Fungal Endocarditis in a Cohort of Adult Patients

The incidence of fungal endocarditis (FE) in large cohorts ranges from 1% to 3% and is associated with high morbidity and mortality. The characteristics of FE in Brazil are still poorly explored. From January 2006 to December 2023, demographic, clinical-laboratory, echocardiographic, microbiological, complication, and outcome data were collected from patients included in a prospective cohort of adults with definite infective endocarditis (IE). A post hoc analysis focused on FE was performed in order to compare fungal endocarditis with bacterial endocarditis (BE) within the same cohort. A total of 502 episodes of IE were included, of which 19 (3.78%) were FE. Non-albicans Candida species predominated, with C. parapsilosis being the most frequent. The mean age of patients with FE was 48.4 ± 21.0 years, compared with 48.4 ± 17.1 years in those with BE. Prosthetic valves or intracardiac devices were present in 11 cases (58%) of FE. Acquisition was hospital-related in 47.4% versus 24.7% (p = 0.033), healthcare-associated non-hospital acquisition in 26.3% versus 9.2% (p = 0.030), and community-acquired in 26.3% versus 66.2% (p < 0.001) for FE and BE, respectively. The most frequent comorbidities in FE were previous cardiac surgery, chronic kidney disease, and heart failure. The most common clinical manifestations were similar to those observed in other cases of IE: fever, embolic vascular events, presence of a new murmur, and elevated C-reactive protein levels. The mean vegetation size was 16.6 ± 4.8 mm in FE versus 12.7 ± 7.9 mm in other IE cases (p not significant). Vegetations involving the pulmonary valve (10.5% vs 0.8%, p = 0.019) and intracardiac devices (21.1% vs 6.9%, p = 0.044) were more frequent in FE. The most frequently described complications were heart failure (42.1% vs 58%, p not significant), splenic embolization (42.1% vs 34.7%, p not significant), and new-onset renal failure (29.4% in FE vs 33.1% in other IE cases, p not significant). Persistent fungemia or bacteremia (22.2% vs 7.4%, p = 0.047), peripheral embolization (26.3% vs 7.3%, p = 0.013), and recurrent embolization (16.7% vs 5.3%, p = 0.077) were more frequently observed in FE. The rate of surgical indication was higher in FE (94.7% vs 83%, p = 0.339), although the rate of surgery actually performed was lower in this group (50% vs 75.2%, p = 0.176). In-hospital mortality was significantly higher in FE (68.4% vs 23.5%, p < 0.001). Fungal endocarditis was infrequent in this IE cohort but was associated with healthcare-related acquisition, complications, a high rate of surgical indication, and high mortality. Infection control measures and early recognition of surgical indications are essential.