Infective Endocarditis in the HIV-era in Central South Africa

Infective endocarditis (IE) remains a serious disease with a significant morbidity and mortality. Recent published surgical data in South Africa in the HIV era was associated with a perioperative mortality ranging from 11 - 28%. This retrospective observational study describe 105 consecutive patients with infective endocarditis operated between 2006 and 2015. All procedures were performed during the initial hospitalization due to IE. Indications for surgery included heart failure, uncontrolled infection or prevention of embolism. Surgical outcomes were compared between HIV+ and HIV- patients. In this era the HIV prevalence stabilized at 12% in the Free State Province general population, compared to 35.8% (19/53) of patients tested and HIV+ patients made up 18% (19/108) of the total series. Patients were operated at an average age of 43 years of which 65 were male and 40 were female and 78% (82/105) had underlying rheumatic heart disease. Staphylococcus and Streptococcus made up 80% of the organisms cultured, but only 52% (55/105) of patients were culture positive. The 105 patients underwent a total of 135 valvular procedures which included 31 valve repairs and 104 valve replacements. Due to the young age, 107 mechanical valves were implanted. In addition 6 tissue valves replacements, two aorta homografts implantations and two Ross procedures were performed. The peri-operative (90 day) mortality was 8.6% (9/105) with 10.5% (2/19) in the HIV+ group and 8% (7/86) in the HIV- group.

Culture negative IE at 48% might reflect pre-admission antibiotic treatment but emphasize the importance of routine screening for HACEK organisms. Confirming previous published data, HIV status per se does not contribute to peri-operative mortality. However, the HIV+ prevalence of 35.8% in the tested population may indicate that HIV status might predispose patients to the development of IE. This is contrary to previously published studies from Africa and warrants further surveillance.