mode of acquisition, and pathogens occurred over this time.

Keywords: HIV/AIDS; ICD9CM codes; epidemiology; etiology; infective endocarditis.

Figure 1

Flow chart of the selection of human immunodeficiency virus (HIV)-infected patients in Spain included in the study (1997 to 2014).

Figure 2

Epidemiological trends of infective endocarditis in HIV-infected patients in Spain (1997 to 2014). (A) Hospital admissions. (B) Incidence; (C) Mortality; (D) Case fatality rate. Statistical: Differences between groups were calculated by the Chi Square test. Linear trends from 1997–1999 to 2008–2014 calculated by the Extended Mantel–Haenszel Chi Square.

Figure 3

Epidemiological trends of causative microorganisms of infective endocarditis in HIV-infected patients in Spain (1997 to 2014). (A) Staphylococcus aureus. (B) Coagulase-Negative staphylococci. (C) Streptococci. (D) Gram-negative bacilli. (E) Enterococci. (F) Fungus. Statistical: Differences between groups were calculated by the Chi Square test. Linear trends from 1997–1999 to 2008–2014 calculated by the Extended Mantel–Haenszel Chi Square.

Figure 4

Epidemiological trends of infective endocarditis (IE) in HIV-infected patients in Spain (1997 Table 2014 stratified by modes of acquisition. (A) Community-acquired IE. (B) Health care-associated IE. Statistical: Differences between groups were calculated by the Chi Square test. Linear trends from 1997–1999 to 2008–2014 calculated by the Extended Mantel–Haenszel Chi Square.

Figure 5

Epidemiological trends of causative microorganisms of infective endocarditis in HIV-infected patients in Spain (1997 to 2014) stratified by health care-associated and community-acquired endocarditis. (A) Staphylococcus aureus. (B) Coagulase-Negative staphylococci. (C) Streptococci. (D) Gram-negative bacilli. (E) Enterococci. (F) Fungus. Statistical: Differences between groups were calculated by the Chi Square test. Linear trends from 1997–1999 to 2008–2014 calculated by the Extended Mantel–Haenszel Chi Square.