Infective Endocarditis After Liver Transplant Linked to Worse Hospital Outcomes

Infective endocarditis is associated with poor hospital outcomes in liver transplant recipients, according to findings from a recent study.1

Leveraging data from the National Inpatient Sample (NIS) data from 2016-2020, investigators found patients who received a liver transplant and had infective endocarditis had greater odds of in-hospital mortality, intensive care unit (ICU) admission, longer length of stay, and greater hospitalization charges than liver transplant recipients without infective endocarditis.1

“Impairment of the immune system due to end-stage liver disease predisposes these patients to various bacterial and fungal infections. As a result, liver disease is associated with a higher incidence of infective endocarditis than individuals without liver disease,” Ajit Brar, MD, resident physician, internal medicine at Hurley Medical Center, and colleagues wrote.1 “While much is known regarding the prevalence and outcomes of infective endocarditis in patients with end-stage liver disease, similar data regarding outcomes or characteristics in liver transplant recipients is currently sparse.”

Infective endocarditis, also called bacterial endocarditis, is a rare infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve, or a blood vessel. Without efficient diagnosis and treatment, it can lead to rapid and significant morbidity and mortality.2

To determine the prevalence, characteristics, and outcomes of infective endocarditis in liver transplant recipients, investigators examined data from the 2016-2020 NIS for liver transplant recipients with and without infective endocarditis, excluding those with missing demographics/mortality data, < 18 years of age, or a history of other organ transplants.1

The primary outcome of the study was in-hospital mortality. Secondary outcomes included shock, ICU admission, acute kidney injury (AKI), length of stay, and total hospitalization charges.1

A total of 170,650 patients who underwent liver transplant were identified from NIS data, 510 (0.003%) of whom had infective endocarditis. Investigators noted the infective endocarditis group was predominantly male (70.6%), Caucasian (71.6%), and had Medicare insurance (70.6%). The most common causative organisms were staphylococcus (18.6%), enterococcus (12.8%), gram-negative bacteria (9.8%), and streptococcus (6.9%).1

Upon analysis, the presence of infective endocarditis was associated with a significantly increased mortality rate compared with those without infective endocarditis (6.9% vs 2.3%). Multivariate regression analysis revealed patients with infective endocarditis had increased odds of mortality (adjusted odds ratio [aOR], 2.2; 95% CI, 1.07–4.78; P = .03).1

Additionally, patients with infective endocarditis had significantly increased rates of shock (15.7% vs 4.4%) and ICU admission (15.7% vs 4.8%). Multivariate regression analysis revealed infective endocarditis was linked to greater odds of shock (aOR, 2.7; 95% CI, 1.61–4.65; P <.001) and ICU admission (aOR, 2.4; 95% CI, 1.4–4.2; P <.001).1

Further analysis revealed the presence of infective endocarditis was also associated with a greater rate of AKI (42.2% vs 38.2%), but without statistical significance in multivariate regression analysis.1

Finally, investigators noted patients with infective endocarditis had a significantly longer length of stay of (10.6 days vs 5.6 days), as confirmed in a multivariate regression model (adj. Coeff, 3.4 days; 95% CI, 0.89–5.9; P <.008). Additionally, infective endocarditis was associated with greater hospitalization charges ($154,807 vs $67,997), with statistical significance observed between groups (adj. Coeff, $65 271; 95% CI, $14 825–$115 718; P = .01).1

“Our study provides comparative insights that underscore the need for early identification and tailored management by recognizing the unique clinical profiles among patients with infective endocarditis and liver transplantation,” investigators concluded.1 “Further research is needed to evaluate the characteristics of attributable organisms for infective endocarditis in liver transplant recipients.”

References

1. Brar A, Garg A, Kohli I, et al. The Prevalence and Characteristics of Infective Endocarditis in Liver Transplant Recipients: Insights From National Inpatient Sample Database. Clinical Cardiology. https://doi.org/10.1002/clc.70130

2. American Heart Association. Heart Valves and Infective Endocarditis. May 24, 2024. Accessed April 14, 2025. https://www.heart.org/en/health-topics/heart-valve-problems-and-disease/heart-valve-problems-and-causes/heart-valves-and-infective-endocarditis