COMMENTARY

Infectious Diseases: February 15, 2004

John Bartlett, MD

Disclosures

February 17, 2004

In This Article

Other Infectious Disease Studies

Vikram HR, Buenconsejo J, Hasbun R, Quagliarello VJ. Impact of valve surgery on 6-month mortality in adults with complicated, left-sided native valve endocarditis: a propensity analysis. JAMA. 2003;290:3207-3214. The authors provide a retrospective review of endocarditis in 7 Connecticut hospitals from 1990 to 2000. Criteria for inclusion were patients with complicated left-sided native valve endocarditis. The criteria for endocarditis were the Duke criteria, and the criteria for "complicated" endocarditis were: congestive heart failure (CHF), new valve regurgitation, refractory infection, or systemic embolization. A propensity was developed to adjust for the lack of randomization. The results were provided for 513 adults including 230 (45%) who underwent valve surgery and 283 (55%) who were treated medically. Baseline features that were associated with statistically significant increases in mortality were: female sex, older age, immunocompromised state, cardiac abscess on echocardiography, moderate to severe CHF, pathogen other than Viridans strep, renal failure, and refractory infection. Valve surgery was associated with a highly statistically significant reduction in the 6-month mortality: 16% in the surgery group vs 33% in the group treated medically. These results are shown in Table 18 .

The authors conclude that patients with complicated left-sided native valve endocarditis have a significant reduction in mortality with surgical management vs medical management. The greatest benefit was in the group that had moderate or severe CHF.

Comment: This is an important study because it provides the best information to date on the role of surgery for complicated left-sided endocarditis. The results are impressive: a 50% reduction in mortality with surgery compared to medical management. The obvious flaw was the lack of randomization. The authors dealt with this by the use of a "propensity score" that predicts the probability that surgery would be recommended. This permitted a subset analysis of a group of 109 patients matched by propensity score with 109 controls. The benefit of surgery was retained in this model with a difference in mortality of 15% with surgery compared to 28% with medical management. The major difference between the 2 groups in the propensity-matched group were those with moderate or severe CHF, which showed a mortality of 14% without surgery vs 51% with medical management. With propensity matching, elimination of CHF resulted in no significant difference between those who received surgery vs medical management. The data support surgery vs medical management for patients with moderate or severe CHF, but do not appear to support the other commonly used indications.

Wreghitt TG, Teare EL, Sule O, Devi R, Rice P. Cytomegalovirus infection in immunocompetent patients. Clin Infect Dis. 2003;37:1603-1606. This is a report from St. George's Hospital in London concerning 124 patients with cytomegalovirus (CMV) infection. The criteria for inclusion were an immunocompetent patient with evidence of recent CMV infection as indicated by a CMV IgM level exceeding 300 u/mL. During the study period, this test was done in 7630 patients; 124 were positive (1.6%). The characteristic clinical features are shown in Table 19 .

The age range of patients was 16-86 years, with 90% being age 20-59 years. The most frequent clinical symptoms were fever, malaise, and sweats, often accompanied by jaundice. The mean temperature was 38.3° C, and 28% had night sweats. The most frequent abnormal laboratory tests were liver function tests. The average duration of symptoms was 7.8 weeks. The initial diagnosis was hepatitis - 28%, "viral illness" - 22%, "glandular fever" - 21%, "influenza-like illness" - 13%, and "malignancy" - 6%.

Comment: This appears to be the largest report of primary CMV infection in immunocompetent adults. The most striking feature is the prolonged duration of symptoms, which averaged 7.8 weeks. The authors noted that patients frequently reported substantial relief to learn this diagnosis, implying resolution with no sequelae.

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