European Journal of Cardiovascular Medicine

Antimicrobial stewardship described as a coordinated intervention designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy and route of administration.1 The primary aim of antimicrobial stewardship is to achieve best clinical outcome while minimizing unintended consequences of antimicrobial use, including toxicity the selection of pathogenic organisms (such as clostridium difficile), and the emergence of resistance.2

Heart failure defined by European Society of Cardiology as a clinical syndrome consisting of cardinal symptoms e.g. breathlessness, ankle swelling and fatigue that may be accompanied by signs (e.g. elevated JVP, pulmonary crackles and peripheral edema).3 The prevalence of heart failure found to increase with age from around 1% for those aged < 55 years, and more than 10% in those aged 70 years or above.4,5

Acute heart failure can be described as the first manifestation of heart failure (new onset) or more frequently, it can be due to an acute decompensation of chronic heart failure.3 Acute decompensated heart failure accounts for 50-70 % of acute heart failure presentations.6,7 Both Acute decompensated heart failure (ADHF) and community acquired pneumonia may have similar presentation of acute dyspnea initially and hence making a definitive diagnosis of primary cause can be difficult. In many cases, the two conditions are simultaneously present in same patient, other studies have demonstrated that large proportion of acute decompensated heart failure patients are concurrently treated for suspected pneumonia.8 Present study was aimed to find out the rational use of antibiotic given in acute heart failure as well as study of total duration and de-escalation of antibiotics in acute heart failure

This was prospective observational study conducted at Fortis Escorts Heart Institute at New Delhi data collected from Emergency Department, Medical ICU- (Intensive care unit), Cardiac ICU (C.I.C.U) over period of 18 months from April 2020 to September 2021 after obtaining approval of the study from the Institutional Ethical Committee and written informed consent.

Inclusion criteria

·         Patients of Age >18 to 75 years, who presented to emergency room with dyspnea, suspected or known heart failure, willing to participate in present study

Exclusion criteria

1.       Pre-existing lung disease

2.       Patients on domiciliary oxygen

3.       Cardiogenic shock

4.       Recent h/o hospital admission (last 3 months).

5.       Immunocompromised patients

6.       Patients on mechanical ventilation.

Study was explained to participants in local language & written informed consent was taken. Details of patient were taken in form of clinical history including chief complaints, duration of symptoms, past history, antibiotic received previously, previous outside hospital admission, additionally tested for SARS COV-2 RT PCR (all included patient were SARS COV-2 RNA negative).

Vitals parameters recorded at admission were - Heart rate with ECG findings, Blood pressure (SBP,DBP,MAP), Respiratory rate, Temperature, SPO2, oxygen requirement, urine output, APACHE II at 24 hrs.. Systemic examination of RS, CVS, Per abdominal done, CNS done. Laboratory investigations done were – CBC, LFT, KFT, Sr. procalcitonin (ng/mL ) Sr. NT-proBNP (pg/mL) Cardiac enzymes, Sr. Lactate mmol/L (ABG), All cultures-blood, urine, Chest-x ray & 2D ECHO. Requirement of oxygen at admission (nasal cannula, face mask, HFNC,NIV). Patients of acute heart failure observed till discharge. Patient who had developed fever or any culture positive and those who were intubated on mechanical ventilatory support were not enrolled. Similarly, patients who had radiographic documentation suggestive of pneumonia or consolidation, were excluded. Any patient who developed infection during admission (e.g. urinary tract infections, pneumonia on radiographic finding or sepsis were excluded. Patients of acute heart failure who were given antibiotics at admission were observed till discharge. Details of patients were noted at admission. The data were collected on admission and after 48 hours of admission. Total duration of antibiotics given was noted in patients.

Data was collected and compiled using Microsoft Excel, analysed using SPSS 23.0 version. Frequency, percentage, means and standard deviations (SD) was calculated for the continuous variables, while ratios and proportions were calculated for the categorical variables. Difference of proportions between qualitative variables were tested using chi- square test or Fisher exact test as applicable. P value less than 0.5 was considered as statistically significant.

In present study, among 100 patients, most common age of presentation in the study was 51-55 years (31%) followed by 56- 60 years (27%). There were 8% of patients with the age ≤ 45 years. The proportion of males and females in the study were almost equal which was 52% and 48% respectively. In present study, common comorbidities were Hypertension (44 %), Diabetes (30 %), CKD (15 %), PTCA (30 %) & CABG (20 %).

Table 1: General characteristics

Out of 100 patients, 4 patients chest x-ray findings were suggestive of cardiomegaly at admission, there were no new changes after 48 hours. 42 patients chest x-ray finding were suggestive of pulmonary edema which were persistent after 48hours. 24 patients chest x-ray on admission were suggestive of pulmonary venous congestion and after 48 hours total 22 patients were found to have persistent finding of pulmonary congestion. 30 patients chest x-ray were found with no significant finding at admission. After 48 hours, total 32 patients were observed to have normal chest x-ray findings. Chest x-ray findings at admission and after 48 hours were statistically non- significant. P- value =0.827

Table 2: Chest x- ray findings in the study patients at admission and at 48 hours of admission:

Common ECG findings at admission were atrial fibrillation (AF) (41 %), Ventricular arrhythmia (VA) (11 %), Sinus tachycardia (ST) (40 %) & Bradyarrhythmia (BA) (8 %).

Table 3: ECG findings at admission

Maximum patients (53 %) had heart failure with reduced ejection fraction (HFrEF). –LVEF <40%. About 36 patients were found to have heart failure with mildly reduced ejection fraction (HFmrEF) –LVEF 41-49%. Only 11 patient were found to have heart failure with preserved ejection fraction.(HFpEF) –LVEF >50%.

Table 4: Ejection Fraction (EF)

Oxygen requirement at admission and after 48 hours of admission were found to be statistically significant. P value <0.0001.

Table 5: Oxygen requirement at admission & at after 48 hours of admission.

A significant fall was noted in TLC/(mm)³ when compared at admission and after 48 hours of admission, difference was statistically significant.

Table 6: Study parameters/investigations at admission and after 48 hours of admission.

It was observed that maximum duration of antibiotic given to the patients were of 8 days and minimum of 2 days. The observed mean of total duration of antibiotic was 5.37±2.62 days.

Table 7: Distribution of patients according to total duration of antibiotic

It was observed that there was no restarting of antibiotic in patients who were stopped after 48 hours.

Table 8: Distribution of patients according to restarting of antibiotic after stopping

It was observed that maximum duration of hospital stay in patients were of 9 days and minimum duration of 3 days. The observed mean of hospital stay was 5.64±1.21 days.

Table 9: Distribution of patients according to duration of hospital stay

Out of 100 patients included in study were 90 were discharged, 10 patients expired.

Table 10: Distribution of patients according to outcome:

Heart failure can present in two different clinical conditions as acute heart failure (AHF) and chronic heart failure (CHF). Patients who have an established diagnosis of heart failure or who have gradual onset of symptoms are described as chronic heart failure. Sometimes, chronic heart failure patients can deteriorate suddenly or slowly this episode usually described as ‘decompensated heart failure’.

Acute heart failure usually presents with rapid or gradual onset of symptoms and /or signs of heart failure, for which such patient may need urgent evaluation and initiation of treatment, leading to a hospital admission or an emergency department visit. Acute heart failure is one of the leading cause of hospitalizations in patients aged >65 years and is associated with high mortality and also repeated hospitalization.4 It is observed that hospital mortality ranges from 4% to 10%.6,7. Patient with new onset heart failure may have a higher in hospital mortality as compared to patients with acute decompensated chronic heart failure.9 Many acute heart failure patients admitted to the emergency department presents with complaints of shortness of breath. In the absence of additional clinical finding, and similar symptoms differentiating between cardiac and pulmonary causes of dyspnea can be difficult for physicians. As most of the time clinical finding in cardiac failure are similar to pulmonary involvement, physical finding are usually resembled in both condition.

The cardiac disease and pulmonary disease have difference in their treatment strategies for patients presenting with dyspnea and there can be probability of worsening of clinical conditions if the primary disease incorrectly diagnosed and initiated with incorrect treatment, so this necessitates early and correct diagnosis for better outcome of the patient.10 According to European Society of Cardiology 2021, Electrocardiogram (ECG) recommended as one of the diagnostics test for the assessment of heart failure. It is helpful in diagnosing cardiac arrhythmia or acute coronary syndrome which are precipitating factor for heart failure. The ECG finding may reveal abnormalities such as AF, Q waves, LVH hypertrophy (LVH),and widened QRS that may increase the likelihood of a diagnosis of heart failure and may also guide therapy.3 Most of the time atrial fibrillation can coexist with heart failure. Both these clinical condition can cause exacerbation of each other. Mechanism causing this such as structural cardiac remodeling, and activation of neurohumoral systems, and rate–related left ventricular impairment.11,12

As per table no.7 out of total 100 patients 41 patients found to have atrial fibrillation,40 patients had sinus tachycardia, 11 patients had ventricular arrhythmia, 8 patient had bradyarrhythmia. Similar to our study, Charlie S.Wang et al.,13 concluded that the presence of atrial fibrillation in a dyspneic patients was the most important finding with LR, 3.8; 95%CI, 1.7-8.8 and evaluated in several studies (n=5 studies) also presence of new T –waves changes ( LR, 3.0; 95 % CI,1.7-5.3) or abnormal ECG findings (LR, 2.2 ;95% % CI,1.6 -3.1 )increase the likelihood of heart failure but were evaluated in fewer studies.

In present study, chest-x ray findings at admission and after 48 hours were statistically non-significant. P value =0.827. Similar to our studies Charlie S. Wang et al.,13 stated that the presence of pulmonary venous congestion (distension of pulmonary veins and redistribution to the apices (LR,12.0; 95%CI, 6.8-21.0 and cardiomegaly (LR,3.3 ;95 % CI,2.4 -4.7) increased the likelihood of heart failure and have undergone more extensive evaluation so that the results may be more reliable. Patients of acute decompensated heart failure commonly associated with multiple co- morbidities as hypertension, diabetes mellitus, atherosclerosis which are obvious risk factors for chronic kidney disease, acute worsening of renal function is one of the independent risk factor for adverse outcome in acute decompensated heart failure, worsening of renal functions can be a consequence of new onset of acute kidney injury or else it can be acute deterioration in previous chronic kidney disease.14

In our study, we calculated we observed that patients having higher APACHE II score received antibiotic for more duration. Similar to our findings, Jason Frisbee et al. 13 observed in their study that ADHF patients who received intravenous antibiotic therapy at their admission had higher APACHE II scores than those who did not (mean APACHE II score -10.1 intravenous antibiotic arm) and 8.1 in the no-intravenous antibiotic arm; P=0.001). Baseline demographic and laboratory data were similar between the antibiotic received group and non

In our study, all the included 100 patients received antibiotic on admission, from observed data minimum duration of antibiotic were given for 2 days and maximum duration were of 8 days. The mean of total duration of antibiotic given to study patients was 5.37±2.62 days. We observed details of restarting antibiotic after stopping at 48 hours, in our study only 10 patients out of 100 antibiotic were stopped after 48 hours, rest of included patient received antibiotic till discharge or prior to discharge. Among 10 patients, none of patients were restarted with antibiotic.

Mean duration of hospital stay in study patients was around 5.64±1.21 days. In our study, 10 patients died due to heart failure and its related complications. The use of antimicrobial therapy was high and de -escalation were done only in 10 % of the patients. Majority of the patients in our study were having multiple co-morbidities, many had history of multiple hospital admissions. These were the reasons given by primary physicians for continuing the antibiotics for more than 48 hours.8 In view of fact a limited number of patients were included in the present study, the findings generated a hypothesis which should be verified with a large sample size. Present study was prospective observational study, antibiotic given to patients was primarily based on treating physicians which might have induced a bias in the study.

The diagnosis of acute heart failure was based on clinical history, routine blood investigations as per availability of data, including NT- proBNP, ECG findings and additionally, 2D-ECHO, Chest x-ray findings were also assessed. All the patients who were included in our study diagnosed with acute heart failure (i.e. acute decompensated heart failure) could be deemed at low risk of concurrent infection during admission based on laboratory and imaging findings and clinical documentation.

All patients despite low probability of infection received antimicrobial therapy. The mean duration of antibiotic study patients was of 5 days. This shows lack of antimicrobial stewardship and need of the hour is to formulate proper policies and adherence of these policies in the hospital.

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