2023 ESC Guidelines for the management of endocarditis

An Approach to Cardiac Implantable Electronic Device Pocket Infections: From Prevention to Diagnosis and Management

Cardiac implantable electronic device (CIED) infections are a highly morbid and potentially fatal complication of CIED implantation. Prompt diagnosis is paramount to the proper management of such infections. This review seeks to highlight the pathophysiology, risk factors, diagnostic approach, and prevention strategies for CIED infection, with an emphasis on pocket infection. Management will be discussed in detail, with complete device removal representing the standard of case, but with conservative management representing a potential alternative for patients at high risk for extraction. The high prevalence of CIED in the cardiac population renders understanding of this subject essential for the practicing clinician.

Isolated pulmonary valve endocarditis leading to right ventricular outflow obstruction

Isolated native pulmonary valve endocarditis is rare. We present a rare case of isolated native pulmonary valve endocarditis resulting in severe right ventricular outflow tract obstruction in an immunocompetent patient with surgically repaired ventricular septal defect caused by Burkholderia cepacia.

Mortality Profile of Deaths Related to Infective Endocarditis in Brazil and Regions: A Population-Based Analysis of Death Records

BACKGROUND

Studies of infective endocarditis (IE) are generally limited to institutions, underlining the need for more comprehensive epidemiological research.

OBJECTIVE

The aim of this study was to determine the mortality profile of IE-related deaths and related causes in Brazil at the national level and across regions.

METHOD

We conducted a population-based study using data from the country's mortality information system for the period 2000 to 2019. We identified IE-related deaths and related causes based on the ICD-10 codes. Cluster analysis was performed to determine the relationship between the variables.

RESULTS

There were 52,055 IE-related deaths during the study period. Deaths occurred predominantly among men and people aged between 60 and 79 years. The Southeast accounted for the largest proportion of deaths. The most frequent ICD-10 chapter mentioned in relation to IE-related deaths was diseases of the circulatory system. We identified three distinctive profiles: 1-an age of 80 years and over and women, where the most frequent chapters were endocrine, circulatory and metabolic diseases and the South and Southeast accounted for the largest proportion of deaths; 2-an age between 30 and 79 years and men, where the most frequent chapters were infectious and genitourinary diseases and the South and Southeast accounted for the largest proportion of deaths; and 3-an age between 0 and 29 years without any difference between sexes, where the most frequent chapter was diseases of the respiratory system and the North, Northeast and Midwest accounted for the largest proportion of deaths.

CONCLUSIONS

The findings of the cluster analysis revealed distinctive IE-related mortality profiles, indicating regional differences.

External validation of EuroSCORE I and II in patients with infective endocarditis: results from a nationwide prospective registry

OBJECTIVES

The primary objective was to externally validate EuroSCORE I and II in surgically treated endocarditis patients. The secondary objective was to assess the predictive performance of both models across sex, redo surgery, age, and urgency.

METHODS

Data were retrieved from the Netherlands Heart Registration. All patients with infective endocarditis who underwent cardiac surgery between 2013 and 2021 were included. Predictive performance was assessed by discrimination (area under the curve), calibration (calibration-in-the-large and calibration plots), and a decision curve analysis.

RESULTS

Two thousand five hundred and sixty-nine cases were included. Overall postoperative 30-day mortality was 10.2%. The area under the curve was 0.73 for EuroSCORE I and 0.72 for EuroSCORE II. Both models overpredict postoperative 30-day mortality, with observed-to-expected ratios of 0.37 and 0.69. EuroSCORE I overpredicts mortality across the full range, whereas EuroSCORE II overpredicts mortality only above a 20% predicted probability. We observed no significant differences in predictive performance across sex, redo surgery, or age. Discriminative capacity of EuroSCORE II was poor in emergency surgeries.

CONCLUSIONS

Both EuroSCORE models demonstrate acceptable discriminative capacity in IE patients. EuroSCORE I consistently overestimates mortality and should not be utilized in endocarditis patients. EuroSCORE II can be used in IE patients up to a predicted probability of approximately 20%, regardless of sex, redo surgery, or age. Beyond this point, the predicted mortality risk should be halved to approach the true mortality risk. EuroSCORE II should not be used for risk prediction in emergency endocarditis surgeries and patients should not be withheld from indicated surgical treatment solely based on high EuroSCOREs.

Cutibacterium acnes infective endocarditis-an emerging pathogen

OBJECTIVES

The study aimed to review a multicentre experience of patients undergoing surgical intervention for infective endocarditis caused by Cutibacterium acnes and to analyse the diagnostic challenges and operative results.

METHODS

We retrospectively reviewed 8812 patients undergoing cardiac surgery for endocarditis at 12 cardiac surgical departments across Germany. The overall population was divided based on the type of endocarditis (i.e. native and prosthetic valve endocarditis). Primary outcomes were in-hospital mortality, 1- and 5-year survival.

RESULTS

Cutibacterium acnes caused endocarditis in 269 patients (3.1%). Median age was 65 years (54-72 years) and 237 (88.1%) were male. We observed significantly higher rates of native valve endocarditis in patients aged 21-40, whereas prosthetic valve endocarditis was more frequent in all other age groups (P < 0.001). The median EuroSCORE II of the cohort was 10.7 (5.0-29.6), with it being significantly higher in the prosthetic valve endocarditis group (P < 0.001). Blood culture-negative infective endocarditis was initially reported in 54.3% of the patients. The in-hospital mortality was comparable between the groups (P = 0.340). Survival at 1 and 5 years was significantly higher in the native valve endocarditis group (P < 0.001).

CONCLUSIONS

Cutibacterium acnes causes native valve endocarditis, especially in younger patients. The incidence of endocarditis caused by C.acnes is alarming and is at par with well-known endocarditis pathogens such as the HACEK group. The pathogen has a low virulence and presents with a rather indolent course. The diagnosis of C.acnes endocarditis is challenging and requires a multimodal specialized approach. Surgical treatment is associated with acceptable outcomes.

Impact of pharmacist-led aminoglycoside stewardship: a 10-year observational study

BACKGROUND

Aminoglycosides are crucial for treating multidrug-resistant gram-negative infections and endocarditis. However, aminoglycosides are associated with significant risks of nephrotoxicity, necessitating careful dose selection and therapeutic drug monitoring. Therapeutic drug monitoring is essential for minimizing risk; however, few institutions routinely perform it. This study aimed to assess the impact of a pharmacist-driven therapeutic drug monitoring intervention on aminoglycoside usage trends and clinical outcomes.

METHODS

This retrospective cohort study included 263 patients treated with aminoglycosides between 2014 and 2023. A pharmacist-led therapeutic drug monitoring intervention began in 2017, focusing on monitoring renal function, documenting patient weight, and closely managing aminoglycoside concentrations. Trends in aminoglycoside use and renal outcomes were analyzed.

RESULTS

Over the study period, appropriate use of aminoglycosides at the time of initial prescription increased from 49 to 82% (P < 0.01). Pharmacist dosing design at initial prescription increased significantly from 21% pre-intervention to 60% post-intervention (P < 0.01). The proportion of pharmacist intervention in initial dosing design increased over time. The proportion of patients with measured aminoglycoside blood concentrations significantly increased from 53% pre-intervention to 72% post-intervention (P < 0.01). The proportion of patients who were able to manage target blood concentrations from the initial aminoglycoside dose without dose adjustments increased from 31% pre-intervention to 42% post-intervention, although the results were not significantly different (P = 0.07). The incidence rate of renal impairment remained similar (11% vs. 12%; P = 0.85), although the annual average number of cases decreased from 4.3 before the intervention to 2.5 after. Similarly, there were no significant differences in clinical efficacy before and after the intervention (65% vs. 71%; P = 0.35). Furthermore, aminoglycoside stewardship led to a 56% cost saving.

CONCLUSIONS

Pharmacist-led aminoglycoside stewardship significantly improved the appropriate use of aminoglycosides and decreased the associated costs. Thus, pharmacist involvement is essential for the proper use of aminoglycosides. However, many patients required aminoglycoside dose reductions despite the pharmacist's guideline-based dosing design. Therefore, further accumulation of information on the management of aminoglycoside blood concentration may be necessary for the revision of these guidelines.

New strategy of early surgery for infective endocarditis complicated by intracranial hemorrhage

PURPOSE

Early surgery for infective endocarditis with intracranial hemorrhage can cause severe bleeding, which is correlated with an increased mortality. In 2005, we started using nafamostat mesilate and low-dose heparin as anticoagulants during cardiopulmonary bypass for early surgery. The outcomes of this strategy have been reviewed.

METHODS

All patients who underwent cardiac surgery for active infective endocarditis with intracranial hemorrhage between 2005 and 2023 were evaluated.

RESULTS

There were 23 consecutive patients (median age 62 years old). Ten patients (43%) had neurologic deficits. The indication for early surgery in most patients was the presence of mobile vegetation or existing embolic events (18 of 23, 78%). No complications were associated with cardiopulmonary bypass. The median interval between the diagnosis and surgery was two days. There was 1 early death (4%) due to sepsis. There was no exacerbation of intracranial hemorrhage. One patient had new ectopic microbleeds without deterioration of neurologic findings. One patient had a new-onset cerebral infarction with neurologic deficits. None of the patients exhibited neurologic deterioration. The median follow-up duration was 26 months. overall survival was 90.7% after 5 years.

CONCLUSIONS

Our strategy of using nafamostat mesilate enabled us to safely perform early surgery in patients with intracranial hemorrhage without hemorrhage exacerbation.

Advancements and Challenges in the Management of Prosthetic Valve Endocarditis: A Review

Prosthetic valve endocarditis (PVE) is the medical term used to describe a focus of infection involving a valvular substitute within the heart. It is a significant concern in the field of cardiology, and the epidemiology of PVE has seen notable developments over the last five decades. The disease currently affects an older demographic and is becoming increasingly prevalent in patients with transcatheter-implanted valves. It is imperative that we urgently address the significant challenges posed by PVE. It is a disease that has a wide range of potential aetiologies, clinical presentations, and courses. In developed countries, Staphylococcus aureus is now the predominant causative organism, resulting in an aggressive form of disease that frequently afflicts vulnerable or elderly populations. However, it is clear that Enterococcus species present a significant challenge in the context of PVE following TAVR procedures, given their elevated prevalence. The 2023 Duke/International Society for Cardiovascular Infectious Diseases infective endocarditis diagnostic criteria now include significant developments in microbiological and image-based techniques for diagnostic purposes, specifically the incorporation of fluorine-18 fluorodeoxyglucose positron emission tomography and computed tomography. These developments unequivocally enhance the diagnostic sensitivity for PVE, while maintaining the specificity. They do so in accordance with the results of studies conducted specifically for the purpose of validation. The lack of rigorous scientific studies and a shortage of funding and resources for research have led to a significant gap in our understanding. Randomized controlled trials could provide invaluable insight and guidance for clinical practice, but they are missing, which represents a major gap. It is clear that there is an urgent need for more research. PVE is a life-threatening condition that must be handled by a multidisciplinary endocarditis team at a cardiac centre in order to improve outcomes. The emergence of innovative surgical techniques has empowered clinicians to steer more patients away from surgical procedures, despite the presence of clear indications for them. A select group of patients can now complete parenteral or oral antimicrobial treatment at home. Additionally, antibiotic prophylaxis is the best option for individuals with prosthetic valves who are going to have invasive dental procedures. These individuals should be given antibiotics beforehand.

A Dual Challenge: Coxiella burnetii Endocarditis in a Patient with Familial Thoracic Aortic Aneurysm-Case Report and Literature Review

Background/Objectives: Thoracic aortic aneurysms (TAAs) are potentially life-threatening medical conditions, and their etiology involves both genetic and multiple risk factors. Coxiella burnetii endocarditis is one of the most frequent causes of blood culture-negative infective endocarditis (BCNIE) in patients with previous cardiac surgery. Our review aims to emphasize the importance of genetic testing in patients with thoracic aortic aneurysms but also the importance of additional testing in patients with suspected endocarditis whose blood cultures remain negative. The reported case has a history of acute DeBakey type I aortic dissection that developed during her second pregnancy, for which the Bentall procedure was performed at that time. Ten years after the surgery, the patient started developing prolonged febrile syndrome with repeatedly negative blood cultures, the serological tests revealing the presence of an infection with Coxiella burnetii. Considering her family history and the onset of her aortic pathology at a young age, genetic tests were performed, disclosing a missense variant in the actin alpha-2 (ACTA2) gene in heterozygous status. Methods: For a better understanding of both conditions, our research was conducted in two directions: one reviewing the literature on patients with Coxiella burnetii BCNIE and the other focusing on patients who had a familial thoracic aortic aneurysm (FTAA) due to the ACTA2 variant. This review incorporates studies found on PubMed and ResearchGate up to August 2024. Conclusions: BCNIE represents a condition with several diagnostic challenges and may lead to severe complications if timely treatment is not initiated. Also, diagnosing an FTAA requires genetic testing, enabling better follow-up and management.

Infective Endocarditis by Biofilm-Producing Methicillin-Resistant Staphylococcus aureus-Pathogenesis, Diagnosis, and Management

Infective endocarditis (IE) is a life-threatening condition with increasing global incidence, primarily caused by Staphylococcus aureus, especially methicillin-resistant strains (MRSA). Biofilm formation by S. aureus is a critical factor in pathogenesis, contributing to antimicrobial resistance and complicating the treatment of infections involving prosthetic valves and cardiovascular devices. Biofilms provide a protective matrix for MRSA, shielding it from antibiotics and host immune defenses, leading to persistent infections and increased complications, particularly in cases involving prosthetic materials. Clinical manifestations range from acute to chronic presentations, with complications such as heart failure, embolic events, and neurological deficits. Diagnosis relies on the Modified Duke Criteria, which have been updated to incorporate modern cardiovascular interventions and advanced imaging techniques, such as PET/CT (positron emission tomography, computed tomography), to improve the detection of biofilm-associated infections. Management of MRSA-associated IE requires prolonged antimicrobial therapy, often with vancomycin or daptomycin, needing a combination of antimicrobials in the setting of prosthetic materials and frequently necessitates surgical intervention to remove infected prosthetic material or repair damaged heart valves. Anticoagulation remains controversial, with novel therapies like dabigatran showing potential benefits in reducing thrombus formation. Despite progress in treatment, biofilm-associated resistance poses ongoing challenges. Emerging therapeutic strategies, including combination antimicrobial regimens, bacteriophage therapy, antimicrobial peptides (AMPs), quorum sensing inhibitors (QSIs), hyperbaric oxygen therapy, and nanoparticle-based drug delivery systems, offer promising approaches to overcoming biofilm-related resistance and improving patient outcomes. This review provides an overview of the pathogenesis, current management guidelines, and future directions for treating biofilm-related MRSA IE.

The Impact of Neurological Complications in Endocarditis: A Systematic Review and Meta-Analysis

Background: Infective endocarditis (IE) is associated with significant neurological complications (NCs). The impact of neurological sequelae due to IE, however, is not well characterized. Thus, the aim of this systematic review and meta-analysis is to determine whether patients who experienced NCs from IE had worse outcomes compared to those without neurological complications. Methods: We conducted a systematic and comprehensive literature search of MEDLINE, Cochrane Library, Google Scholar, and BioMed Central (PROSPERO registration ID: CRD42024518651). Data on the primary outcome of all-cause mortality and the secondary outcome of surgical timing were extracted from 25 observational studies on patients with confirmed IE, both with and without NC. Results: In the pooled total of patients with IE, NCs were present in 23.7% (60.8% ischaemic stroke and 16.4% haemorrhagic stroke). All-cause mortality was significantly higher in patients with IE and NCs (OR 1.78, CI 1.47-2.17, p < 0.0001) compared to those without, particularly in those with major neurological events (OR 2.18, CI 1.53-3.10, p < 0.0001). Conversely, minor or asymptomatic strokes showed no significant correlation with mortality (OR 1.10, CI 0.82-1.47, p = 0.543). There was no significant difference in the timing of surgical intervention (standardized mean difference -0.53, CI -1.67 to 0.61, p = 0.359) between the two patient groups. Conclusions: Major NCs due to infective endocarditis were associated with a significantly increased all-cause mortality. This underscores the critical importance of early recognition and management strategies tailored to the severity of neurological events.

Revisiting the Evidence Base That Informs the Use of Adjunctive Therapy for Enterococcus faecalis Endocarditis: A Systematic Review and Meta-Analysis

BACKGROUND

Guidelines recommend adjunctive gentamicin for the treatment of Enterococcus faecalis infective endocarditis (EFIE) despite a risk of toxicity. We sought to revisit the evidence for adjunctive therapy in EFIE and to synthesize the comparative safety and effectiveness of aminoglycosides versus ceftriaxone by systematic review and meta-analysis.

METHODS

For historical context, we reviewed seminal case series and in vitro studies on the evolution from penicillin monotherapy to modern-day regimens for EFIE. Next, we searched MEDLINE and Embase from inception to 16 January 2024 for studies of EFIE that compared adjunctive aminoglycosides versus ceftriaxone or adjunctive versus monotherapy. Where possible, clinical outcomes were compared between regimens using random effects meta-analysis. Otherwise, data were narratively summarized.

RESULTS

The meta-analysis was limited to 10 observational studies at high risk of bias (911 patients). Relative to adjunctive ceftriaxone, gentamicin had similar all-cause mortality (risk difference [RD], -0.8%; 95% confidence interval [CI], -5.0 to 3.5), relapse (RD, -0.1%; 95% CI, -2.4 to 2.3), and treatment failure (RD, 1.1%; 95% CI, -1.6 to 3.7) but higher discontinuation due to toxicity (RD, 26.3%; 95% CI, 19.8 to 32.7). The 3 studies that compared adjunctive therapy to monotherapy included only 30 monotherapy patients, and heterogeneity precluded meta-analysis.

CONCLUSIONS

Adjunctive ceftriaxone appeared to be equally effective and less toxic than gentamicin for the treatment of EFIE. The existing evidence does not clearly establish the superiority of either adjunctive therapy or monotherapy. Pending randomized evidence, if adjunctive therapy is to be used, ceftriaxone appears to be a reasonable option.

Infective endocarditis with or without congenital heart disease: clinical features and outcomes

BACKGROUND AND AIMS

Patients with congenital heart disease (CHD) form a high-risk subgroup for infective endocarditis (IE), necessitating tailored prevention and treatment strategies. However, comprehensive nationwide data comparing IE characteristics and outcomes in patients with and without CHD, including children, are sparse. This study aims to address this gap in knowledge.

METHODS

Using Danish nationwide registries, all patients with IE from 1977 to 2021 were identified and stratified on whether they had a diagnosis of CHD, regardless of its complexity. Characteristics prior to and during admission as well as associated outcomes (i.e. in-hospital mortality, 1-year mortality, and 10-year mortality, and IE recurrence) were compared between groups.

RESULTS

In total, 14 040 patients with IE were identified, including 895 (6.4%) with CHD. Patients with vs. without CHD were younger at the time of IE diagnosis (median age 38.8 vs. 70.7 years), less comorbid, and more frequently underwent cardiac surgery during admission (35.7% vs. 23.0%, P < .001). Notably, 76% of patients with IE < 18 years of age had CHD. The IE-related bacteraemia differed between groups: Streptococci (29.9%) were the most common in patients with CHD, and Staphylococcus aureus (29.9%) in patients without CHD. Patients with CHD had a significantly lower cumulative incidence of in-hospital mortality (5.7% vs. 17.0%, P < .001) and 1-year mortality (9.9% vs. 31.8%, P < .001) compared with those without CHD. The 10-year cumulative incidence of IE recurrence was similar between groups (13.0% and 13.9%, P = .61).

CONCLUSIONS

Patients with CHD who develop IE exhibit distinct characteristics and improved long-term outcomes compared with patients without CHD. Notably, the majority of children and adolescents with IE have underlying CHD.

Rapidly Worsening Infective Endocarditis With Severe Mitral Stenosis

Infective endocarditis (IE) rarely results in mitral stenosis (MS), but MS in patients with IE can be life-threatening. We present a case of prosthetic MS secondary to IE. A 69-year-old Japanese man underwent mitral valve replacement with a bioprosthetic valve 2 years previously. The patient presented with a 1-month history of illness, and we diagnosed prosthetic valve IE with severe MS and planned for time-sensitive surgery. However, the patient developed cardiogenic shock in response to prosthetic mitral valve obstruction while awaiting surgery. The patient then had to undergo emergency surgery. There are no management guidelines for IE-induced valve stenosis, whose treatment differs from that of valve regurgitation. Our literature review reveals that achieving survival in patients with MS secondary to IE is difficult without surgical intervention. Patients with MS caused by IE may require surgery, and specific criteria should be outlined in future guidelines.

Antibiotic Prophylaxis Prior to Dental Procedures

Antibiotic prophylaxis in dentistry has been recommended for different groups of patients, such as patients with impaired immunologic function, patients at risk of developing infective endocarditis or prosthetic joint infection, patients previously exposed to high-dose irradiation of the head and neck regions, and patients receiving intravenous bisphosphonate and antiangiogenic treatment. The guidelines have been changed over the years, and the list of medical conditions requiring antibiotic prophylaxis has been shortened considerably in the context of antibiotic resistance and unnecessary antibiotic prescription.

Streptococcus suis infective endocarditis in patients with Streptococcus suis bacteremia: a retrospective study of prevalence and outcomes

BACKGROUND

Streptococcus suis (S. suis) is a zoonotic disease that is transmitted to humans via contact or oral route. Although the major clinical presentation of this pathogen is known to be meningitis, S. suis infective endocarditis (IE) has recently emerged as a clinical manifestation of increasing interest. Echocardiography may be an underutilized modality for evaluating patients with S. suis bacteremia.

OBJECTIVE

The primary objective was to estimate the prevalence of S. suis IE in patients with S. suis bacteremia. The secondary objective was to investigate the predictors, echocardiographic features, and clinical outcomes of S. suis IE in patients with S. suis bacteremia.

MATERIALS AND METHODS

This single-center retrospective study was conducted at Siriraj Hospital - Thailand's largest university-based tertiary referral center. Adult patients (aged > 18 years) who were admitted to our center with confirmed diagnosis of S. suis bacteremia during January 2007 to September 2023 were included. Prevalence is reported as percentage and confidence interval. Baseline characteristics and clinical manifestation were compared between the IE and non-IE groups. Factors found to be statistically significant were further analyzed using binary logistic regression analysis to identify univariate predictors of S. suis IE.

RESULT

A total of 71 patients with S. suis bacteremia were included in this study. The prevalence of S. suis IE was 26.8% (95% confidence interval: 17.85-38.05). Perivalvular complications and significant valvular regurgitation were found in 52.6% and 80.0% of patients, respectively. Thirteen of 19 patients (68.4%) required valvular surgery according to standard guidelines. By univariate analysis, dyspnea, new murmur, immunologic phenomenon, and heart failure were predictors of S. suis IE in patients with S. suis bacteremia.

CONCLUSION

The results of this study revealed a sizable prevalence of S. suis IE in patients with S. suis bacteremia, and there were high rates of both valvular damage and perivalvular complications. Our results strongly suggest that echocardiography may be indicated to evaluate for S. suis IE in patients diagnosed with S. suis bacteremia. Reclassification of S. suis from an atypical organism to a typical organism should be considered.

Early Diagnostic Prediction of Infective Endocarditis: Development and Validation of EndoPredict-Dx

BACKGROUND

Infective endocarditis is a life-threatening disease with diverse clinical presentations, making diagnosis challenging and requiring a range of complementary tests. The level of suspicion, based on clinical judgment, guides decisions regarding the initiation of empirical treatment and the selection of appropriate diagnostic tools. This study aimed to develop and validate the EndoPredict-Dx score for early prediction of infective endocarditis diagnosis.

METHODS

Patients admitted to a specialized cardiovascular hospital emergency department with suspected infective endocarditis between January 2011 and January 2020 were included. The primary outcome was left-sided infective endocarditis according to the Duke criteria. Logistic regression was used to derive the scoring system, with internal validation performed through bootstrapping. Candidate variables were obtained from the admission medical history, physical examination, and laboratory parameters.

RESULTS

Of the 805 individuals with suspected infective endocarditis (median age 56 years (40-73); 58.6% men), 530 confirmed the diagnosis based on the Duke criteria. The EndoPredict-Dx assigned points for male sex, previous endocarditis, petechiae, heart murmur, suspected embolism, symptoms lasting 14 or more days at the time of admission, hemoglobin level ≤ 12 g/dL, leukocyte level ≥ 10 × 109/L, C-reactive protein level ≥ 20 mg/L, and urine red blood cells ≥ 20,000 cells/mL. Patients were divided into three risk groups. The AUROC was 0.78 (95% CI 0.75-0.81) for the derivation cohort and 0.77 for the internal validation.

CONCLUSIONS

The EndoPredict-Dx score accurately predicted the likelihood of infective endocarditis using clinical and laboratory data collected at admission.

Stroke in the young: infective endocarditis due to mitral valve prolapse leading to acute ischemic stroke and subsequent hemorrhagic transformation

BACKGROUND

Stroke in young needs an individualized approach before considering thrombolysis. Here we present a case of undiagnosed mitral valve prolapse presenting with stroke due to associated infective endocarditis. Young stroke patients presenting with fever need a panoramic approach. This 39-year-old female with a background history of fever and loss of weight for two months presented to the emergency department with a history of altered sensorium and aphasia. The Magnetic Resonance Imaging (MRI) showed a hyperacute infarct. Hence, thrombolysis with alteplase was considered. Post thrombolysis, the patient had a parenchymal bleed. The diagnostic evaluation yielded stroke secondary to infective endocarditis because of undiagnosed mitral valve prolapse.

CONCLUSION

Mitral valve prolapse is not associated with stroke in young patients. However, the undiagnosed infective endocarditis and subsequent septic emboli led to an increased risk. Emergency physicians and intensivists should anticipate infective causes before considering thrombolysis, as the results could be counterproductive.

Antibiotics Knowledge and Prescription Patterns Among Dental Practitioners in Croatia, Bosnia and Herzegovina, and Serbia: A Comparative E-Survey with a Focus on Medically Healthy and Compromised Patients

BACKGROUND

The non-specific prescription of antibiotics, especially in dentistry, contributes to the global problem of antimicrobial resistance and highlights the need for education on the proper use and serious consequences of overprescribing these drugs. The main objective of this study is to assess and evaluate antibiotic knowledge and prescribing patterns in dental practice in Croatia, Bosnia and Herzegovina, and Serbia, focusing on understanding the rationale for prescribing, adherence to evidence-based guidelines, and dentists' awareness of antibiotic resistance.

METHODS

A total of 795 dentists participated in this electronic cross-sectional survey (Croatia N = 336, Bosnia and Herzegovina N = 176, and Serbia N = 283). The study utilized a self-structured questionnaire to collect data on various aspects of antibiotic use, including knowledge, prescribing practices, awareness of guidelines, and demographic and professional information about dentists. Data analysis included the Mann-Whitney test, the Kruskal-Wallis test with post hoc analysis, and chi-square tests, with statistical significance set at p < 0.05.

RESULTS

The overall score for the participants' knowledge of antibiotics was 6.40 ± 1.40 out of a maximum of eight points, which indicates a generally good level of knowledge among dentists. Factors such as gender, specialty, and practice location significantly influenced the level of knowledge (p < 0.05). However, actual prescribing practice was a cause for concern. Only 66.1% of Croatian dentists felt they had received adequate training during their studies, and even fewer in Serbia (48.4%) and Bosnia (46.6%). It is noteworthy that 9.7% of dentists in Bosnia and Herzegovina prescribe antibiotics at the request of patients, while 22.3% of Croatian and 25.4% of Serbian dentists do so. Many dentists prescribe no or only one antibiotic per week. In addition, 50.9% of Croatian dentists reported adverse effects related to the use of antibiotics, while only 31.3% of Bosnian and 33.6% of Serbian dentists reported similar experiences.

CONCLUSIONS

While the study results indicate that dentists in the region generally possess good knowledge of antibiotic use, there are significant discrepancies between this knowledge and actual prescribing practices. This highlights the need for enhanced educational programs and awareness initiatives focused on proper antibiotic guidelines to improve prescribing behaviors.

Prolonged outpatient parenteral antimicrobial treatment: frequency and evolution over a six-year period in a Swiss University Hospital

BACKGROUND

Emerging research indicates the potential for early transition from intravenous to oral antimicrobial therapy in certain infections. This trend may have implications for outpatient parenteral antibiotic therapy (OPAT) programs, as the demand for prolonged intravenous treatment could decrease. The objective of this study was to evaluate the frequency and evolution of OPAT courses of ≥ 14 days over the years and determine the medical justification for those prolonged treatments.

METHODS

All patients treated intravenously for ≥ 14 days by the OPAT program at Lausanne University Hospital, Switzerland, between 2017 and 2022 were included in the study. Data were extracted from a prospectively established OPAT database. Prevalence of prolonged antibiotic treatment and its clinical and microbiological information were identified.

RESULTS

During the study period, a total of 2,448 treatment courses were administered: 1,636 intravenous (IV) and 812 oral treatments. Of the IV treatments courses, 749 (36%) were of a duration of ≥ 14 days, without discernible trend over the 6-year study period. The most common type of infections needing prolonged treatment were bone and joint infections (31%), endovascular infections (18%), complicated intra-abdominal infections (15%), and urinary tract infections (11%), with only minor fluctuations in these proportions during the study period. Finally, the use of second-line antibiotics (piperacillin-tazobactam, carbapenems and vancomycin) did not increase over the years, suggesting that prolonged intravenous antibiotic therapy is not linked to an increase of anti-microbial resistance in our cohort.

CONCLUSIONS

Despite the general trend towards shorter intravenous treatment courses in infectious diseases, our OPAT unit did not observe a decline in the use of prolonged intravenous antibiotic therapy between 2017 and 2022, suggesting that OPAT units will probably not see a decrease in their activities in the near future.

Over-the-Wire Retrieval of Infectious Hemodialysis Catheter-Related Right Atrial Thrombus Causing Recurrent Pleural Empyema and Sepsis: A Case-Based Review

Introduction: Infectious catheter-related right atrial thrombus (CRAT) is a potentially fatal but often underestimated contingency associated with central venous catheter (CVC) in patients on hemodialysis. Management guidelines for CRAT are lacking, and its occurrence poses clinical challenges. Here, we describe the case of an infectious CRAT in a young patient on hemodialysis with peculiar clinical complications and perform a literature review. Case presentation and literature review: A 30-year-old man on hemodialysis after bilateral nephrectomy due to polycystic disease presented with hyperpyrexia resistant to broad-spectrum antibiotics. A pleural empyema caused by methicillin-resistant Staphylococcus aureus (MRSA) was diagnosed. Since fever persisted despite targeted antibiotic therapy, a transthoracic echocardiogram to exclude infective endocarditis was performed, showing a right atrial thrombus. CVC was promptly removed and the thrombus was aspirated through a percutaneous retrieval system. The thrombus cultural exam resulted positive for MRSA. After performing an extensive literature review, we could not find another case reporting the concomitance of these two rare complications. Conclusions: CRAT is a life-threatening complication in hemodialysis patients. While various treatment options exist, evidence-based guidelines are lacking, leading to individualized management strategies. Minimizing CVC use remains the best option for preventing such a complication.

Use of teicoplanin monotherapy for the treatment of enterococcal infective endocarditis: a retrospective and comparative study at a referral centre

OBJECTIVES

Clinical experience in the use of teicoplanin for treating enterococcal infective endocarditis (EIE) is scarce. The aim of this study was to describe the characteristics and outcomes of patients with EIE treated with teicoplanin monotherapy compared to standard therapy with ampicillin plus ceftriaxone.

METHODS

All consecutive adult patients diagnosed with EIE between January 2018 and September 2022 at a referral centre were reviewed. Characteristics of individuals treated with teicoplanin for ≥14 days [the treated with teicoplanin (TT) group] were compared with those who received ampicillin plus ceftriaxone (AC group).

RESULTS

Sixty-six patients were included [61 (92%) E. faecalis infective endocarditis (IE) and 5 (8%) E. faecium IE]. Twenty-seven (41%) received teicoplanin: eight as first-line treatment and 19 as continuation therapy.The median duration of teicoplanin treatment was 30 (25-43) days. Surgery was indicated in 14/27 (52%) in the TT group and in 21/39 (54%) in the AC group, but was finally performed in 11/14 (79%) and 13/21 (62%) (P = 0.46), respectively. In-hospital mortality rate was 3/27 (11%) in the TT group and 12/39 (31%) in the AC group (P = 0.06). Patients treated with teicoplanin were more often discharged on outpatient parenteral antibiotic therapy [18/27 (67%) versus 6/39 (15%), P < 0.001] and median hospital stay was shorter [29 days (IQR 20-61) versus 50 days (IQR 43-68), P = 0.006]. One-year cumulative mortality was 8/27 (30%) in the TT group and 13/39 (33%) in the AC group (P = 0.46). There was one relapse in each group.

CONCLUSION

Teicoplanin seems an effective treatment for selected patients with enterococcal IE, mainly to facilitate discharge.

A Case of Infective Endocarditis Following Bone Marrow Transplantation for Myelodysplastic Syndrome

A 63-year-old man was diagnosed with myelodysplastic syndrome (MDS) at the age of 62 by the hematology department. The patient underwent four cycles of azacitidine (AZA) therapy, followed by successful bone marrow transplantation (BMT). Subsequently, he was hospitalized twice for graft-versus-host disease (GVHD). Prednisolone was initially administered at 60 mg and was gradually tapered to 10 mg/day. Additionally, the patient was prescribed 10 mg/day of a Janus kinase inhibitor. At age 63, approximately one month prior to admission, he began experiencing recurrent upper respiratory symptoms with fevers of around 37°C. He developed a persistent fever of 38°C, accompanied by dyspnea on exertion, and visited the hematology outpatient clinic. Chest radiography revealed prominent pulmonary congestion, leading to the decision to perform echocardiography, which revealed severe aortic valve regurgitation with vegetation attached to the valve. Laboratory findings included a white blood cell count of 13,200/μL and a C-reactive protein (CRP) level of 13.7 mg/dL. Blood cultures revealed the presence of gram-positive cocci. As the patient's respiratory condition progressively worsened, emergency aortic valve replacement was planned. Additionally, because of a history of percutaneous coronary intervention (PCI) at another institution, he was referred for a coronary artery bypass graft (CABG) on the right coronary artery to be performed concurrently. Surgery was performed via median sternotomy under cardioplegic arrest. The aortic valve was perforated at the right coronary cusp and was covered with vegetation. The patient underwent aortic valve replacement with a biological valve, and a saphenous vein graft was used for bypass grafting to the posterior descending branch of the right coronary artery. Postoperatively, antibiotic therapy was administered without infection recurrence. The patient was discharged 47 days postoperatively. This case demonstrated the rapid progression of infective endocarditis following BMT, highlighting the need for prompt recognition and management.

Update on the epidemiology, diagnosis, and management of infective endocarditis: A review

Despite advancements in the diagnosis and treatment of infective endocarditis (IE), the burden of IE has remained relatively high over the past decade. With an ageing population and an increasing proportion of healthcare-associated IE, the epidemiology of IE has undergone significant changes. Staphylococcus aureus has evolved as the most common causative microorganism, even in most low- and middle-income countries. Several imaging modalities and novel microbiological tests have emerged to facilitate the diagnosis of IE. Outpatient parenteral antibiotic treatment and oral step-down antibiotic treatment have become new trends for the management of IE. Early surgical intervention, particularly within seven days, should be considered in cases of IE with appropriate surgical indications. We comprehensively review the updated epidemiology, microbiology, diagnosis, and management of IE.

Serratia marcescens Prosthetic Valve Endocarditis: Portending a Dismal Course

Serratia marcescens, an opportunist pathogen mainly isolated in healthcare-associated infections, is a rare cause of infective endocarditis (IE) that generates an increased mortality rate compared to the usual agents. We report a case of a 70-year-old male patient who underwent a mitral valve replacement and was readmitted two months later with a high-grade continuous fever and deterioration of the general status. The diagnosis of early IE due to S. marcescens was established upon further investigation. The patient was treated with ertapenem and underwent surgery. Nevertheless, the prognosis was not favorable. Due to the rarity of similar presentations and the grim prognosis that S. marcescens IE portends, further investigation on this subject is warranted. This can aid in preventing future occurrences and help issue guidelines for therapeutic management, especially in patients with prosthetic valves.

Patent ductus arteriosus with pulmonary endarteritis leading to pulmonary infarction in a 9-year-old boy: a case report

BACKGROUND

Pulmonary endarteritis secondary to Patent ductus arteriosus (PDA) can present even in silent PDAs. Pulmonary endarteritis is treated with prolonged duration of antibiotics followed by PDA closure. It can also cause septic pulmonary emboli requiring critical care if multi-organ dysfunction ensues.

CASE PRESENTATION

A 9-year-old boy had high grade fever for one week and few nonspecific complaints. Echocardiogram showed PDA with infective endarteritis. Child was admitted with IV antibiotics. CECT chest done for resurgence of fever and need for increased oxygen demand showed multiple septic pulmonary emboli with pulmonary infarction. Surgical closure of PDA prevented further clinical deterioration.

CONCLUSION

This case highlights the poor medical scenario of rural communities of Nepal. Such life- threatening complication can be prevented by timely recognition of the condition which is only possible by implementation of standard, accessible and affordable health care system across the country.

Management of cardiogenic shock: state-of-the-art

The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock.

British Cardiovascular Society survey of the provision and structure of cardiology multidisciplinary meetings in England

Multidisciplinary meetings (MDMs) are central to clinical decision-making in many areas of cardiology. This study assessed current provision and structure of cardiology MDMs in England in comparison with national guidelines. British Cardiovascular Society (BCS) members were surveyed regarding frequency, core attendees, and organisational aspects of cardiology MDMs for myocardial revascularisation, endocarditis, heart failure, aortic valve, mitral and tricuspid valve MDMs, whether local, regional or outside of the region. Access to electrophysiology (EP), inherited cardiac conditions, and adult congenital heart disease (ACHD) MDMs was also assessed. Survey responses were received from 64 hospitals across England, of which 40 (62%) were secondary care centres and 24 (38%) were tertiary care centres. All units had access to revascularisation MDMs, although 6% of them (all in secondary care centres) lacked any surgical representation. Heart failure MDMs were available in 94% of centres, but 7% reported no attendance by a cardiologist with specialist interest in heart failure, and 23% reported no attendance by a device specialist. 61% of centres had access to dedicated endocarditis MDMs; however, 11% were not attended by a microbiologist or infectious disease physician, and 22% were not attended by a surgeon. Aortic valve MDMs were available in 69% of centres, while mitral and tricuspid valve MDMs were available in 56% of centres. One quarter of centres reported no access to EP, and one third of centres reported no access to ICC or ACHD MDMs. Substantial improvements in provision and structure of cardiology MDMs in England are needed in order to meet national guidance.

Using machine learning to improve the diagnostic accuracy of the modified Duke/ESC 2015 criteria in patients with suspected prosthetic valve endocarditis - a proof of concept study

INTRODUCTION

Prosthetic valve endocarditis (PVE) is a serious complication of prosthetic valve implantation, with an estimated yearly incidence of at least 0.4-1.0%. The Duke criteria and subsequent modifications have been developed as a diagnostic framework for infective endocarditis (IE) in clinical studies. However, their sensitivity and specificity are limited, especially for PVE. Furthermore, their most recent versions (ESC2015 and ESC2023) include advanced imaging modalities, e.g., cardiac CTA and [18F]FDG PET/CT as major criteria. However, despite these significant changes, the weighing system using major and minor criteria has remained unchanged. This may have introduced bias to the diagnostic set of criteria. Here, we aimed to evaluate and improve the predictive value of the modified Duke/ESC 2015 (MDE2015) criteria by using machine learning algorithms.

METHODS

In this proof-of-concept study, we used data of a well-defined retrospective multicentre cohort of 160 patients evaluated for suspected PVE. Four machine learning algorithms were compared to the prediction of the diagnosis according to the MDE2015 criteria: Lasso logistic regression, decision tree with gradient boosting (XGBoost), decision tree without gradient boosting, and a model combining predictions of these (ensemble learning). All models used the same features that also constitute the MDE2015 criteria. The final diagnosis of PVE, based on endocarditis team consensus using all available clinical information, including surgical findings whenever performed, and with at least 1 year follow up, was used as the composite gold standard.

RESULTS

The diagnostic performance of the MDE2015 criteria varied depending on how the category of 'possible' PVE cases were handled. Considering these cases as positive for PVE, sensitivity and specificity were 0.96 and 0.60, respectively. Whereas treating these cases as negative, sensitivity and specificity were 0.74 and 0.98, respectively. Combining the approaches of considering possible endocarditis as positive and as negative for ROC-analysis resulted in an excellent AUC of 0.917. For the machine learning models, the sensitivity and specificity were as follows: logistic regression, 0.92 and 0.85; XGBoost, 0.90 and 0.85; decision trees, 0.88 and 0.86; and ensemble learning, 0.91 and 0.85, respectively. The resulting AUCs were, in the same order: 0.938, 0.937, 0.930, and 0.941, respectively.

DISCUSSION

In this proof-of-concept study, machine learning algorithms achieved improved diagnostic performance compared to the major/minor weighing system as used in the MDE2015 criteria. Moreover, these models provide quantifiable certainty levels of the diagnosis, potentially enhancing interpretability for clinicians. Additionally, they allow for easy incorporation of new and/or refined criteria, such as the individual weight of advanced imaging modalities such as CTA or [18F]FDG PET/CT. These promising preliminary findings warrant further studies for validation, ideally in a prospective cohort encompassing the full spectrum of patients with suspected IE.

A rare complication of blood culture-negative infective endocarditis on tricuspid valve: case report

Background

Endocarditis is an infectious disease, with an incidence of ∼15 cases per 100 000 people, affecting the tricuspid valve in 10% of cases. Infective endocarditis with negative blood cultures (BCNIE) accounts for more than 20% of cases of infective endocarditis. Perivalvular extension of the infection represents the most detrimental complications of BCNIE.

Case summary

A 25-year-old South Asian male was admitted due to fever for 15 days and new onset chest pain. The blood tests showed an increase in inflammatory indices. A chest X-ray showed enlargement of the cardiac shadow. On cardiac examination, a holosystolic murmur at the left sternal edge border was heard. The transthoracic echocardiogram showed a filamentous formation on the tricuspid valve and communication between the aorta and right atrium with left-right shunt. A transoesophageal echocardiogram (TEE) was performed to confirm the diagnosis of IE. Three sets of blood cultures were performed, with negative results, empirical therapy was managed and a decision for TEE-guided cardiac surgery was made.

Discussion

Fistula is a rare complication of IE representing the most insidious consequence of uncontrolled infection like BCNIE, a condition that has restricted the therapeutic possibilities to empirical therapy only and to early surgery. The TEE was instrumental in diagnosing right-sided infective endocarditis and allowing us to focus on the perivalvular spread of the infection in our case.

Infective Endocarditis With Origin in Orbital Vascular Malformation and Maxillary Sinusitis: A Case Report and Review of Four Patients in the Literature

Infective endocarditis is a life-threatening disease and the early diagnosis is crucial for a better outcome. We report an old adult who developed infective endocarditis in association with new-onset maxillary sinusitis as well as proptosis, which was caused by an orbital mass lesion in the background of pre-existing orbital vascular malformation. A 74-year-old woman was found incidentally to have right orbital vascular (venous) malformation by head magnetic resonance imaging when she was hospitalized for left dorsal pontine infarction. No paranasal sinusitis was noted at that time. She was well until half a year later when she developed fatigue and appetite loss for two days. At the same time, she had proptosis on the right side but did not have a fever. Blood examinations showed leukocytosis and a marked increase of C-reactive protein to 22 mg/dL as well as a moderate increase of bilirubin and liver enzymes. Emergency computed tomography scans from the head to abdomen showed nothing to be noted except for maxillary sinusitis and a retrobulbar orbital mass on the right side, which was in the same location as pre-existing vascular malformation. She began to have empirical antibiotics suspected of infective endocarditis. Head magnetic resonance imaging showed ischemic lesions in the right parietal lobe. Transthoracic and transesophageal echocardiography showed mitral valve regurgitation but no apparent vegetation. Streptococcus anginosus was detected by blood culture and the antibiotics were switched to intravenous penicillin G for 32 days. She was discharged in healthy condition with no proptosis. The orbital vascular malformation might serve as a route for infective endocarditis with the infectious origin in maxillary sinusitis. Maxillary sinusitis would be a predisposing factor for the development of infective endocarditis, and proptosis caused by an infectious focus of abnormal vascular channels in the orbit would lead to the early diagnosis of infective endocarditis. The present patient is unique in showing infective endocarditis in association with orbital vascular malformation.

Evidence-Based Data on the Diagnostic Role and Clinical Usefulness of [18F]FDG PET/CT in Endocarditis and Cardiac Device Infections

Infective endocarditis and infection of cardiac devices are conditions characterized by high morbidity and mortality, thus requiring a prompt diagnosis. Advanced imaging modalities are often required in the management of infectious endocarditis according to guidelines. The aim of this review is to collect and describe evidence-based knowledge about the diagnostic role and clinical usefulness of [18F]FDG PET/CT in endocarditis and cardiac device infections based on published systematic reviews and meta-analyses on this topic and on recent guidelines. [18F]FDG PET/CT is recommended only in selected cases. This imaging method has good diagnostic accuracy in detecting prosthetic valve endocarditis and cardiac device infection. Furthermore, it can identify extra-cardiac infectious foci changing the clinical management in a significant percentage of cases.

Prescribing for change - safer antimicrobial use in hospitals

The World Health Organization (WHO) has stated that antimicrobial resistance is one of the greatest health threats facing humanity and is responsible for significant morbidity and mortality, with a disproportionate impact on vulnerable groups of patients. The WHO set out its global action plan in 2015 and most countries have their own national plans, which take a whole system One Health approach that includes infection prevention and optimising the use of antimicrobials through stewardship programmes and diagnostics. In hospitals, antimicrobials are some of the most commonly prescribed medications, creating significant selection pressure for emerging resistance. Antimicrobial stewardship (AMS) in hospitals comprises a set of structured interventions that seek to optimise the benefits of treatments while limiting the harms. AMS is effective and has proven benefits such as improved outcomes and reduced spread of resistance in hospitals. This paper highlights key principles for antimicrobial prescribing and highlights recent evidence, some of which has been practice changing.

Acute coronary syndrome as the initial manifestation of infective endocarditis in an apparently normal native valve: a case report

Background

Acute coronary syndrome is a rare complication of infectious endocarditis. We present the case of a patient with a bicuspid aortic valve who presented an acute ST elevation myocardial infarction (STEMI) of the inferior wall secondary to vegetation that generated obstruction of the ostium of the right coronary artery (RCA).

Case summary

A 54-year-old patient with only a history of smoking was admitted for chest pain. An acute STEMI in the inferior wall was documented; he underwent an emergent coronary angiography, which showed a mass that obstructed the ostium of the RCA that did not allow its channelling. An angiotomography of the aorta was performed, where dissection was ruled out and the presence of a mass in the right coronary sinus that protruded towards the ostium of the coronary artery was confirmed. In the extension studies, a bicuspid aortic valve and thrombosis in the right brachial artery and in the infrarenal abdominal aorta were documented.

Discussion

The case was taken to a medical meeting and given the embolic and mechanical compromise; it was decided to perform surgery where a mass that invaded the proximal segment of the RCA was resected. The histopathological study documented findings of vegetation; the cultures were positive for Staphylococcus epidermidis, and he finally received antibiotic and anticoagulation treatment.

Multi-Modality Imaging to Detect Ischemic and Valvular Heart Disease in Adult Cancer Patients

Thanks to impressive advances in the field of oncology over the last 30 years, there has been a significant rise in cancer survivors. Nowadays, cardiovascular disease is one of the leading causes of death in this patient population. Coronary artery disease (CAD) is a major problem due to shared risk factors, an aging population and in many cases induced and/or accelerated atherosclerosis by antitumoral treatment during and even decades after the end of cancer therapy. Furthermore, the presence of CAD or valvular heart disease (VHD) at the time point of cancer diagnosis largely increases the risk of any cancer therapy-related cardiovascular toxicity (CTR-CVT). It is therefore of utmost importance to detect CAD and VHD before, during, and after certain types of chemotherapy, target therapies, and radiotherapy. Multimodality cardiovascular imaging plays a central role in this vulnerable population where individual risk stratification and multidisciplinary decision-making are critical.

Staphylococcus aureus bacteraemia for the general physician: A narrative review of a metastatic infection with malignant complications

Staphylococcus aureus bacteraemia (SAB) is a multi-system disease associated with a 20-25% mortality in the UK setting. Many patients with SAB are admitted acutely unwell and are treated by the general physician. This review summarises the key management steps that a general physician needs to be aware of when treating patients with SAB. Successful management relies on appropriate empirical and definitive antimicrobial therapy, effective source control, accurate risk stratification and timely identification of metastatic foci of infection, as well as exclusion of infective endocarditis, which can be present in up to 10% of patients with SAB.

Streptococcus equi Subspecies zooepidemicus Endocarditis and Meningitis in a 62-Year-Old Horse Rider Patient: A Case Report and Literature Review

The present article presents a case report and literature review concerning the Streptococcus equi subspecies zooepidemicus (SEZ), a rare zoonotic pathogen in humans. The case involves a 62-year-old man with no prior heart disease, presenting with endocarditis, pneumonia, and meningitis following close contact with a horse. The patient underwent urgent aortic valve replacement due to severe valvular damage caused by the infection. Blood and cerebrospinal fluid cultures confirmed the presence of SEZ, and the patient was treated with a combination of antibiotics, followed by a successful step-down to oral therapy using linezolid. A review of 25 additional Streptococcus equi endocarditis cases highlights the rarity of the condition, its association with animal contact, and its tendency to cause multi-site infections, such as pneumonia and meningitis. Early diagnosis, appropriate antibiotic therapy, and, in severe cases, surgical intervention are critical for a favorable outcome. This report emphasizes the importance of recognizing zoonotic infections in at-risk populations and the potential need for public health surveillance in these scenarios.

Splenic abscess: treatment options in a disease with high mortality

BACKGROUND

Spleen abscess is a rare and serious condition. Splenectomy and imaging-guided percutaneous catheter drainage (PCD) are the methods used in the treatment, but there is still a debate about the appropriate treatment for the patient.

METHODS

The results of 16 patients treated for spleen abscesses in our clinic between 2012 and 2021 were reviewed. The patients were divided into two groups according to splenectomy and PCD.

RESULTS

In the study, PCD was performed in 11 patients (68.75%), but three of these patients required splenectomy due to inadequate drainage. The patients who underwent splenectomy were significantly younger than the patients who underwent PCD (p < 0.05). One patient underwent PCD and 2 patients underwent splenectomy after PCD died.

CONCLUSION

Spleen abscess is a serious clinical picture that requires a multidisciplinary approach and is life-threatening. New clinical studies are needed for a treatment algorithm that will provide good results.

Treatment of Carbapenem-Resistant Acinetobacter baumannii in Real Life (T-ACI): A Prospective Single-Center Observational Study

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) poses significant challenges in healthcare due to its multidrug resistance and high mortality rates among critically ill patients. Results: We enrolled 45 patients. Cefiderocol was administered to 40% of patients, often (38.8%) in combination with other antibiotics. Colistin was administered to 60% of patients and always in combination, mostly with ampicillin-sulbactam. The overall ECS and OCS rates were 77.8% and 66.7%, respectively. Patients treated with an initial cefiderocol-based regimen showed a higher rate of ECS compared with patients initially treated with colistin-based regimens (100% vs. 63%, p < 0.05). Patients treated with cefiderocol alone showed a higher rate of ECS compared with patients treated with cefiderocol-based regimens (100% vs. 70.6%, p < 0.05). No differences in OCS rates were recorded depending on the treatment received. Additionally, cefiderocol regimens were associated with fewer ADRs compared to colistin-based treatment. Methods: This prospective observational study enrolled patients with CRAB infections from January 2022 to August 2023. Patients were treated with cefiderocol-based or colistin-based regimens and were monitored for 28 days to assess early clinical success (ECS), overall clinical success (OCS) and adverse drug reactions (ADRs). Conclusions: This study highlights the potential advantages of cefiderocol, even used as a monotherapy, in treating CRAB, especially when early clinical and laboratory response was assessed. This research contributes to the ongoing discussion on the most effective and safe treatments for combating CRAB infections, supporting the use of cefiderocol in clinical practice.

Adults with congenital heart disease: what every cardiologist should know about their care

As patients with congenital heart disease (CHD) continue to enjoy longer lives, non-congenital cardiologists and other healthcare professionals are increasingly encountering them in their practice and are challenged by their specific needs. Most under- and post-graduate medical training tends to overlook this common pathology, resulting in insufficient awareness of post-repair or post-palliation residual lesions and sequelae from previous interventions. In a strive towards improving the quality of care for this ever-growing cardiovascular patient cohort, it is prudent to outline the areas of concern and specific management needs pertaining to adult patients with CHD and share it with non-CHD professionals. The purpose of this paper is to offer essential guidance to physicians, including cardiologists, when they encounter a patient with CHD in a non-congenital healthcare setting.

Broviac Catheter-Related Aortic Valve Infective Endocarditis Complicated With Massive Aortic Regurgitation Requiring Emergency Surgery: A Case Report

Introduction: Broviac catheter is a type of central venous catheter (CVC) used for long-term parenteral nutrition in specific patients, e.g., diagnosed with intestinal failure as short bowel syndrome (SBS). The way of the catheter insertion is conceived to minimalize the risk of infections. However, CVC-related blood stream infections (CVC-BSIs), including infective endocarditis (IE), remain most important complications associated with Broviac catheter. Staphylococcus epidermidis stands out as a prevalent pathogen. The increasing number of CVCs results in an increased incidence of healthcare-associated IE. Complete parenteral treatment is an independent risk that increases the likelihood of IE. Treatment of IE is mainly based on antibiotic therapy, but in certain cases, surgical treatment is needed. Presentation of Case: A 71-year-old female with SBS who had been receiving total parenteral nutrition through the Broviac catheter for several months was admitted in a serious condition with significant weakness, increasing shortness of breath, deteriorating cough, fever, low blood pressure, and heart palpitations. Echocardiography revealed severe aortic valve IE with a large, longitudinal, highly mobile vegetation (up to 40 mm) and massive aortic regurgitation with pulmonary edema. Fast pathogen detection in the patients' blood (S. epidermidis) was obtained using PCR-based multiplex test. Due to life-threatening conditions, emergency surgery with aortic valve replacement was performed. Consistent rehabilitation resulted in good condition achievement. Follow-up echocardiography showed normal function of the aortic valve bioprosthesis. Conclusion: The use of CVC, including Broviac catheter, is associated with an increased risk of infections, including IE. Treatment-resistant severe HF complicating IE requires emergency surgery.

Emergence of resistance to last-resort antimicrobials in bacteremia patients: A multicenter analysis of bloodstream pathogens in Korea

This study retrospectively reviewed the microbiological and clinical characteristics of patients diagnosed with bacteremia. Results from the first positive blood cultures were consecutively collected from July 2022 to June 2023 at a public secondary hospital, a university-affiliated tertiary hospital, and a university-affiliated secondary hospital in the Seoul metropolitan area. Antibiotic spectrum coverage (ASC) scores were calculated on the day the blood culture was performed (B0) and on two days after the blood culture results were reported (R+2). A total of 3,397 isolates were collected from 3,094 patients. Among these, 949 isolates obtained from 893 patients were classified as multidrug-resistant organisms (MDRO), including 170 imipenem-resistant gram-negative bacteria, 714 methicillin-resistant staphylococci, and 65 vancomycin-resistant enterococci. Interestingly, 13 and 42 gram-positive isolates were resistant to linezolid and quinupristin/dalfopristin, respectively. Moreover, 44 and 181 gram-negative isolates were resistant to amikacin and tigecycline, respectively. The proportion of ASC scores corresponding to broad or extremely broad-spectrum coverage was not significantly different between MDRO and non-MDRO groups at B0 (p = 0.0925). However, it increased in the MDRO group at R+2 (p <0.001). This study found that resistance to last-resort antimicrobials is emerging. Therefore, developing and incorporating molecular diagnostics using a wide range of resistance targets may facilitate rapid, tailored antimicrobial treatments.

Transcatheter vacuum-assisted aspiration of large intracardiac and intravascular masses

Intravascular and intracardiac masses are usually represented by thrombi, tumours, and vegetations. They can affect both the right and left chambers of the heart and the venous and arterial circulation. Traditionally, their treatment is surgical or, in some circumstances, based on systemic anticoagulation/fibrinolysis. However, the complexity and frailty of patients who sometimes present with these conditions have pushed surgeons to find alternative minimally invasive effective treatments. While small masses can be removed with multiple devices, large masses are a more challenging problem. Vacuum-assisted aspiration systems such as the AngioVac System were developed to treat intravenous and right-sided heart thrombi. The application of the AngioVac System was widened to right-sided endocarditis and, later, to left-sided thrombi and vegetations. This review summarises the clinical results of different uses of the vacuum-assisted aspiration system to treat intravenous and intracardiac masses.

Native Valve Infective Endocarditis with Severe Regurgitation: What Matters Is Heart Failure

Background/Objectives: Heart failure worsens the prognosis of patients with infective endocarditis (IE) and is mainly caused by severe valvular regurgitation. The aim of our investigation is to describe the clinical, epidemiological, microbiological, and echocardiographic characteristics of patients with native left-sided infective endocarditis (NLSIE) with severe valvular regurgitation; to describe the prognosis according to the therapeutic approach; and to determine the prognostic factors of in-hospital mortality. Methods: We prospectively recruited all episodes of possible or definite NLSIE diagnosed at three tertiary hospitals between 2005 and 2022. Patients were divided into two groups: patients with severe valvular regurgitation at the time of admission or during hospitalization and patients without severe valvular regurgitation. We analyzed up to 85 variables concerning epidemiological, clinical, analytical, microbiological, and echocardiographic data. Results: We recovered 874 patients with NLSIE, 564 (65%) of them with severe valvular regurgitation. There were no differences in mortality among patients with and without severe regurgitation (30.2% vs. 26.5%, p = 0.223). However, mortality increased when patients with severe regurgitation developed heart failure (33% vs. 11.4%, p < 0.001). Independent factors related to heart failure were age (OR 1.02 [1.01-1.034], p = 0.001), anemia (OR 1.2 [1.18-3.31], p = 0.01), atrial fibrillation (OR 2.3 [1.08-4.89], p = 0.03), S. viridans-related IE (OR 0.47 [0.3-0.73], p = 0.001), and mitroaortic severe regurgitation (OR 2.4 [1.15-5.02], p = 0.019). Conclusions: Severe valvular regurgitation is very frequent among patients with NLSIE, but it does not worsen the prognosis of patients unless complicated with heart failure.